A technique for nerve reconstruction following resection of soft-tissue sarcoma

A systematic review of functional outcomes after nerve reconstruction in extremity soft tissue sarcomas: A need for general implementation in the armamentarium

Resection of nerves in extremity soft tissue sarcomas (STS) can lead to large functional deficits. Nerve reconstructions are rarely performed and little is known on their outcomes and indications for their use, even though they are essential in restoring sensation in limb salvage procedures. This study investigated current knowledge on functional outcomes and considerations to be taken before performing such reconstructions after sarcoma resection. A systematic search was performed in July 2018 in PubMed and Embase databases according to PRISMA guidelines. Search terms related to "soft tissue sarcoma" and "nerve reconstruction" were used. Studies evaluating functional outcomes after nerve grafting or nerve transfers in extremity STS were included. Qualitative synthesis was performed on all studies. Nineteen studies were included after full-text screening, describing 26 patients. The majority of patients had a nerve reconstruction in the upper extremity (65%). Perioperative radiotherapy was administered in 67% and perioperative chemotherapy in 29% of patients. Nerve grafting was most commonly performed (n = 23) and nerve transfers were performed in six patients. A wide variety of outcome measures were used. Most patients recovered at least some motor function and sensation, but success rates were higher after upper than lower extremity defects. Multimodal treatment did not preclude successful reconstructions. Nerve reconstructions in extremity STS allow the restoration of sensation in limb salvation, even motor nerve function can be restored with satisfactory function. The use of multimodal therapy does not seem to interfere with success. Nerve reconstructions should therefore be considered in STS patients.

Surgical considerations when reporting MRI studies of soft tissue sarcoma of the limbs

Soft tissue sarcomas (STS) are rare tumours that require prompt diagnosis and treatment at a specialist centre. Magnetic resonance imaging (MRI) has become the modality of choice for identification, characterisation, biopsy planning and staging of soft tissue masses. MRI enables both the operating surgeon and patient to be optimally prepared prior to surgery for the likelihood of margin-negative resection and to anticipate possible sacrifice of adjacent structures and consequent loss of function. The aim of this review is to aid the radiologist in performing and reporting MRI studies of soft tissue sarcomas, with particular reference to the requirements of the surgical oncologist.

Reconstructive treatment of soft tissue sarcoma of the upper extremity

Limb-sparing surgery is currently the cornerstone of treatment for most patients with soft-tissue sarcoma of the upper extremity. To achieve the best outcome, the reconstructive surgeon must be part of a multidisciplinary team and is required to have a thorough understanding of the whole treatment concept. This article provides an update for the current surgical management of patients with soft tissue sarcoma of the upper extremity. Relevant nonsurgical aspects are also highlighted.

Complete femoral nerve resection with soft tissue sarcoma: functional outcomes

BACKGROUND

The functional consequences of resecting the femoral nerve in conjunction with soft tissue sarcoma management are not well described. In comparison, sciatic nerve involvement by sarcoma was once considered an indication for amputation, but sciatic resection is now commonly performed as part of a limb-salvage approach. We compared functional outcomes following resection of either the femoral or sciatic nerve in patients with soft tissue sarcoma. We also compared both groups with patients with large thigh sarcomas without nerve involvement.

METHODS

The prospectively collected database from a tertiary referral center for sarcomas was retrospectively reviewed to identify all patients with resection of the femoral nerve performed during wide excision of a soft tissue sarcoma. Patient demographics, treatment, complications, and functional outcomes in the form of the Musculoskeletal Tumor Society (MSTS) 1987 score, MSTS 1993 score, and Toronto Extremity Salvage Score (TESS) were collected. Control groups of sarcoma patients with sciatic nerve resection in the thigh as well as similarly sized tumors in the quadriceps requiring no nerve resections were also analyzed.

RESULTS

Ten patients with femoral nerve resections were identified, all women, aged 47-78 years, with large soft tissue sarcomas of varied subtypes. All patients received adjuvant radiotherapy, most preoperatively. Six patients developed fractures during long-term follow-up, four in nonirradiated portions of the skeleton but directly from falls related to absent active knee extensors, and two at least partially attributable to sequelae of radiation. MSTS 1987 hip scores demonstrated one excellent, four good, and five fair results. MSTS 1993 hip scores averaged 71.4 +/- 17.2% and TESS averaged 61.7 +/- 21.8. There were no significant differences between the functional scores for patients with femoral or sciatic nerve resections (P = 1.0).

CONCLUSIONS

Femoral nerve resection appears more morbid than anticipated. The falls to which patients were prone, even years after surgery, subject them to ongoing long-term risks for fractures and other injuries. These nerve-specific functional implications should be considered when counseling patients in preparation for possible resection of the femoral nerve when it is directly involved by a soft tissue sarcoma.

Peripheral nerve considerations in the management of extremity soft tissue sarcomas

Evaluation of peripheral nerves, both clinically and with imaging, is critical in the evaluation of patients with extremity soft tissue sarcomas. If an essential peripheral nerve is felt to be adjacent to a soft tissue sarcoma but not circumferentially surrounded, it can usually be salvaged using the technique of epineural dissection in the setting of adjuvant radiation. If, however, a critical nerve is circumferentially involved with tumor, it must be sacrificed for the sake of local control. Various reconstruction techniques are available in this situation, including nerve grafting, distal nerve transfer, and tendon transfer, with each technique having specific indications. Regardless of the technique, it is important to inform the patient that normal extremity function is not likely to be achieved. The issue of nerve involvement therefore becomes a critical factor in determining the possibility of limb salvage in borderline cases. For the situation in which postoperative function is already expected to be compromised due to vascular, bone, or extensive soft tissue resection, nerve resection may be the ultimate deciding factor in recommending amputation rather than limb salvage.

Resection of the sciatic, peroneal, or tibial nerves: assessment of functional status

BACKGROUND

Lower-extremity tumors are often treated by amputation rather than limb-sparing excision that sacrifices the sciatic nerve or a branch. This study assessed the functional outcome of major nerve sacrifice during limb-sparing resections for lower-extremity soft tissue sarcoma.

METHODS

Patients who underwent division of the sciatic, tibial, or peroneal nerve(s) during limb-sparing sarcoma surgery (January 1982 through June 2000) were identified. Eleven surviving patients evaluated their pre- and postoperative functional status by self-administered questionnaire (six sciatic, two tibial, and three peroneal nerve divisions).

RESULTS

Eighteen patients (10 male, 8 female; 14-84 years old) had nine primary and nine locally recurrent tumors. Tumors were high (16) or low grade (two). Five patients died of disease and two died of other causes. Median overall survival was 50 months. One of 11 reported increased pain. Eight had new phantom sensations with a median intensity of 4.5 (1 = least; 10 = most). All patients used an ankle brace to walk after a sciatic (four) or peroneal (one) division. Walking ability and distance after surgery was unchanged (nine), improved (one), and worsened (one). Standing improved in 7 of 11 patients. Proprioception in the affected extremity was retained in six. The median postoperative leg functional score was 8 (1 = worst; 10 = best). No patient developed foot ulcers. One patient underwent amputation for recurrence. All patients preferred their status over having an amputation.

CONCLUSIONS

Objectively and subjectively, division of the major lower-extremity nerves causes acceptable functional deficits in most patients. Resection of affected sciatic nerve (branches) during limb-sparing tumor surgery is an excellent alternative to amputation.

Acute nerve grafting in traumatic injuries: two case studies

Primary nerve grafting in traumatic injuries is rarely performed because of the uncertainty of the extent of injury, the limited availability of nerve grafts, and the damage to adjacent soft tissue. In this report the authors present two cases of acute nerve grafting after trauma-the first of the common peroneal nerve and the second of the ulnar nerve above the elbow-with sensory and motor recovery. Although compelling general arguments against primary posttraumatic nerve grafting exist, these cases illustrate that, in certain favorable and critical clinical situations, acute nerve grafting may be successful.

Sciatic nerve reconstruction: limb preservation after sarcoma resection

Limb salvage for extremity sarcoma has become the standard of care when possible. This review attempts to determine the outcome of sciatic nerve reconstruction after surgical tumor resection. The authors' objective was to determine the clinical value of extremity salvage with such a defect. Five patients (two male, three female) were selected from a department database at The University of Texas M.D. Anderson Cancer Center between 1995 and 1999 who met the following criteria: lower limb tumor resection involving a gap in the sciatic nerve with subsequent nerve autograft reconstruction. An additional patient who underwent primary sciatic nerve neurorrhaphy was also included. The average tumor size was 203 cm2. The most common tumor histology was spindle cell sarcoma. The average autograft length was 13 +/- 3.2 cm with one to four cables employed. Currently, 3 patients are still alive. Four of the 5 patients who received sciatic autonerve grafts reported partial distal sensory recovery subjectively. The patient who underwent primary neurorrhaphy has both motor and sensory innervation 42 months after surgery. Although not ideal for all patients, sciatic nerve reconstruction is a viable option for those willing to undergo limb preservation. Notable limitations to daily activity do not appear to be present, and patients are able to ambulate with or without assistive devices. With aggressive rehabilitation, some patients are able to function quite well with this bioprosthesis. Patients should consider, however, that their extremity is on loan. Substantial wound complications or infections may ultimately lead to amputation.