Reconstruction after soft tissue sarcoma resection in the setting of brachytherapy: a 10-year experience

Single-Stage Free Flap Reconstruction Following Extremity Sarcoma Resection: a Regional Cancer Center Experience

Surgery remains mainstay modality of treatment of STS of extremity. In majority of patients, primary closure is possible following surgical resection of the tumor. Primary closure of wound may not be feasible in tumors with large area of skin involvement and sometimes following a whoops procedure. We analyzed postoperative complications and oncological outcomes in patients who underwent free flap reconstruction. Thirty-seven patients who required a free flap for reconstruction of the defect following resection of the STS were included in the study. There were 26 men and 11 women with a mean age of 40 years. Seventy-three percent tumors were in lower limb; 62% patients had undergone a whoops procedure elsewhere. Flaps were fasciocutaneous in 19, myocutaneous in 15, and free muscle transfers in 3 patients. Seventeen patients had early surgical site complications. Nine patients had early flap failures. Of the 9, 6 patients had total loss of flap and in 3 the flaps were salvaged. Two patients had partial loss (< 50% of total area) of flap. Four patients had edge necrosis and two had suture diastasis. Nine patients had late surgical site complications. Four had post-radiotherapy wound dehiscence. Late SSI was noted in two. Late joint contracture and chronic lymphedema was seen in one patient each. One died due to sepsis. Statistically significant association was not found between patient, tumor or treatment-related factors and complications or flap failures. Mean duration of surgery was 7.73 h. Twenty-three patients required multiple surgeries due to complications. Mean time to initiate adjuvant therapy from the date of surgery was 47 days. Mean OS of the group was 67 ± 7.3 months. Mean RFS was 58 ± 7.8 months. Single-stage free flap reconstruction following surgical resection of extremity sarcoma is a viable option of reconstruction while salvaging the limb. Though associated with high rate of early surgical site complications, they are manageable.

CivaSheet® use for soft tissue sarcoma: A single institution experience

OBJECTIVE

CivaSheet is a palladium-103, implantable, intraoperative radiation therapy device which emits unidirectional radiation that enables boost doses in patients who have otherwise received the maximum radiation dose. Here, we present our initial clinical experience with the first 10 cases using this new technology.

METHODS AND MATERIALS

A retrospective chart review of all patients with STS treated with surgical resection and CivaSheet placement at the University of Miami Hospital, a tertiary care center, from January 2018 to December 2019, was performed. Adjuvant radiation was administered by a palladium-103 implant, which delivered an average of 47 Gy (35-55) to a depth of 5 mm.

RESULTS

Nine patients underwent CivaSheet placement from January 2018 until December 2019 for a total of 10 CivaSheets placed (1 patient had 2 CivaSheets inserted) and followed for a mean of 27 months (4-45 months). Four tumors were located in the retroperitoneum, two in the chest, two in the groin, and two within the lower extremity. At the time of tumor resection and CivaSheet placement, tumor sizes ranged from 2.5 cm to 13.8 cm with an average of 7.6 cm. Four patients necessitated musculocutaneous tissue flaps for closure and reconstruction. All patients with Grade 4 complications had flap reconstruction and prior radiation. Four patients' tumors recurred locally for a local recurrence rate of 40%. Three patients had modified accordion Grade 4 complications necessitating additional surgery for CivaSheet removal. Extremity tumors unanimously developed modified accordion Grade 4 adverse events.

CONCLUSIONS

CivaSheet may be an acceptable alternative treatment modality compared to prior brachytherapy methods.

Concomitant upper extremity soft tissue sarcoma limb-sparing resection and functional reconstruction: assessment of outcomes and costs of surgery

BACKGROUND

The purpose of this study is to investigate functional outcomes and cost impacts of immediate functional reconstruction performed in conjunction with limb-sparing resection of upper extremity soft tissue sarcomas.

METHODS

Patients undergoing simultaneous limb-sparing upper extremity soft tissue sarcoma resection and functional reconstruction between December 1998 and March 2004 were retrospectively identified, their medical records reviewed, and costs of surgery analyzed. Functional outcomes and patient satisfaction were assessed via patient surveys and the Toronto Extremity Salvage Score (TESS).

RESULTS

Thirteen patients met the inclusion criteria. Average follow-up was 43.3 months. Reconstructions included rotational innervated muscle flaps (n = 6), free innervated myocutaneous flaps (n = 1), and tendon transfers or grafts (n = 6). Overall survival was 85 % (n = 11) and disease-free survival was 77 % (n = 10). Average total cost of surgery was $26,655. Patients undergoing reconstruction for hand and forearm sarcomas had significantly higher total costs of surgery than those undergoing reconstruction for elbow and upper arm sarcomas. Survey response rate was 91 % (n = 10). Average TESS score was 76. Of the patients who worked preoperatively, 88 % returned to work postoperatively, and all patients who returned to work currently use their affected limb at work.

CONCLUSIONS

Patients undergoing immediate functional reconstruction for upper extremity soft tissue sarcoma resection achieved very good to excellent functional outcomes with quick recovery times and a high return-to-work rate following immediate functional reconstruction, thereby minimizing surgical cost impacts. Immediate functional reconstruction in the same surgical setting is thus a viable strategy following upper extremity soft tissue sarcoma resection.

The pedicled myocutaneous flap as a choice reconstructive technique for immediate adjuvant brachytherapy in sarcoma treatment

Successful treatment of soft-tissue sarcomas is highly dependent on total tumour resection coupled with adjuvant radiation therapy to achieve local control and decrease recurrence. Reconstruction of soft-tissue defects after resection aims to cover vital structures, while providing enough stable tissue to withstand adjuvant brachytherapy treatment. In the present study, pedicled myocutaneous flaps were used as a vital adjunct in the treatment of soft-tissue sarcoma, and our experience with 2 such patients is described. The flaps served to reconstruct large three-dimensional defects while providing stable coverage over brachytherapy hardware to allow for delivery of radiation in the immediate postoperative period. Pedicled locoregional myocutaneous flaps provide a safe, easy, and reliable reconstructive technique in the treatment of soft-tissue sarcoma.

Early complications of high-dose-rate brachytherapy in soft tissue sarcoma: a comparison with traditional external-beam radiotherapy

BACKGROUND

Radiotherapy and surgery are routinely utilized to treat extremity soft tissue sarcoma. Multiple radiation modalities have been described, each with advantages and disadvantages, without one modality demonstrating clear superiority over the others.

QUESTIONS/PURPOSES

We determined the overall initial complication rate in patients receiving surgery and radiotherapy, which specific complications were found when comparing different modalities, and whether combination therapy increased the overall rate of complications compared with surgery and single-modality radiotherapy.

PATIENTS AND METHODS

We retrospectively reviewed the records of 190 patients who received external-beam radiotherapy (141 patients), high-dose-rate brachytherapy (37 patients), or both (12 patients). We evaluated 100 men and 90 women (mean age, 57 years; range, 18-94 years) for tumor size and subtype, comorbidities, stage, grade, margin of resection, type of adjuvant treatment, and complications. Minimum followup was 3 months (mean, 40 months; range, 3-155 months).

RESULTS

The most frequent early complications in the high-dose-rate brachytherapy cohort were infection, cellulitis, and seroma and/or hematoma. In the external-beam radiotherapy cohort, chronic edema, fibrosis, and chronic radiation dermatitis were more frequently encountered. The total number of early complications and overall incidence of major complications requiring further surgery were similar among the three cohorts, but a larger number of patients in the high-dose-rate brachytherapy group required subsequent surgery for infection compared with the external-beam radiotherapy group.

CONCLUSIONS

High-dose-rate brachytherapy decreases radiation exposure and allows shorter duration of treatment compared with traditional external-beam radiotherapy but has a higher perioperative wound complication rate.

LEVEL OF EVIDENCE

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

The management of soft tissue sarcoma

SUMMARY

Soft tissue sarcomas are a rare group of mesenchymal tumours that display cardinal signs, which can raise suspicion to their diagnosis. Management in a sarcoma treatment centre by its multidisciplinary team has improved outcome. Good local disease control with limb salvage and adjuvant radiotherapy has considerably reduced the morbidity of previous limb amputation. By the early involvement of a plastic surgeon, tissue reconstruction is optimised and wound complications reduced. This article looks at the contemporary management of soft tissue sarcoma and, in particular, its relevance to the plastic surgeon today.

Outcomes of skin graft reconstructions with the use of Vacuum Assisted Closure (VAC(R)) dressing for irradiated extremity sarcoma defects

Background

Flaps are currently the predominant method of reconstruction for irradiated wounds. The usefulness of split-thickness skin grafts (STSG) in this setting remains controversial. The purpose of this study is to examine the outcomes of STSGs in conjunction with VAC therapy used in the treatment of irradiated extremity wounds.

Methods

The records of 17 preoperatively radiated patients with extremity sarcomas reconstructed with STSGs in conjunction with VAC^® therapy were reviewed regarding details of radiation treatment, wound closure, and outcomes.

Results

STSGs healed without complications (>95% of the graft take) in 12 (71%). Minor loss (6% – 20% surface) was noted in 3 patients (17.6%) and complete loss in 2 (11.7%). Two patients (11.7%) required flap reconstructions and 12 (88%) healed without further operative procedures.

Conclusion

Although flap coverage is an established treatment for radiated wounds, STSG in conjunction with liberal utilization of VAC therapy is an alternative for selected patients where acceptable soft tissue bed is preserved. Healing of the preoperatively radiated wounds can be achieved in the vast majority of such patients with minimal need for additional reconstructive operations.

Go for the jugular: a 10-year experience with end-to-side anastomosis to the internal jugular vein in 320 head and neck free flaps

Preferential use of end-to-side anastomosis to the internal jugular vein in head and neck reconstruction offers distinct advantages and has consistently yielded excellent outcomes. Presented is a series of 320 consecutive cases by a single surgeon at 1 institution over 10 years. The most common flaps employed were the rectus (33%), forearm (28%), and fibula (21%) flaps. The most common defects were the mandible +/- floor of mouth (27%), pharyngoesophagus (25%), and tongue or cheek (17% each). Minor wound-healing problems, infection, and hematoma were noted in 5% or less. Partial flap loss was seen in 2%. Total flap loss and arterial or venous thrombosis occurred in less than 1% of patients. The size, constant anatomy, patency, and possibility for multiple anastomoses make use of the internal jugular vein very advantageous. Kinking is not observed when the neck is rotated, and high patency rates can be expected.

[Brachytherapy for soft tissue sarcomas. Technique and therapeutic indications]

The role of brachytherapy in the therapeutic strategy of soft tissue sarcomas has been difficult to assess due to the fact it has been during a long time institution-specific. However, the experience gained specially with low dose-rate treatments has allowed formulating guidelines for technical rules and patient selection. Brachytherapy used as an isolated treatment combined with surgery has proven to be effective in high-grade sarcomas, compared to surgery alone, in a unique randomized trial. Beside, a number of data have shown that the combination of brachytherapy and external beam irradiation could be superior to brachytherapy or external beam irradiation alone in the treatment of tumors with high-grade, or central location, locally advanced or on contact with neurovascular structures. Brachytherapy alone, combined with surgery, is of interest for conservative treatment of recurrent sarcomas occurring in previously irradiated areas. The occurrence of side effects remains acceptable if technical guidelines are followed, for surgery as well as for brachytherapy, using the most modern available treatment techniques. Brachytherapy should be at the moment an integrated part of the multidisciplinary treatment of soft tissue sarcomas.