Wound complications following pre-operative radiotherapy for soft tissue sarcoma

The Perioperative Effects of Preoperative Radiotherapy in Metastatic Spinal Tumor Patients

OBJECTIVE

Radiotherapy is one of the important treatment options for metastatic spinal tumors but is not the definite intervention in all cases, as there are patients who still require surgical treatment because of severe pain or neurologic events after this treatment. We evaluated the perioperative effects of preoperative radiotherapy in these cases as a future guide for surgeons on critical considerations in this period.

METHODS

We included 328 patients in this study who had undergone decompression and fusion surgery for metastatic spinal tumors. Patients who underwent surgery with preoperative radiotherapy were designated as the radiotherapy group (group RT, n = 81), and cases of surgery without preoperative radiotherapy were assigned to the non-radiotherapy group (group nRT, n = 247). We compared the demographic, intraoperative, and postoperative factors between these 2 groups.

RESULTS

In terms of intraoperative factors, statistically significant differences were evident in operation time, estimated blood loss, and transfusion (RT vs. nRT: 188.1 ± 80.7 minutes vs. 231.2 ± 106.1 minutes, 607.2 ± 532.7 mL vs. 830.1 ± 1324.7 mL, and 30.9% vs. 43.3%, P < 0.001, P < 0.031, and P < 0.048, respectively). With regard to postoperative factors, the incidence of infection, wound problems, and local recurrence were statistically higher in group RT (RT vs. nRT: 6.2% vs. 0.8%, 12.3% vs. 0.8%, 23.4% vs. 13.7%, P = 0.004, P < 0.001, and P = 0.038, respectively).

CONCLUSIONS

Preoperative radiotherapy has the intraoperative advantages of reducing bleeding and shortening the operating time, but postoperative caution is needed because of the possibility of infection, wound problems, and local recurrence increases.

Nasal Crust-Related Morbidity and Debridement After Endoscopic Skull Base Surgery

Introduction:  Nasal crust after endoscopic skull base surgery can cause nasal congestion, obstruction, and pain, which can affect quality of life. The use of debridement aims to provide symptomatic relief and improve quality of life. Generally, most adult patients tolerate office-based debridement, except in a few select patients that require further sedation in the operating room for a debridement. The study sought to determine the rate of symptomatic crust-related morbidity and the rate of debridement in both the office and the operating room. Methods:  Premorbid, operative, and postoperative data of adult patients who had endoscopic skull base surgery in our institution from 2014 to 2018 were reviewed retrospectively. The characteristics of nasal symptoms in the postoperative period were determined and the number of debridements in the office and the operating room were analyzed. Results:  Two hundred and thirty-four (234) patients with 244 surgeries were included in the study. The majority, 68.9%, had a sellar lesion and a free mucosa graft (FMG) was the most common skull base reconstruction at 53.5%. One hundred and twenty (49.0%) had crust-related symptoms during the postoperative period and 11 patients (4.5%) required the operating room for debridement. The use of a pedicled flap, anxiety, and preoperative radiotherapy were significantly associated with intolerance to in-office debridement ( p -value=0.05). Conclusions:  The use of a pedicled flap or anxiety may predispose patients to require an OR debridement. Previous radiotherapy also influenced the tolerance to the in-office debridement.

Pelvic Ewing sarcoma: Should all patients receive pre-operative radiotherapy, or should it be delivered selectively?

BACKGROUND

Locally recurrent disease following surgical resection of Ewing sarcoma (ES) confers a poor prognosis. Limited evidence is available evaluating non-selective use of pre-operative radiotherapy (RT) for patients with pelvic ES and its effect on local control and survival.

PATIENTS AND METHODS

49 consecutive patients with pelvic ES were identified retrospectively from a prospectively collated database. Patients either received non-selective pre-operative RT and surgery (n = 27), or selective post-operative RT (n = 22) (surgery alone (n = 11) or surgery and post-operative RT (n = 11)).

RESULTS

Patients who had non-selective pre-operative radiotherapy appeared to have a higher LRFS, 88.0% compared to 66.5% in the selective RT group (p = 0.096, Kaplan Meier; p = 0.028, Chi-squared). Administration of non-selective, pre-operative RT to all patients with pelvic ES elevates the LFRS to that of the good responder group (≥90% tumour necrosis and margins, p = 0.880). There was no difference in metastasis-free survival, 60.0% and 54.5% (p = 0.728) and overall survival (OS), 57.7% and 63.6% (p = 0.893). The majority of pre-operative RT patients had both good necrosis (≥90%) (p = 0.003) and widely excised tumours, 81.5% vs 59.1% (p = 0.080). Tumour volume ≥250 ml was associated with worse LRFS (p = 0.045) and post-operative complications (p = 0.017). There may be improved LRFS (p = 0.057) with pre-operative proton-beam RT compared to surgery and selective post-operative RT.

CONCLUSION

Pre-operative photon or proton-beam RT to all pelvic ES may improve LRFS compared to the selective delivery of post-operative RT. Radiotherapy delivered to all patients results in a greater percentage of highly necrotic tumours at surgical excision, enabling a greater proportion of patients with wide resection margins.

The Interval Between Preoperative Radiation and Surgery Is Not Associated with Overall Survival for Soft-tissue Sarcomas: An Analysis of the National Cancer Database

BACKGROUND

Most cancer centers prefer preoperative radiation therapy (preRT) over postoperative therapy to treat soft-tissue sarcoma (STS) to limit long-term fibrosis, joint stiffness, and edema. Surgery is often delayed after preRT to allow for tissue recovery and to reduce wound complications. However, the association between the time interval between preRT and surgery and survival is unknown.

QUESTIONS/PURPOSES

(1) What factors are associated with the preRT-surgery interval in patients with STS? (2) Is the preRT-surgery interval associated with overall survival?

METHODS

The National Cancer Database, a nationwide registry that includes 70% of all new cancers in the United States with 90% follow-up, was reviewed to identify 6378 patients who underwent preRT and surgical resection for a localized extremity or pelvic STS from 2004 to 2014. Patients were excluded if they had lymphatic or metastatic disease at diagnosis (23%; n = 1438), underwent neoadjuvant chemotherapy (24%; 1531), were missing vital status (8%; 487), had chemosensitive histologies (9%; 603), underwent radiation other than external beam (1%; 92), were missing preRT-surgery interval (1%; 45), or had a preRT-surgery interval greater than 120 days (< 1%; 6). A total of 2176 patients were included for analysis, with a mean preRT-surgery interval of 35 ± 16 days. A multiple linear regression model was generated to assess demographic, clinicopathologic, and treatment characteristics associated with the preRT-surgery interval. A Kaplan-Meier survival analysis was then conducted, stratified by the preRT-surgery interval, to assess survival over 10 years. Finally, a multivariate Cox regression analysis model was constructed to further evaluate the association between the preRT-surgery interval and overall survival, adjusted for demographic, clinicopathologic, and treatment characteristics.

RESULTS

A longer preRT-surgery interval was associated with higher age (β = 0.002 per year [95% CI 0.0 to 0.004]; p = 0.026), tumor location in the pelvis (compared with the lower extremity; β = 0.15 [95% CI 0.082 to 0.22]; p < 0.001), and malignant peripheral nerve sheath tumor subtype (compared with undifferentiated pleomorphic sarcoma; β = 0.17 [95% CI 0.044 to 0.29]; p = 0.008). A shorter preRT-surgery interval was associated with higher facility volume (β = -0.002 per case [95% CI -0.003 to -0.002]; p = 0.026) and higher tumor stage (compared with Stage I; β = -0.066 [95% CI -0.13 to -0.006]; p = 0.03 for Stage II; β = -0.12 [95% CI -0.17 to -0.065]; p < 0.001 for Stage III). The 5-year overall survival rates were similar across all preRT-surgery interval groups: less than 3 weeks (66% [95% CI 60 to 72]), 3 to 4 weeks (65% [95% CI 60 to 71]), 4 to 5 weeks (65% [95% CI 60 to 71]), 5 to 6 weeks (66% [95% CI 60 to 72]), 6 to 7 weeks (63% [95% CI 54 to 72]), 7 to 9 weeks (66% [95% CI 58 to 74]), and more than 9 weeks (59% [95% CI 48 to 69]). Over 10 years, no difference in overall survival was observed when stratified by the preRT-surgery interval (p = 0.74). After controlling for potentially confounding variables, including age, sex, Charlson/Deyo comorbidity score, histology, tumor size, stage and surgery type, the preRT-surgery interval was not associated with survival (hazard ratio = 1 per day [95% CI 1 to 1]; p = 0.88).

CONCLUSION

With the numbers available, this study demonstrates that a delay in surgery up to 120 days after radiation is not associated with poorer survival. Therefore, clinicians may be able to delay surgery to minimize the risks of wound complications and modifiable comorbidities without affecting overall survival.Level of Evidence Level III, therapeutic study.

Six-Week Interval Between Preoperative Radiation and Surgery Is Associated With Fewer Major Wound Complications in Soft Tissue Sarcoma

OBJECTIVES

A total of 30% to 40% of soft tissue sarcoma (STS) patients develop major wound complications (MWCs) after preoperative radiation (preRT). The optimal preRT-surgery interval and its association with MWCs is unknown. This study investigated whether a longer preRT-surgery interval is associated with fewer MWCs compared with historical controls.

METHODS

All patients treated by a single surgeon after preRT with limb-sparing wide resection for extremity and trunk STS were retrospectively reviewed from 2004 to 2014. The primary outcome was MWCs defined as a secondary operation, invasive procedure, wound packing, or readmission for wound care. Secondary outcomes of local recurrence and survival were followed and independent variables were analyzed for an association with MWCs.

RESULTS

Fifty-four patients were included with a median follow-up of 32 months and age of 61 years. The majority of tumors were deep (91%), large (median size of 11 cm), high grade (78%) and within the lower extremity (78%). The median preRT-surgery interval was 43 days and 80% of patients received surgery 35 to 49 days after radiation. MWCs were observed in 15% of patients and 88% occurred within 40 days. Predictors for MWCs on multivariate analysis were peripheral vascular disease (P=0.03), location in the medial compartment of the thigh (P=0.03), and neurovascular involvement (P=0.03).

CONCLUSIONS

This study presents a cohort of STS patients with an extended preRT-surgery interval of ~6 weeks. MWCs in this population occurred at a lower rate than historical controls. Overall these findings support the exploration of a longer interval to reduce MWCs and their associated morbidity.

Planned combined onco-plastic (COP) surgical approach improves oncologic outcomes in soft tissue sarcomas

BACKGROUND

Combined modality of radiotherapy and surgery is the standard of treatment of soft tissue sarcomas (STS). The goal of this study was to assess whether a Combined Onco-Plastic (COP) surgical approach in the setting of neo-adjuvant radiotherapy can improve the oncologic outcomes of STS and reduce the rate of wound complications.

METHODS

We performed a retrospective review of all patients with STS treated at a single sarcoma centre (St Vincent's Hospital, Melbourne) between 2007 and 2018. Patients were stratified into two groups based on whether they have received the COP approach or were closed primarily by the orthopaedic surgeon. We analysed oncological outcomes and rate of wound complications.

RESULTS

A total of 546 patients with comparable demographics and tumor characteristics were included. The COP approach was performed in 75.6% of the patients. Wide margins were obtained in 97.4% of the cases, and this was significantly higher in the COP group (p < 0.001). The cumulative rate of local recurrence was 4.9%, with a 52% risk reduction in the COP approach, although this reduction was not significant (HR = 0.48; 95% CI 0.21-1.06; p = 0.070). The COP approach had better disease free survival (DFS) (aHR 1.86, 95% CI 1.45-2.37; p < 0.001) and Overall survival (risk of death aHR 0.49; 95% CI 0.30-0.79; p = 0.004). The overall wound complication rate was 18.6% with no difference between the two groups.

CONCLUSION

A planned collaboration between the orthopaedic oncologist and the plastic surgeon is beneficial in the treatment of STS after neo-adjuvant radiotherapy, allowing remarkably good oncological outcomes and a low rate of wound complications.

Can the ACS-NSQIP surgical risk calculator predict postoperative complications in patients undergoing sacral tumor resection for chordoma?

BACKGROUND AND OBJECTIVES

The ACS-NSQIP surgical risk calculator is an online tool that estimates the risk of postoperative complications. Sacrectomies for chordoma are associated with a high rate of complications. This study was to determine if the ACS-NSQIP calculator can predict postoperative complications following sacrectomy.

METHODS

Sixty-five (42 male, 23 female) patients who underwent sacrectomy were analyzed using the Current Procedural Terminology (CPT) codes: 49215 (excision of presacral/sacral tumor), 63001 (laminectomy of sacral vertebrae), 63728 (laminectomy for biopsy/excision of sacral neoplasm) and 63307 (sacral vertebral corpectomy for intraspinal lesion). The predicted rates of complications were compared to the observed rates.

RESULTS

Complications were noted in 44 (68%) patients. Of the risk factors available to input to the ACS-NSQIP calculator, tobacco use (OR, 20.4; P < .001) was predictive of complications. The predicted risk of complications based off the CPT codes were: 49215 (16%); 63011 (6%); 63278 (11%) and 63307 (15%). Based on ROC curves, the use of the ACS-NSQIP score were poor predictors of complications (49215, AUC 0.65); (63011, AUC 0.66); (63307, AUC 0.67); (63278, AUC 0.64).

CONCLUSION

The ACS-NSQIP calculator was a poor predictor of complications and was marginally better than a coin flip in its ability to predict complications following sacrectomy for chordoma.

Risk factor for wound complications following wide resection of soft tissue sarcoma in the adductor compartment of the thigh

Background

The purpose of this study was to investigate deep-seated soft tissue sarcoma (STS) occurring in the adductor compartment of the thigh that underwent wide resection and to clarify the high-risk group for wound complications.

Patients and methods

From 2000 to 2017, we reviewed 104 cases of deep-seated STS occurring in the adductor compartment of the thigh that were treated at four specialized facilities with expertise in sarcoma treatment.

Results

Wound complications occurred in 40 cases (38.5%), of which 23 cases (22.1%) were cases with major wound complications (MWC). In univariate analysis, BMI (P &lt; 0.01), maximum tumor diameter (P &lt; 0.01), operation time (P &lt; 0.01), amount of intraoperative bleeding (P &lt; 0.01), and intraoperative intervention to the femoral artery and vein (P &lt; 0.01) were significantly associated with wound complications. In multivariate analysis, the associated parameters were BMI (P &lt; 0.01), maximum tumor diameter (P = 0.02), and intraoperative intervention to the femoral artery and vein (P = 0.01). When limited to cases with MWC, univariate analysis showed that maximum tumor diameter (P &lt; 0.01), diabetes mellitus (P = 0.03), operation time (P &lt; 0.01), amount of intraoperative bleeding (P &lt; 0.01), and intraoperative intervention to the femoral artery and vein (P = 0.02) were significantly associated parameters. In multivariate analysis, maximum tumor diameter (P = 0.02) and amount of intraoperative bleeding (P = 0.04) were associated parameters.

Conclusions

For patients with risk factors for wound complications, control of bleeding are crucial when resecting deep-seated STS in the adductor compartment of the thigh. In cases with large tumors, surgeons should be especially cautious of cases requiring interventions that surround the femoral artery and vein in order to attain an appropriate surgical margin.

Retroperitoneal soft tissue sarcoma: low-dose neoadjuvant radiation therapy followed by surgery with or without intraoperative radiotherapy and adjuvant radiation therapy

BACKGROUND

We describe the clinical history, outcome, and toxicity of five patients with high-grade retroperitoneal soft tissue sarcoma (RSTS) who were treated with neoadjuvant low-dose radiotherapy (RT) followed by resection with or without intraoperative radiotherapy (IORT), followed by adjuvant RT. We aim to provide additional evidence for the various treatment options that exist for this rare tumor entity.

METHODS

Most patients presented with mild abdominal symptoms. Diagnosis was confirmed by biopsy. Additional imaging was done by sonography, magnetic resonance imaging (MRI), and/or positron emission tomography (PET)/computed tomography (CT). All patients were treated with neoadjuvant RT of 19.8 Gy in 1.8-Gy fractions followed by resection and postoperative RT up to 45 Gy with a median interval between resection and start of postoperative RT of 5 weeks. Two patients received additional IORT. Median follow-up was 61 months.

RESULTS

One patient developed a local recurrence that was diagnosed 30 months after the start of the first therapy. He was treated with a salvage resection and had no evidence of disease at the last follow-up. Another patient developed a right-sided RSTS on the contralateral side from the primary radiation field with pelvic bone infiltration 56 months after the start of RT. He was treated again by RT and resection and was without evidence of disease at last follow-up. Radiotherapy was well tolerated without major toxicity.

CONCLUSION

The treatment of RSTS by low-dose neoadjuvant RT, resection with IORT and adjuvant RT seems to be a feasible and effective treatment approach. Further studies comparing neoadjuvant with adjuvant RT are necessary to find the best treatment option.

Low dose radiotherapy is associated with local complications but not disease control in sacral chordoma

BACKGROUND

We reviewed the disease control and complications of the treatment of sacrococcygeal chordoma from four tertiary cancer centers with emphasis on the effects of radiotherapy in surgically treated patients.

METHODS

A total of 193 patients with primary sacrococcygeal chordoma from 1990 to 2015 were reviewed. There were 124 males, with a mean age of 59 ± 15 years and a mean follow-up of 7 ± 4 years. Eighty-nine patients received radiotherapy with a mean total dose of 61.8 ± 10.9 Gy.

RESULTS

The 10-year disease-free and disease-specific survival was 58% and 72%, respectively. Radiation was not associated with local recurrence (hazard ratio [HR], 1.13; 95% confidence interval [CI], 0.59-2.17; P = 0.71), metastases (HR, 0.93; 95% CI, 0.45-1.91; P = 0.85) or disease-specific survival (HR, 0.96; 95% CI, 0.46-2.00; P = 0.91). Higher doses (≥70 Gy; HR, 0.52; 95% CI, 0.20-1.32; P = 0.17) may be associated with reduced local recurrence. Radiotherapy was associated with wound complications (HR, 2.76; 95% CI, 1.64-4.82;, P < 0.001) and sacral stress fractures (HR, 4.73; 95% CI, 1.88-14.38; P < 0.001).

CONCLUSIONS

In this multicenter review, radiotherapy was not associated with tumor outcome but associated with complications. The routine use of radiotherapy with en-bloc resection of sacrococcygeal chordomas should be reconsidered in favor of a selective, individualized approach with a radiation dose of ≥70 Gy.

Morbid Obesity Increases the Risk of Postoperative Wound Complications, Infection, and Repeat Surgical Procedures Following Upper Extremity Limb Salvage Surgery for Soft Tissue Sarcoma

BACKGROUND

Obesity is a known risk factor for wound complications; however, unlike elective upper extremity procedures, where obesity can be modified preoperatively, excision of soft tissue sarcomas (STSs) is not elective, and as such, obesity cannot be modified. There is a paucity of data concerning the impact of obesity on wound healing in upper extremity sarcoma surgery.

METHODS

A total of 261 (159 males and 102 females) patients with a STS of the upper extremity from 2006-2014 were reviewed. The mean age and body mass index (BMI) were 56 (18-97) years and 26.6 (15.4-40.8) kg/m², respectively. Sixty-nine patients (26%) were classified as obese (BMI ⩾30 kg/m²): class I (obese, BMI = 30-34.9 kg/m²; n = 48, 18%), class II (severely obese, BMI = 35.0-39.9 kg/m²; n = 16, 6%), and class III (morbidly obese, BMI ≥ 40 kg/m²; n = 5, 2%). Functional outcomes were also compared between obese and nonobese patients using the Musculoskeletal Tumor Society (MSTS) 1993 rating system and Toronto Extremity Salvage Scores (TESS).

RESULTS

Forty-nine patients (19%) sustained a wound dehiscence, delayed healing, or infection. Class III obesity increased the risk of wound complications (hazard ratio [HR] = 8.19, 95% confidence interval [CI] = 1.96-22.96, P < .001) and infection (HR = 10.09, 95% CI = 1.60-34.83, P = .01). There was no difference in the mean TESS (93 vs 90, P = .13) or MSTS93 (95 vs 93, P = .39) between obese and nonobese patients.

CONCLUSIONS

The results of this study indicate morbid obesity significantly increased the risk of a postoperative wound complication and infection. However, following upper extremity limb salvage surgery, obese patients should expect to have excellent functional outcome.

Time dependent dynamics of wound complications after preoperative radiotherapy in Extremity Soft Tissue Sarcomas

AIMS

The purpose of the study was to investigate the time dependent dynamics of wound complications and local control after preoperative radiotherapy (RT) in Extremity Soft Tissue Sarcomas (ESTS).

PATIENTS & METHODS

In this retrospective cohort study, all patients treated for an extremity sarcoma with pre-operative radiotherapy followed by surgery were identified from a prospectively maintained database. A wound complication (WC) was defined as any local complication of the surgical area requiring intervention, hospital readmission or significant extension of the initial admission period.

RESULTS

A total of 191 preoperatively irradiated ESTS patients were included in this study. WC was seen in 31% of the patients (n = 60). WC started after a median time of 25 days from surgery, with a median duration of 76 days. Adiposity, smoking and a lower extremity or superficial tumor localization were significantly correlated with an increased WC rate. Risk factors for a duration of WC ≥ 120 days are early development of WC (≤21 days after surgery) and smoking. Local control rates after 1, 3 and 5 years were 99%, 93% and 93%, respectively.

CONCLUSION

Approximately one-third of patients selected for preoperative RT develops a WC, typically in smoking, adipose patients with superficial tumor localizations in the lower extremity. Based upon the well-established superior long-term functional outcome, maintained excellent local control rates and the temporary nature of the WC issue, preoperative RT remains our preferred treatment. Although, in patients at high risk of WC, post-operative RT might be considered.

Postoperative Day 1 Glucose May Be Associated With Wound Complications in Sarcomas Treated With Preoperative Radiation

BACKGROUND

Uncontrolled blood glucose impacts key phases of the wound healing process. Various factors have been associated with postoperative wound complications in soft tissue sarcomas; however, the association of postoperative early morning blood glucose with wound complications, if any, remains to be determined. Because blood glucose levels may be modified, understanding whether glucose levels are associated with wound complications has potential therapeutic importance.

QUESTIONS/PURPOSES

The purposes of this study were (1) to evaluate if postoperative early morning blood glucose is associated with the development of wound complications in soft tissue sarcomas; (2) to determine a blood glucose cutoff that may be associated with an increased risk of wound complications; and (3) to evaluate if patients with diabetes have higher postoperative blood glucose and an associated increased risk of wound complications.

METHODS

From 2000 to 2015, 298 patients with Stage I to III soft tissue sarcomas of the extremity or chest wall were treated with preoperative radiation ± chemotherapy followed by limb-sparing resection. Of those, 191 (64%) patients had demographic, treatment, and postoperative variables and wound outcomes available; these patients' results were retrospectively evaluated. None of the 191 patients were lost to followup. Early morning blood glucose levels on postoperative day (POD) 1 were available in all patients. Wound complications were defined as those resulting in an operative procedure or prolonged wound care for 6 months postresection. Variables that may be associated with wound complications were evaluated using logistic regression for multivariate analysis. Receiver operative curve (ROC) analysis was used to assess the early morning blood glucose level that best was associated postoperative wound complications.

RESULTS

After controlling for potentially relevant confounding variables such as patient comorbidities, tumor size, and location, lower extremity soft tissue sarcomas (p = 0.002, odds ratio [OR], 6.4; 95% confidence interval [CI], 1.97-20.84) and elevated POD 1 early morning blood sugars (p < 0.001; OR, 1.1; 95% CI, 1.04-1.11) were associated with increased wound complications postoperatively. ROC analysis revealed that early morning POD 1 blood glucose of > 127 mg/dL was associated with postoperative wound complications with a sensitivity of 89% (area under the curve 0.898, p < 0.001). Median POD 1 early morning blood glucose in patients without diabetes was 118 mg/dL and 153 mg/dL in patients with diabetes (p = 0.023). However, with the numbers available, there was no increase in wound complications in patients with diabetes compared with those without it.

CONCLUSIONS

Our study provides preliminary information suggesting that POD 1 early morning blood glucose in patients with soft tissue sarcomas may be associated with a slightly increased risk of postoperative wound complications. An early morning blood glucose of > 127 mg/dL may be a threshold associated with this outcome. Although patients with diabetes had higher POD 1 early morning blood glucose levels, diabetes itself was not associated with the development of wound complications. We cannot conclude that better glycemic control will reduce wound complications in patients who receive preoperative radiation, but our data suggest this should be further studied in a larger, prospective study.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Preoperative Radiotherapy and Wide Resection for Soft Tissue Sarcomas: Achieving a Low Rate of Major Wound Complications with the Use of Flaps. Results of a Single Surgical Team

Background

Surgery in combination with radiotherapy (RT) has become the standard of care for most soft tissue sarcomas. The choice between pre- and postoperative RT is controversial. Preoperative RT is associated with a 32–35% rate of major wound complications (MWC) and 16–25% rate of reoperation. The role of vascularized soft tissue “flaps” in reducing complications is unclear. We report the outcomes of patients treated with preoperative RT, resection, and flap reconstruction.

Patients and methods

122 treatment episodes involving 117 patients were retrospectively reviewed. All patients were treated with 50.4 Gy of external beam radiation. Surgery was performed at 4–8 weeks after completion of RT by the same combination of orthopedic oncology and plastic reconstructive surgeon. Defects were reconstructed with 64 free and 59 pedicled/local flaps.

Results

30 (25%) patients experienced a MWC and 17 (14%) required further surgery. 20% of complications were exclusively related to the donor site. There was complete or partial loss of three flaps. There was no difference in the rate of MWC or reoperation for complications with respect to age, sex, tumor site, previous unplanned excision, tumor grade, depth, and type of flap. Tumor size ≥8 cm was associated with a higher rate of reoperation (11/44 vs 6/78; P = 0.008) but the rate of MWC was not significant (16/44 vs 14/78; P = 0.066).

Conclusion

The use of soft tissue flaps is associated with a low rate of MWC and reoperation. Our results suggest that a high rate of flap usage may be required to observe a reduction in complication rates.

A new rabbit model of impaired wound healing in an X-ray-irradiated field

Radiation is an important therapy for cancer with many benefits; however, its side effects, such as impaired wound healing, are a major problem. While many attempts have been made to overcome this particular disadvantage, there are few effective treatments for impaired wound healing in an X-ray-irradiated field. One reason for this deficiency is the lack of experimental models, especially animal models. We have previously reported a mouse model of impaired wound healing in which the irradiation area was restricted to the hindlimbs. In this mouse model, due to the size of the animal, a diameter of five millimeters was considered the largest wound size suitable for the model. In addition, the transplanted cells had to be harvested from other inbred animals. To investigate larger wounds and the impact of autologous specimen delivery, a rabbit model was developed. Rabbits were kept in a special apparatus to shield the body and hindlimbs while the irradiation field was exposed to radiation. Six weeks after irradiation, a 2 x 2 cm, full-thickness skin defect was made inside the irradiation field. Then, the wound area was observed over time. The wound area after irradiation was larger than that without irradiation at all time points. Both angiogenesis and collagen formation were reduced. For further study, as an example of using this model, the effect of autologous platelet-rich plasma (PRP) was observed. Autologous PRP from peripheral blood (pb-PRP) and bone marrow aspirate (bm-PRP) was processed and injected into the wounds in the irradiated field. Two weeks later, the wounds treated with bm-PRP were significantly smaller than those treated with phosphate buffer vehicle controls. In contrast, the wounds treated with pb-PRP were not significantly different from the controls. This rabbit model is useful for investigating the mechanism of impaired wound healing in an X-ray-irradiated field.

Surgical Innovation in Sarcoma Surgery

The field of orthopaedic oncology relies on innovative techniques to resect and reconstruct a bone or soft tissue tumour. This article reviews some of the most recent and important innovations in the field, including biological and implant reconstructions, together with computer-assisted surgery. It also looks at innovations in other fields of oncology to assess the impact and change that has been required by surgeons; topics including surgical margins, preoperative radiotherapy and future advances are discussed.

Effect of Previous Irradiation on Vascular Thrombosis of Microsurgical Anastomosis: A Preclinical Study in Rats

BACKGROUND

The objective of the present investigation was to compare the effect of neoadjuvant irradiation on the microvascular anastomosis in cervical bundle using an experimental model in rats.

METHODS

One hundred forty male Sprague-Dawley rats were allocated into 4 groups: group I, control, arterial microanastomosis; group II, control, venous microanastomosis; group III, arterial microanastomosis with previous irradiation (20 Gy); and group IV, venous microanastomosis with previous irradiation (20 Gy). Clinical parameters, technical values of anastomosis, patency, and histopathological parameters were evaluated.

RESULTS

Irradiated groups (III and IV) and vein anastomosis groups (II and IV) showed significantly increased technical difficulties. Group IV showed significantly reduced patency rates (7/35) when compared with the control group (0/35). Radiotherapy significantly decreased the patency rates of the vein (7/35) when compared with the artery (1/35). Groups III and IV showed significantly reduced number of endothelial cells and also showed the presence of intimal thickening and adventitial fibrosis as compared with the control group.

CONCLUSION

Neoadjuvant radiotherapy reduces the viability of the venous anastomosis in a preclinical rat model with a significant increase in the incidence of vein thrombosis.

Patterns of major wound complications following multidisciplinary therapy for lower extremity soft tissue sarcoma

BACKGROUND AND OBJECTIVES

The purpose of this study was to determine the pattern and timing of major wound complications (MWCs) in patients at our institution who received multimodality treatment for lower extremity soft tissue sarcoma (LE-STS) and to evaluate the impact of MWCs on tumor control and patient outcomes.

METHODS

The medical records of 102 LE-STS patients treated with limb-sparing surgery and radiation therapy were reviewed. MWCs were defined as secondary operations with anesthesia, seroma/hematoma aspiration, admission for IV antibiotics, or persistent deep packing.

RESULTS

MWCs occurred in 22% of patients, with 45% of events occurring >120 days after resection. On multivariate analysis, preoperative external beam radiation therapy (EBRT) (OR 4.29, 95% CI 1.06-17.40, P = 0.042) and skin graft placement (OR 6.39, 95% CI 1.37-29.84, P = 0.018) were found to be independent predictors of MWCs. MWC occurrence did not predict for chronic toxicity and did not impact tumor control or survival.

CONCLUSIONS

A considerable proportion of MWCs occur >120 days from surgical resection with preoperative EBRT and skin graft placement independent predictors for MWCs. While an additional source of morbidity, MWC occurrence did not impact tumor control, nor did it predict for chronic toxicity. J. Surg. Oncol. 2016;114:385-391. © 2016 Wiley Periodicals, Inc.

Tumor volume is a better predictor of post-operative wound complications compared to tumor size in soft tissue sarcomas of the proximal lower extremity

Background

Wide local excision with or without radiation therapy (RT) and chemotherapy is widely accepted as appropriate management for soft tissue sarcomas (STS) of the extremity. Although survival and local control rates are comparable to amputation, post-operative wound complications (WC) following limb salvage can result in significant morbidity for the patient. Certain risk factors such as location, pre-operative RT, and age have been shown to increase the risk of WCs. Somewhat surprisingly, size has not consistently been shown to impact WC rates. The goal of this study is to assess whether tumor volume, as opposed to the traditional measurement of the largest dimension in one plane, correlates with the development of post-operative WCs.

Methods

Between 2000 and 2013, 81 patients with STS of the proximal lower extremity, buttock and pelvis were retrospectively identified from our prospective database. We reviewed the impact of patient, tumor, and treatment variables on postoperative WC. Predictors for WC were evaluated using the Fisher exact test for univariate analysis and logistic regression for multivariate analysis. Tumor volume was determined using the medical image merge (MIM) ^® software program (version 6.5.4, MIM Software, Cleveland, OH). Tumor size (diameter) was determined the historical way of measuring the widest dimension on the sagittal, coronal, and axial planes from the MRI scan at midplane.

Results

The overall WC rate within 6 months of tumor resection was 32 %. WC were more likely to occur with larger tumor volumes (p = 0.015), although not with tumor diameters ≥10 cm (p = 0.55). Neither volume of subcutaneous fat (p = 0.34) or depth of the subcutaneous fat layer (p = 0.82) significantly impacted WC rates. Tumor proximity to skin surface also did not significantly impact WC risk (p = 0.73).

Conclusions

Increase in tumor volume led to a higher risk of post-operative WCs. Assessing tumor volume may allow clinicians to better counsel patients on their risk of post-operative WCs. Tumor volume, as opposed to size alone, should be considered in future sarcoma outcome studies.

Plastic Surgery in the Multimodal Treatment Concept of Soft Tissue Sarcoma: Influence of Radiation, Chemotherapy, and Isolated Limb Perfusion on Plastic Surgery Techniques

Surgical intervention is the mainstay treatment for soft tissue sarcomas (STSs). The significance of adjuvant and neoadjuvant therapies, such as chemotherapy, radiation, and isolated limb perfusion, remains under controversial discussion. The goal of this review is to discuss the effects of the aforementioned treatment modalities and their timing of application in plastic surgery techniques. Furthermore, options of reconstruction in cases of complications caused by adjuvant and neoadjuvant therapies are discussed. When compared with adjuvant radiation, neoadjuvant treatment can reduce negative side effects such as fibrosis and edema because radioderma can be removed during the subsequent surgical procedure. Furthermore, there have not been any reports of negative effects of neoadjuvant radiation on microsurgical procedures. However, the dose of neoadjuvant radiation correlates with increased risks of impaired wound healing postoperatively. Thus, a patient-specific approach to decide whether radiation should be performed adjuvant or neoadjuvant is necessary. Preoperative irradiation should be considered in cases where functional structures are exposed after tumor resection, in order to ensure the best possible functionality. Adjuvant radiation should be considered in all other cases because of its known superior wound healing. As for chemotherapy, no negative influence of its use adjuvant or neoadjuvant to reconstructive procedures, such as local or free flaps, has been reported. Lastly, small sample size studies have not shown increased risks of microsurgical failure or wound complications after isolated limb perfusion. The findings of this review suggest that the chronological order of the discussed therapeutic approaches is not a decisive factor in the surgical outcome of reconstructive procedures for STS.

Biopsies in the Community Lead to Postoperative Complications in Soft Tissue Sarcomas

Percutaneous biopsies allow for precise diagnosis in soft tissue sarcomas and have a low rate of complications. However, it is unknown whether biopsies performed in a community setting lead to higher rates of wound complications at the time of resection. The goal of this study was to determine whether percutaneous biopsies performed at a sarcoma center have lower rates of wound complications compared with those performed in the community setting. A total of 125 patients with soft tissue sarcomas were treated with neoadjuvant radiation followed by limb-sparing resection. Of these, 92 underwent percutaneous biopsy. Patient, demographic, and treatment variables and postoperative wound complications were reviewed. Predictors of wound complications were evaluated with Fisher's exact test for univariate analysis and with logistic regression for multivariate analysis. The wound complication rate was 27% for open or percutaneous biopsies. When only percutaneous biopsies were assessed, the wound complication rate was 25%. The wound complication rate for percutaneous biopsies was 18% when the biopsy was performed at the authors' sarcoma center and 46% when the biopsy was performed in the community setting (P=.01). The Common Terminology Criteria for Adverse Events grade 4 wound complication rate was 73% in patients who underwent percutaneous biopsy at a community hospital vs 14% in those who underwent percutaneous biopsy at the authors' sarcoma center (P=.005). Multivariate analysis showed that lower-extremity soft tissue sarcomas (P=.03) and biopsies performed in the community setting (P=.01) had an increased rate of postoperative wound complications. Percutaneous biopsies performed at community hospitals had an increased incidence of grade 4 postoperative wound toxicity compared with biopsies done at tertiary centers. These wound results confirmed previous recommendations that biopsy of soft tissue sarcomas should be performed at an experienced sarcoma center.

Quality of life, functional outcomes, and wound complications in patients with soft tissue sarcomas treated with preoperative chemoradiation: a prospective study

BACKGROUND

Preoperative irradiation reduces local recurrence of soft tissue sarcomas (STSs), but major wound complication rates approach 25-35 %. Using a novel neoadjuvant chemoradiation protocol, we prospectively documented functional outcomes and quality of life (QOL) and hypothesized a lower major wound complication rate.

METHODS

Patients with STS deep to muscular fascia were treated with 3 days of doxorubicin (30 mg/day) and 10 days of irradiation (300 cGy/day) followed by limb-sparing surgery. Wound complications were assessed, and functional assessment and QOL were followed prospectively using the Toronto Extremity Salvage Score (TESS), Musculoskeletal Tumor Society (MSTS), and Short Form (SF)-36 questionnaires preoperatively and 6 and 12 months postoperatively.

RESULTS

Altogether, 52 consecutive patients were accrued during 2006-2011. Overall, 80.8 % of STSs were >5 cm, and 67.3 % involved the lower extremity. Seven (13.5 %) major wound complications occurred, all requiring reoperation. Preoperative scores for TESS, MSTS, and SF-36 physical (PCS) and mental (MCS) health components were 83.3, 86.7, 40.6, and 49.4, respectively. There were no differences seen 6 months postoperatively. By 12 months, however, patients showed improved functional scores (TESS 93.0, p = 0.02; MSTS 93.3, p < 0.01) and QOL scores (PCS 45.1, p = 0.02; MCS = 52.9, p = 0.05). No differences in scores were seen between patients with or without wound complications.

CONCLUSIONS

Patients treated with our neoadjuvant chemoradiation protocol had stable QOL and functional scores 6 months postoperatively and showed improvement by 12 months. Importantly, the major wound complication rate was low.

Evaluation of vacuum-assisted closure in patients with wound complications following tumour surgery

Covering the reconstructed area with a healthy soft-tissue envelope is a major challenge after limb-sparing surgery in patients with malignant bone and soft-tissue tumours. Negative pressure wound therapy (NPWT) of open wounds hastens healing and minimises the requirement for complex reconstructive soft-tissue surgery. The aim of this study was to investigate the effectiveness and safety of NPWT in bone and soft-tissue malignant tumour patients with postoperative wound complications. Between January 2006 and November 2009, at a single institution, 13 patients with malignant bone and soft-tissue tumours who had undergone wide resection were retrospectively analysed. NPWT was performed in all patients to temporarily close the soft-tissue defects. After obtaining the culture negativity and normal infection markers, definitive soft-tissue reconstruction was performed to close the wound with primary suturisation in two patients, split thickness grafts in four patients, full thickness grafts in two patients, rotational flaps in three patients and free flaps in two patients. Mean duration of hospitalisation was 20 (range 8-48) days and mean follow-up period was 57·3 (range 50-74) months. There was no tumour recurrence or skip metastasis in the follow-up period. In addition, there was no periprosthetic infection or complication associated with NPWT. In conclusion, NPWT therapy seems to be a safe and effective option in the management of local wound problems and secondary surgical site infections after musculoskeletal tumour surgery.

Negative pressure wound therapy in the management of postoperative infections after musculoskeletal tumour surgery

OBJECTIVE

The aim of the present retrospective study was to report on the effectiveness of the negative pressure wound therapy (NPWT) in the treatment of infected wounds after musculoskeletal tumour surgery.

METHOD

A total of 12 patients (10 male, 2 female, mean age 44.9 years with 9 early and 3 late infections) were included in the study. Patient parameters measured include age, gender, tumour diagnosis and localisation, pathogen organism, foam used, pressure height and modus, number of NPWT dressings changes, total duration of NPWT, need for secondary wound closure, length of hospitalisation, complications, and follow-up.

RESULTS

The NPWT dressings were changed on average 6.7 (SD±6.9) times after a mean duration of 5.6 (SD±2.4) days. The total duration of NPWT was 37.7 (SD±32.9) days. The mean hospital stay was 77.5 (SD±58.8) days. In 7 out of 12 cases, a split-thickness skin graft transplantation was performed. In these cases, no seroma or hematoma formation beneath the skin graft could be observed. At a mean follow-up 39.2 (range: 9-73) months, no reinfection or infection persistence was apparent.

CONCLUSION

NPWT can be of valuable assistance in the treatment of infected wounds following musculoskeletal tumour surgery. The patients should be informed about the long treatment period.

Neoadjuvant treatment with preoperative radiotherapy for extremity soft tissue sarcomas: long-term results from a single institution in Turkey

BACKGROUND

To assess the long term clinical outcome of preoperative radiotherapy with or without chemotherapy followed by limb sparing surgery in patients with non-metastatic soft tissue sarcomas (STS) of the extremities.

MATERIALS AND METHODS

Sixty patients with locally advanced STS were retrospectively analyzed. The median tumor diameter was 12 cm. All patients were treated with preoperative radiotherapy delivered with two different fractionation schedules (35Gy/10fr or 46-50Gy/23-25fr). Neoadjuvant chemotherapy was added to 44 patients with large and/or high grade tumors. Surgery was performed 2-6 weeks after radiotherapy. Chemotherapy was completed up to 6 courses after surgery in patients who had good responses.

RESULTS

Median follow-up time was 67 months (8-268 months). All of the patients had limb sparing surgery. The 5-year local control (LC), disease free (DFS) and overall survival (OSS) rates for all of the patients were 81%, 48.1% and 68.3% respectively. 5-year LC, DFS and cause specific survival (CSS) were 81.7%, 47%, 69.8%, and 80%, 60%, 60% in the chemoradiotherapy and radiotherapy groups, respectively. On univariate analysis, patients who were treated with hypofractionation experienced significantly superior LC, DFS and CSS rates with similar rates of late toxicity when compared with patients who were treated with conventional fractionation and statistical significance was retained on multivariate analysis.

CONCLUSIONS

Treatment results are consistent with the literature. As neoadjuvant chemoradiotherapy provides effective LC and CSS with acceptable morbidity, it should be preferred for patients with large and borderline resectable STS.

Silver negative pressure dressing with vacuum-assisted closure of massive pelvic and extremity wounds

BACKGROUND

Massive soft tissue loss involving the pelvis and extremities from trauma, infections, and tumors remains a challenging and debilitating problem. Although vacuum-assisted closure (VAC) technology is effective in the management of soft tissue loss, the adjunct of a silver dressing in the setting of massive wounds has not been as well tested.

QUESTIONS/PURPOSES

Does a silver negative pressure dressing used in conjunction with a wound VAC decrease (1) the length of acute hospital stay and overall length of treatment; (2) the number of surgical débridements the patients underwent as part of their care; and (3) the likelihood of wound closure without soft tissue transposition?

METHODS

We evaluated 42 patients with massive (> 200 cm(2)) pelvic and extremity wounds from trauma, infection, or tumor who were treated with the wound VAC with or without a silver negative pressure dressing between January 2003 and January 2010; the first 26 patients were treated with the wound VAC alone, and in the final 16 consecutively treated patients, the silver dressing was added to the regimen. We reviewed medical records to determine length of treatment as well as the number and type of surgical interventions these patients underwent. We compared the group treated with the wound VAC alone with those patients treated with the wound VAC and silver negative pressure dressing.

RESULTS

Hospital stay averaged 19 days in the VAC only group and 7.5 days in the VAC with silver dressing group (p < 0.041), length of overall treatment averaged 33 days in the VAC only group and 14.3 days in the VAC with silver dressing group (p < 0.022), number of operative débridements averaged 7.9 in the VAC alone group and 4.1 in the VAC with silver dressing group (p < 0.001), and success of wound closure without soft tissue transposition was 16 of 26 patients in the VAC alone group and three of 16 patients in the VAC with silver dressing group (p < 0.033).

CONCLUSIONS

Based on the reduced length of care and the number of surgical procedures these patients with massive wounds of the pelvis and extremities underwent, we now use the silver negative pressure dressing in combination with the wound VAC as part of routine care of such patients. These results may be used as hypothesis-generating data for future randomized studies.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgical site infection in orthopaedic oncology

BACKGROUND

This study addressed risk factors for surgical site infection in patients who had undergone orthopaedic oncology surgical procedures.

METHODS

We retrospectively reviewed data on 1521 orthopaedic oncologic surgical procedures in 1304 patients. We assessed patient demographics, updated Charlson comorbidity index, surgery-specific data, and treatment-related data and attempted to identify predictors of surgical site infection with bivariate and multivariable analysis.

RESULTS

Eight factors independently predicted surgical site infection: body mass index (odds ratio [OR]:, 1.03, 95% confidence interval [CI]: 1.00 to 1.07), age (OR: 1.18, 95% CI: 1.05 to 1.33), total number of preceding procedures (OR: 1.19, 95% CI: 1.07 to 1.34), preexisting implants (OR: 1.94, 95% CI: 1.17 to 3.21), infection at another site on the date of the surgery (OR: 4.13, 95% CI: 1.57 to 10.85), malignant disease (OR: 1.46, 95% CI: 0.94 to 2.26), hip region affected (OR: 1.96, 95% CI: 1.35 to 2.84), and duration of the procedure (OR: 1.16, 95% CI: 1.07 to 1.25).

CONCLUSIONS

These factors can inform patients and surgeons of the probability of surgical site infection after orthopaedic oncologic surgery. While most risk factors are unmodifiable or related to the complexity of the case, infection at another site on the date of the surgery is one factor amenable to intervention.

[Soft tissue sarcoma : resection and plastic reconstruction]

Adequate surgical removal of soft tissue sarcomas of the trunk and extremities employing safety margins of 1-2 cm is the accepted basis of multidisciplinary treatment. In cases of high risk tumors (grades G2/G3) the tumor board decision should include radiochemotherapy under study conditions. Difficult peripheral locations or perioperative complications require additional techniques, such as hyperthermic perfusion with tumor necrosis factor alpha or the complete spectrum of reconstructive plastic procedures. Patients with soft tissue sarcoma of the trunk or of the extremities should always be referred to high volume centers.

Predictors for major wound complications following preoperative radiotherapy and surgery for soft-tissue sarcoma of the extremities and trunk: importance of tumor proximity to skin surface

PURPOSE

Preoperative and postoperative RT for the treatment of high-grade soft-tissue sarcoma result in similar local control and overall survival rates, but morbidities differ. Postoperative RT is associated with a higher rate of long-term fibrosis, edema, and joint stiffness. Preoperative RT is associated with higher rates of wound complications. It is important to identify predictors for major wound complications (MWC) and to develop strategies to minimize this outcome. We reviewed our experience to determine predictors for MWC following preoperative radiotherapy (RT) and surgery for soft-tissue sarcoma.

METHODS

Between January 2006 and May 2011, 103 patients with soft-tissue sarcoma of the extremities and trunk were treated with preoperative RT followed by surgery. MWCs were defined as those requiring operative or prolonged nonoperative management. Fisher's exact test was used to compare rates. Logistic regression was used for multivariable analysis of factors potentially associated with MWCs.

RESULTS

Median tumor size was 8.4 cm (range 2-25). All patients had wide or radical resections. Wound closures were primary in 70 %, a vascularized flap in 27 %, and split-thickness skin graft (STSG) in 3 %. There were 36 MWCs (35 %). Significant predictors for MWCs on univariate analysis included diabetes, tumors >10 cm, tumors <3 mm from skin surface, and vascularized flap/STSG closure. The same four variables were significant predictors on multivariable analysis.

CONCLUSIONS

MWCs following preoperative RT and surgery were common. Tumor proximity to skin surface <3 mm is a previously unreported independent predictor, and further strategies to minimize wound complications are needed.

Management of radiation wounds

Radiotherapy forms an integral part in cancer treatment today. It is used alone or in combination with surgery and chemotherapy. Although radiotherapy is useful to effect tumour death, it also exerts a deleterious effect on surrounding normal tissues. These effects are either acute or can manifest months or years after the treatment. The chronic wounds are a result of impaired wound healing. This impairment results in fibrosis, nonhealing ulcers, lymphoedema and radionecrosis amongst others. This article will discuss the pathophysiology in brief, along with the manifestations of radiation-induced injury and the treatment available currently.

[Soft tissue sarcoma. Resection and plastic reconstruction]

Adequate surgical removal of soft tissue sarcomas of the trunk and extremities employing safety margins of 1-2 cm is the accepted basis of multidisciplinary treatment. In cases of high risk tumors (grades G2/G3) the tumor board decision should include radiochemotherapy under study conditions. Difficult peripheral locations or perioperative complications require additional techniques, such as hyperthermic perfusion with tumor necrosis factor alpha or the complete spectrum of reconstructive plastic procedures. Patients with soft tissue sarcoma of the trunk or of the extremities should always be referred to high volume centers.

Wound complications in preoperatively irradiated soft-tissue sarcomas of the extremities

PURPOSE

To determine whether the involvement of plastic surgery and the use of vascularized tissue flaps reduces the frequency of major wound complications after radiation therapy for soft-tissue sarcomas (STS) of the extremities.

METHODS AND MATERIALS

This retrospective study evaluated patients with STS of the extremities who underwent radiation therapy before surgery. Major complications were defined as secondary operations with anesthesia, seroma/hematoma aspirations, readmission for wound complications, or persistent deep packing.

RESULTS

Between 1996 and 2010, 73 patients with extremity STS were preoperatively irradiated. Major wound complications occurred in 32% and secondary operations in 16% of patients. Plastic surgery closed 63% of the wounds, and vascularized tissue flaps were used in 22% of closures. When plastic surgery performed closure the frequency of secondary operations trended lower (11% vs 26%; P=.093), but the frequency of major wound complications was not different (28% vs 38%; P=.43). The use of a vascularized tissue flap seemed to have no effect on the frequency of complications. The occurrence of a major wound complication did not affect disease recurrence or survival. For all patients, 3-year local control was 94%, and overall survival was 72%.

CONCLUSIONS

The rates of wound complications and secondary operations in this study were very similar to previously published results. We were not able to demonstrate a significant relationship between the involvement of plastic surgery and the rate of wound complications, although there was a trend toward reduced secondary operations when plastic surgery was involved in the initial operation. Wound complications were manageable and did not compromise outcomes.

Surgical site infection in malignant soft tissue tumors

BACKGROUND

Postoperative wound complications, including surgical site infections, which frequently occur in the course of management of musculoskeletal sarcomas, sometimes necessitate repeat surgeries, including amputation, and may result in a prolonged healing time, prolonged hospital stay, or fatal outcome. A comprehensive understanding of surgical site infections associated with specific diseases is needed to reduce the risk.

METHODS

This series comprised 84 patients with malignant soft tissue tumors treated at our institute. The occurrence rate, management modality and clinical course of surgical site infections, impact of surgical site infections on the length of hospitalization, risk factors for the development of surgical site infections, and the impact of surgical site infections on the oncological outcomes were analyzed. Surgical site infection was defined according to Centers for Disease Control and Prevention guidelines.

RESULTS

Surgical site infections occurred in 7 cases (8.3%). Although successful clinical cure was achieved in all cases, surgical site infection was identified as one of the independent risk factors for prolongation of hospitalization. Both univariate and multivariate analyses identified larger intraoperative blood loss and a trunk location as risk factors associated with deep infections. No association was detected between age, tumor grade, chemotherapy, tumor volume, or plastic surgery and the risk of surgical site infections. Although the differences were not statistically significant, patients with surgical site infections showed worse oncological outcomes in terms of local recurrence and total survival.

CONCLUSION

The incidence rate of surgical site infection was larger than that associated with conventional orthopedic surgeries, such as osteosynthesis, spine surgery, or arthroplasty. Surgical site infections remain a critical and frequent complication of surgical treatment of soft-tissue malignancies and often result in prolongation of hospital stay. Although practical options to prevent surgical site infections seem quite limited, the present data provide a rationale for perioperative evaluation in patients at a high risk of surgical site infections.

Side effects of radiation in musculoskeletal oncology: clinical evaluation of radiation-induced fractures

Radiation therapy and chemotherapy, while they remain an essential part of the multidisciplinary treatment of cancers, they have led to unwanted complications. Radiation-induced complications include wound and bone, growth, nervous system, tumorigenic, lung, gastrointestinal, hepatic and other complications. In this article we review the side effects of radiation therapy in musculoskeletal oncology emphasizing on bone, present our long experience, and discuss the current literature regarding radiation-induced bone complications and their management and outcome.

Complications of radiation therapy to the hand after soft tissue sarcoma surgery

PURPOSE

Radiation has been shown to improve local control after resection of soft tissue sarcomas. However, it may also result in major complications in the hand, given the compact nature of functional tissues and limited tissue volumes in the hand. The purpose of this investigation was to describe the hand-specific complications of radiation therapy for patients with soft tissue sarcoma of the hand (STSH).

METHODS

We performed a retrospective chart review of 55 consecutive patients with STSH treated by a single surgeon between 1993 and 2006. We identified 26 patients who were treated with external beam radiation, brachytherapy, or both, either preoperatively or postoperatively, and reviewed their clinical course.

RESULTS

After a median follow-up of 7 years, 29 treatment-related complications occurred in 19 patients who had received radiation, whereas 3 of the 29 patients treated with surgery alone developed complications. All patients who received brachytherapy and 14 of the 21 treated with external beam radiation alone developed complications. There were 5 early minor, 2 early major, 3 late minor, and 19 late major complications.

CONCLUSIONS

Patients with STSH who underwent radiation therapy had a high rate of complications. The complication rate in our series was higher in patients who had brachytherapy catheters placed adjacent to finger joints. A better understanding of predictors of complications will help to determine the optimal timing and type of radiation therapy to treat patients with STSH.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Radiotherapy for soft tissue sarcoma of the proximal lower extremity

Soft-tissue sarcoma (STS) is a histopathologically diverse group of tumors accounting for approximately 10,000 new malignancies in the US each year. The proximal lower extremity is the most common site for STS, accounting for approximately one-third of all cases. Coordinated multimodality management in the form of surgery and radiation is often critical to local control, limb preservation, and functional outcome. Based on a review of currently available Medline literature and professional experience, this paper provides an overview of the treatment of STS of the lower extremity with a particular focus on the modern role of radiotherapy.

Low-dose neoadjuvant external beam radiation therapy for soft tissue sarcoma

PURPOSE

For soft tissue sarcoma, neoadjuvant external beam radiation therapy (EBRT) to 50 Gy has the same local control (LC) and overall survival as postoperative radiation therapy (PORT) to 60 Gy, but with increased wound complications. We examined whether low-dose neoadjuvant EBRT would decrease acute toxicity while maintaining LC.

METHODS AND MATERIALS

From 1971 to 2008, 1,765 patients with nonmetastatic soft tissue sarcoma were treated with radiation therapy at Massachusetts General Hospital. We identified 42 patients treated with low-dose neoadjuvant EBRT (median, 20 Gy; range, 16-26) followed by surgical resection and PORT. PORT included EBRT (25 patients; median, 40 Gy; range, 20-56.2), brachytherapy (13 patients; median, 42 Gy; range, 26-50), and intraoperative radiation therapy (IORT) (4 patients; median, 12.5 Gy; range, 8-20). The median total dose was 63.3 Gy (range, 28-78.4).

RESULTS

Median follow-up was 36 months (range, 4-318). Severe acute wound complications were reported in 15 patients (36%) and correlated to PORT technique (16% EBRT, 69% brachytherapy, 50% IORT, p = 0.004). The 5-year LC was 73% and correlated to PORT technique (68% EBRT, 100% brachytherapy, 50% IORT, p = 0.03) and histology (p = 0.05), with a trend to improvement if >60 Gy (p = 0.10). The 5-year overall survival was 65% and correlated to extent of resection (p < 0.001) and margin status (p < 0.001).

CONCLUSIONS

Despite using low-dose neoadjuvant EBRT, we report a high rate of severe acute wound complications that was strongly associated with brachytherapy. Modification of the brachytherapy technique may decrease acute toxicity while maintaining excellent local control. Further study must be conducted before recommending broader application.

The significance of size change of soft tissue sarcoma during preoperative radiotherapy

AIM

To assess the significance of change in tumour size during preoperative radiotherapy in patients with soft tissue sarcoma (STS).

METHODS

A retrospective review of 91 cases with STS was performed. Inclusion criteria were localised extremity and truncal STS with measurable disease, older than 18 years, treated with preoperative radiotherapy and wide local excision, in the period between January 1966 and December 2005. Patients with head and neck STS, or who received neoadjuvant chemotherapy were excluded. A difference in excess of 10% of the greatest tumour diameter of the pre-radiotherapy and the post-radiotherapy MRI scans was considered as change in tumour size.

RESULTS

Increase in tumour size was noted in 28 patients (31%) (Group 1). No change or decrease in size was observed in 63 patients (Group 2). There were no significance differences in local control or overall survival rates between the 2 groups. The estimated overall actuarial local recurrence free, event-free and overall survival rates were 90.5%, 64.4%, 62.9% in Group 1, and 85.7%, 60.8%, 68.9% in Group 2 respectively.

CONCLUSION

Increase in tumour size during preoperative radiotherapy for soft tissue sarcoma does not seem to associate with inferior local tumour control or compromise survival. Lack of reduction in tumour size is not necessarily a sign of lack of response to preoperative radiotherapy.

Limb salvage in malignant tumors

Limb-sparing resection and reconstruction has become the treatment of choice in extremity malignancies, as amputation does not provide better long-term survival rates or functional advantages. R0 resection, the removal of the tumor in sano, remains the prerequisite and most important oncologic parameter to avoid local recurrence. Successful treatment requires the combination of surgical eradication and the patient's specific functional and aesthetic rehabilitation. Our clinical rationale resulting from more than 2000 cases will be demonstrated. The problematic aspects of different tumor entities and the locoregional clearance of lymphatic pathways will be discussed. Differential diagnosis and multimodality treatment in high-volume tumor centers is likely to achieve superior oncologic statistics. Long-term survivors after microsurgical reconstructions and possible secondary malignancies will be addressed.

Dynamics of micronuclei in rat skin fibroblasts after X irradiation

In a previous study, we demonstrated DNA damage, expressed as micronuclei, in binucleate dermal fibroblasts obtained from human skin 2-9 weeks after fractionated radiotherapy. Here we assessed micronuclei in X-irradiated skin fibroblasts from 9-14-week-old female Lewis rats as a function of time after a single dose of radiation to determine the lifetime of such damage in the skin. After irradiation with 5, 10, 15 and 18 Gy, formation of micronuclei at 1 day or 2 months postirradiation increased up to about 10 Gy, with evidence for a plateau at higher doses. The time course of micronuclei present in the skin fibroblasts demonstrated a plateau region (approximately 20 days after 18 Gy and about 2 months after 10 Gy) before the number of micronuclei started to decline. Residual micronuclei were observed for more than 1 year after irradiation. Monomicronucleated cells predominated in fibroblasts from nonirradiated skin, whereas in fibroblasts from irradiated skin, multimicronucleated cells predominated and persisted (together with monomicronucleated cells) in the residual levels of damage at late times. The results suggest that DNA damage in dermal fibroblasts can be assayed by the micronucleus assay in samples from irradiated skin up to 1 month after irradiation for doses up to at least 10 Gy. Further studies are needed to define the dose-response relationship in detail.

The effect of neutron radiation on conventional and highly cross-linked ultrahigh-molecular-weight polyethylene wear

The effects of a sarcoma therapy dose level neutron radiation on oxidation and wear were compared between conventional (N2\Vac, Stryker Orthopedics, Mahwah, NJ) and highly cross-linked (Crossfire, Stryker Orthopedics) ultrahigh-molecular-weight polyethylene acetabular liners. Liners were exposed to 15 Gy, a typical sarcoma treatment dose. Wear testing was conducted on a hip simulator. Transvinylene and oxidation indices were measured to determine if significant radiolytic reactions and oxidation occurred after the neutron beam exposure. The neutron bombardment produced further oxidation in both N2\Vac and Crossfire liners. Surprisingly, neutron radiation caused 62% increase in wear for N2\Vac but 0% change for the Crossfire acetabular liners. This study suggested that when joint implants are exposed to neutron beam radiation therapy, the conventional polyethylene liner is at risk for rapid wear.