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Brunetti B, Salzillo R, De Bernardis R, Petrucci V, Pazzaglia M, Camilloni C, Putti A, Morelli Coppola M, Tenna S, Persichetti P. Lower Abdominal vs. Lateral Thigh Perforator Flaps in Microsurgical Sarcoma Reconstruction: The Aesthetics of Donor Site Matters. J Clin Med 2024; 13:3622. [PMID: 38930149 PMCID: PMC11204950 DOI: 10.3390/jcm13123622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/05/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Introduction: Sarcoma resection often leaves patients with big defects only amenable through microsurgical reconstruction. In such cases, it is hard for the surgeon to uphold low donor-site morbidity with an aesthetic result. The purpose of this study was to investigate the clinical outcome and the patient's perception regarding the donor site in a cohort of patients undergoing microsurgical reconstruction with lateral thigh and lower abdominal perforator flaps. Methods: A retrospective evaluation of all patients who underwent sarcoma reconstruction with flaps harvested from the lower abdominal region (deep inferior epigastric artery perforator flap, superficial circumflex iliac artery perforator flap) or lateral thigh region (anterolateral thigh perforator flap and its variations) was performed. Only patients with defects greater than 100 cm2 were included. Patient demographics and operative variables were recorded, together with complications. Patient satisfaction and quality of life with the donor site were registered using the SCAR-Q questionnaire, which was administered at least six months post-operatively. Results: Eighteen anterolateral thigh (ALT) perforator flaps and twenty-two deep inferior epigastric artery perforator (DIEP) and superficial circumflex iliac artery perforator (SCIP) flap procedures were performed. The two groups were homogeneous for major post-operative complications (p > 0.999). Patient satisfaction with the donor site measured using the SCAR-Q questionnaire showed significantly higher scores in the DIEP/SCIP group when compared with the thigh group (p < 0.001), indicating a superiority of the lower abdominal area as an aesthetic donor site. Conclusions: The DIEP and SCIP flaps are a versatile option for reconstructing large soft-tissue defects following sarcoma resection. Therefore, flaps harvested from the lower abdomen yield a higher patient satisfaction with the donor site, which is a feature worth considering when planning a reconstructive procedure.
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Affiliation(s)
| | - Rosa Salzillo
- Department of Plastic, Reconstructive and Aesthetic Surgery, Fondazione Policlinico Universitario Campus Bio-Medico di Roma, 00128 Rome, Italy; (B.B.); (R.D.B.); (V.P.); (M.P.); (C.C.); (A.P.); (M.M.C.); (S.T.); (P.P.)
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Wu SA, deVries JA, Plantz MA, Dumanian G, Attar S, Ko JH, Peabody TD. Immediate Plastic Surgery Intervention after Soft Tissue Sarcoma Resection: Examining Wound Healing, Readmission, and Reoperation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4988. [PMID: 37305195 PMCID: PMC10256372 DOI: 10.1097/gox.0000000000004988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/16/2023] [Indexed: 06/13/2023]
Abstract
Many orthopedic and surgical oncologists use a multidisciplinary approach to soft tissue sarcoma (STS) resection. This study assesses the role of immediate plastic surgeon involvement during index soft tissue sarcoma resection. Methods Adult patients who underwent index STS resection between 2005 and 2018 were queried from an institutional database. Main outcomes analyzed were 90-day same-site reoperation, any-cause readmission, and wound healing complications. Univariate and multivariate logistic regression were used to identify risk factors. Additional evaluation was then performed for the following two cohorts: patients with and without plastic surgeon involvement. Results In total, 228 cases were analyzed. Multivariate regression demonstrated the following predictors for 90-day wound-healing complications: plastic surgery intervention [OR = 0.321 (0.141-0.728), P = 0.007], operative time [OR = 1.003 (1.000-1.006), P = 0.039], and hospital length of stay [OR = 1.195 (1.004-1.367), P = 0.010]. For 90-day readmission, operative time [OR = 1.004 (1.001-1.007), P = 0.023] and tumor stage [OR = 1.966 (1.140-3.389), P = 0.015] emerged as multivariate predictors. Patients whose resection included a plastic surgeon experienced similar primary outcomes despite these patients having expectedly longer operative times (220 ± 182 versus 108 ± 67 minutes, P < 0.001) and hospital length of stay (3.99 ± 3.69 versus 1.36 ± 1.97 days, P < 0.001). Conclusions Plastic surgeon involvement emerged as a significant protector against 90-day wound healing complications. Cases that included plastic surgeons achieved similar complication rates in all categories relative to cases without plastic surgery intervention, despite greater operative time, hospital length of stay, and medical complications.
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Affiliation(s)
- Scott A. Wu
- From the Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - John A. deVries
- Department of Orthopaedic Surgery, University of Nevada Las Vegas, Las Vegas, Nev
| | - Mark A. Plantz
- From the Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Gregory Dumanian
- Department of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Samer Attar
- Department of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Jason H. Ko
- Department of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Terrance D. Peabody
- From the Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Simman R, Bach K, Abbas F, Klomparens K, Brickman BJ. Management of Radiation-induced Tissue Injuries: A Review of Current Treatment Strategies. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5043. [PMID: 37456134 PMCID: PMC10348732 DOI: 10.1097/gox.0000000000005043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 04/10/2023] [Indexed: 07/18/2023]
Abstract
Although radiation therapy remains an integral component in cancer treatment, the sequela of tissue damage can result in long-term morbidity and mortality for patients. This article aimed to perform a comprehensive review of the current literature for both nonsurgical and surgical management strategies for radiation-induced injuries. Methods A literature search was performed on PubMed to review the current described management and treatment options for radiation-induced injuries. Patient demographics, medical diagnoses, complications, strategies of management care, and outcomes were reviewed. Results The most commonly described management options and reconstructive techniques of radiation wounds were analyzed and reported. Conclusions Consideration of current techniques and outcomes in the management of radiation-induced wounds demonstrates that impaired wound healing remains a major problem. This literature review provides a detailed overview of the most frequently used therapies with recommendations for surgeons.
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Affiliation(s)
- Richard Simman
- From the Department of Surgery, Jobst Vascular Institute, ProMedica Health Network, Toledo, Ohio
- Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio
| | - Karen Bach
- Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio
| | - Fuad Abbas
- Department of Surgery, Wayne State School of Medicine, Detroit, Mich
| | - Kara Klomparens
- Department of Surgery, Wayne State School of Medicine, Detroit, Mich
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Thomas B, Bigdeli AK, Nolte S, Gazyakan E, Harhaus L, Bischel O, Lehner B, Egerer G, Mechtersheimer G, Hohenberger P, Horch RE, Andreou D, Schmitt J, Schuler MK, Eichler M, Kneser U. The Therapeutic Role of Plastic and Reconstructive Surgery in the Interdisciplinary Treatment of Soft-Tissue Sarcomas in Germany-Cross-Sectional Results of a Prospective Nationwide Observational Study (PROSa). Cancers (Basel) 2022; 14:cancers14174312. [PMID: 36077847 PMCID: PMC9454490 DOI: 10.3390/cancers14174312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The mainstay of soft-tissue-sarcoma treatment remains ablative surgery with complete tumor resection. In this context, reconstructive plastic surgery has become an important aspect of multidisciplinary sarcoma therapy aiming at limb preservation as an alternative to amputations. In this present study, cross-sectional data collected prospectively at 39 study centers across Germany were analyzed, focusing on both the inhouse availability of plastic surgery and external accessibility to plastic surgery in 621 cases. In summary, unplanned and incomplete primary tumor resections carried out at centers with lower degrees of specialization were associated with a significantly increased need for subsequent flap-based defect coverage. In line with this, a readily available team of plastic surgeons was independently associated with successful defect reconstruction, which in turn was associated with significantly higher chances of limb preservation. We conclude that easily accessible plastic surgery and a high degree of expertise in the field of sarcoma treatment are indispensable for limb preservation following sarcoma resection. Plastic and reconstructive surgery therefore plays a vital role in achieving the best possible outcomes in the interdisciplinary treatment of soft-tissue sarcomas. Abstract Although the involvement of plastic surgery has been deemed important in the treatment of sarcoma patients to avoid oncological compromises and ameliorate patient outcomes, it is not ubiquitously available. The accessibility of defect reconstruction and its therapeutic impact on sarcoma care is the subject of this analysis. Cross-sectional data from 1309 sarcoma patients were collected electronically at 39 German study centers from 2017 to 2019. A total of 621 patients with surgical treatment for non-visceral soft-tissue sarcomas were included. The associated factors were analyzed exploratively using multifactorial logistic regression to identify independent predictors of successful defect reconstruction, as well Chi-squared and Cochran–Mantel–Haenszel tests to evaluate subgroups, including limb-salvage rates in extremity cases. A total of 76 patients received reconstructive surgery, including 52 local/pedicled versus 24 free flaps. Sarcomas with positive margins upon first resection (OR = 2.3, 95%CI = 1.2–4.4) that were excised at centers with lower degrees of specialization (OR = 2.2, 95%CI = 1.2–4.2) were independently associated with the need for post-oncological defect coverage. In this context, the inhouse availability of plastic surgery (OR = 3.0, 95%CI = 1.6–5.5) was the strongest independent predictor for successful flap-based reconstruction, which in turn was associated with significantly higher limb-salvage rates (OR = 1.4, 95%CI = 1.0–2.1) in cases of extremity sarcomas (n = 366, 59%). In conclusion, consistent referral to specialized interdisciplinary sarcoma centers significantly ameliorates patient outcomes by achieving higher rates of complete resections and offering unrestricted access to plastic surgery. The latter in particular proved indispensable for limb salvage through flap-based defect reconstruction after sarcoma resection. In fact, although there remains a scarcity of readily available reconstructive surgery services within the current sarcoma treatment system in Germany, plastic and reconstructive flap transfer was associated with significantly increased limb-salvage rates in our cohort.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Steffen Nolte
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Oliver Bischel
- Department of Trauma and Orthopedics, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
| | - Burkhard Lehner
- Department of Orthopaedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Gerlinde Egerer
- Department of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | | | - Peter Hohenberger
- Division of Surgical Oncology, Department of Surgery, Mannheim University Medical Center, University of Heidelberg, 68167 Mannheim, Germany
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Dimosthenis Andreou
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Münster, 48149 Münster, Germany
- Department of Orthopedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Jochen Schmitt
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Center for Evidence-based Healthcare, University Hospital Carl Gustav Carus, Technical University Dresden, 01307 Dresden, Germany
| | - Markus K. Schuler
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Martin Eichler
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
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Sheoran A, Garg A, Yadav U, Kundu ZS, Sherawat R, Singla M, Nemani M, Wason D, Kulaar HS, Singha SB. Outcomes of Wide Resection of Soft-Tissue Sarcoma of the Extremity: A Retrospective Analysis. Cureus 2022; 14:e27329. [PMID: 36042997 PMCID: PMC9413370 DOI: 10.7759/cureus.27329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/29/2022] Open
Abstract
Background Soft-tissue sarcomas (STSs) are a rare heterogeneous group of tumors. Good functional results can be achieved with tumor excision in combination with suitable supplemental adjuvant therapies if needed. This study aimed to investigate the outcomes of wide resection of STS of the extremities. Methodology In this retrospective study, a total of 139 patients diagnosed with STS of the extremities by radiological and/or histopathological study/biopsy were included. All patients irrespective of metastasis were included. Results The mean age of the patients in our study was 43.5 ± 18.89 years. Overall, the mean tumor size was found to be 11.81 ± 6.218 cm. Malignant fibrous histiocytoma was the most common histology encountered (41%). Synovial sarcoma was the second most common histology encountered (14.38%). Recurrence was observed in 14 (10.1%) patients. The overall survival was 64.7% in our study. Conclusions The surgical margin achieved during the surgery is the most detrimental factor in local tumor control, and the overall survival of the patient after resection mainly depends on the stage of the tumor.
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Martin E, Pendleton C, Verhoef C, Spinner RJ, Coert JH. Morbidity and Function Loss After Resection of Malignant Peripheral Nerve Sheath Tumors. Neurosurgery 2022; 90:354-364. [PMID: 34528095 DOI: 10.1093/neuros/nyab342] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/16/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive soft tissue sarcomas. Their resection may lead to serious morbidity. Incidence of postoperative motor and sensory deficits is unknown, and reconstruction aimed at restoring such deficits is infrequently carried out. OBJECTIVE To identify the incidence and risk factors of postoperative morbidity in MPNST as well as the use and outcomes of functional reconstructions in these patients. METHODS Postoperative function and treatment of MPNSTs diagnosed from 1988 to 2019 in 10 cancer centers was obtained. Two models were constructed evaluating factors independently associated with postoperative motor (<M3) or critical sensory loss. Critical sensation was defined as partial or complete loss of hand, foot, or buttocks sensation. RESULTS A total of 756 patients (33.4% neurofibromatosis type 1, NF1) were included. MPNSTs originated in 34.4% from a major nerve. Of 658 surgically treated patients, 27.2% had <M3 muscle power and 24.3% critical sensory loss. Amputations were carried out in 61 patients. Independent risk factors for motor and sensory loss included patients with NF1, symptomatic, deep-seated, extremity, or plexus tumors originating from major nerves (all P < .05). A total of 26 patients underwent functional reconstructions. The majority (64%) of these patients regained at least M3 muscle power and 33% M4 despite 86% receiving multimodal therapy. CONCLUSION Resection of MPNSTs commonly results in motor and sensory deficits. Patients with NF1, symptomatic, deep-seated tumors, arising from major nerves were associated with a higher risk for developing postoperative morbidity. Functional reconstructions are infrequently performed but can improve functional outcomes.
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Affiliation(s)
- Enrico Martin
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht , the Netherlands
- Department of Surgical Oncology, Erasmus Medical Center , Rotterdam , the Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Center , Rotterdam , the Netherlands
| | - Robert J Spinner
- Department of Neurosurgery, Mayo Clinic , Rochester , Minnesota , USA
| | - J Henk Coert
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht , the Netherlands
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Immediate Versus Staged Soft Tissue Reconstruction After Soft Tissue Sarcoma Resection Has Similar Wound and Oncologic Outcomes. Ann Plast Surg 2021; 85:163-170. [PMID: 31913884 DOI: 10.1097/sap.0000000000002192] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to compare the wound complication rate and oncologic outcome in patients undergoing immediate versus staged soft tissue reconstruction after soft tissue sarcoma (STS) resection. METHODS This is a retrospective analysis of a single sarcoma referral center between 2006 and 2016 which identified a cohort that underwent resection of an extremity or trunk STS with reconstruction surgery (split thickness skin graft or flap coverage). Patients were divided into 2 groups based on the reconstruction timing: immediate (same day) versus staged (later date). Demographic characteristics, wound complications, and oncologic outcomes were compared. RESULTS Of the 491 patients who underwent resection of an extremity or trunk STS, 81 (16%) received reconstructive surgery, with 26 patients undergoing immediate reconstruction and 55 patients undergoing staged reconstruction. Overall wound complication (58% vs 45%, P = 0.347) and infection rates (35% vs 25%, P = 0.602) were similar between immediate and staged groups, respectively. Likewise, local recurrence (8% vs 7%, P = 1.000), metastasis (19% vs 20%, P = 0.755), and all-cause mortality (27% vs 27%, P = 1.000) rates after reconstruction was similar. Patients in the staged group with positive margins after resection were re-excised before definitive reconstruction, whereas those in the immediate group were not. The staged group required fewer surgical intensive care unit stays after resection surgery (22% vs 58%, P = 0.006). The mean ± SD final follow-up was 38 ± 33 months. CONCLUSIONS Wound complication rates and oncologic outcomes remain similar, regardless of timing for reconstruction. Staged reconstructions were associated with fewer surgical intensive care unit stays, while also affording opportunity for reintervention after positive margins with little additional morbidity.
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Perrault DP, Lee GK, Yu RP, Carre AL, Chattha A, Johnson MB, Gardner DJ, Carey JN, Tseng WW, Menendez LR, Wong AK. Risk Factors for Wound Complications After Soft Tissue Sarcoma Resection. Ann Plast Surg 2021; 86:S336-S341. [PMID: 33234885 DOI: 10.1097/sap.0000000000002592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Soft tissue sarcomas are a heterogenous group of malignant tumors that represent approximately 1% of adult malignancies. Although these tumors occur throughout the body, the majority involved the lower extremity. Management may involve amputation but more commonly often includes wide local resection by an oncologic surgeon and involvement of a plastic surgeon for reconstruction of larger and more complex defects. Postoperative wound complications are challenging for the surgeon and patient but also impact management of adjuvant chemotherapy and radiation therapy. To explore risk factors for wound complications, we reviewed our single-institution experience of lower-extremity soft tissue sarcomas from April 2009 to September 2016. We identified 127 patients for retrospective review and analysis. The proportion of patients with wound complications in the cohort was 43.3%. Most notably, compared with patients without wound complications, patients with wound complications had a higher proportion of immediate reconstruction (34.5% vs 15.3%; P = 0.05) and a marginally higher proportion who received neoadjuvant radiation (30.9% vs 16.7%; P = 0.06).
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Affiliation(s)
| | - Gene K Lee
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | - Roy P Yu
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | - Antoine Lyonel Carre
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Maxwell B Johnson
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Joseph N Carey
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Lawrence R Menendez
- Department of Orthopedic Surgery, Keck School of Medicine of USC, Los Angeles, CA
| | - Alex K Wong
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
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Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review. J Plast Reconstr Aesthet Surg 2020; 74:755-767. [PMID: 33277214 DOI: 10.1016/j.bjps.2020.10.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 06/25/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Upper limb preservation after soft tissue sarcoma (STS) surgical excision is now the accepted gold standard and it often requires reconstruction with free flaps. The purpose of this review is to summarize current literature on upper limb reconstruction with free flaps after STS resection. METHODS A systematic review was performed in July 2019 in PubMed and MedLine Ovid databases according to the PRISMA guidelines. RESULTS A total of 17 studies were included in the final analysis, with 132 patients. The most common diagnosis was Malignant Fibrous Histiocytoma. The most frequent timing of flap coverage was immediate. The success rate was almost always 100%. The length of follow-up was reported in 11 studies with a range of 2-187 months. The most commonly reported patient-centered outcome was the MSTS Score. Based on the evidence of the literature collected, we divided the upper limb into four parts (shoulder, elbow and arm, forearm and wrist, and hand) and described the most common and functional free flaps used for reconstruction after STS resection. CONCLUSIONS Free flaps in the treatment of STS of the upper extremity have a good overall outcome, with a low postoperative complication rate. A wide array of free flaps is available for reconstruction, and the choice of flap is based on defect size, types of tissue required, postoperative functional goal, and surgeon preference. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.
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10
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A comparison of delayed versus immediate reconstruction following lower-extremity sarcoma resection. Arch Plast Surg 2020; 47:49-53. [PMID: 31964123 PMCID: PMC6976757 DOI: 10.5999/aps.2019.00780] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/28/2019] [Indexed: 11/22/2022] Open
Abstract
Background Identifying patients who may be at high risk for wound complications postsarcoma resection and reconstruction is essential for improving functional outcomes and quality of life. Currently, the effect of timing on sarcoma reconstruction has been poorly investigated. The purpose of this study was to compare outcomes of delayed and immediate reconstruction in the setting of sarcoma resection requiring flap reconstruction in the lower extremity. Methods A retrospective review of the senior author’s sarcoma reconstruction patients from January 2005 to July 2017 was completed. All patients undergoing flap reconstruction of the lower extremity were included. Complications in the early postoperative period were compared between delayed and immediate reconstructive procedures. Results A total of 32 patients (7 delayed, 25 immediate) were included in this study. There was a significantly increased rate of overall complications (100% vs. 28.0%, P=0.001) and rate of hematomas (28.6% vs. 0.0%, P=0.042) in the delayed reconstruction group. Other complications including dehiscence, seroma, infection, venous thrombosis, and total/partial flap loss were also increased in the delayed reconstruction group, but this was not considered to be significant. Conclusions This study suggests that delayed reconstruction following sarcoma resection of the lower extremity had a higher incidence of overall complications and hematoma formation. We emphasize the importance of early plastic and reconstructive surgeon referral and the necessity to closely monitor delayed reconstruction patients for complications.
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Resuscitating extremities after soft tissue sarcoma resections: Are functional reconstructions an overlooked option in limb salvage? A systematic review. Eur J Surg Oncol 2019; 45:1762-1769. [DOI: 10.1016/j.ejso.2019.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 12/27/2022] Open
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Complex Reconstruction After Sarcoma Resection and the Role of the Plastic Surgeon: A Case Series of 298 Patients Treated at a Single Center. Ann Plast Surg 2018; 80:59-63. [PMID: 28737559 DOI: 10.1097/sap.0000000000001190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND More than 1000 new patients present to the London Sarcoma Unit each year and between 5% and 10% require plastic surgery intervention. Advancements in radiotherapy and chemotherapy protocols combined with higher expectations for limb preservation has led to increased reconstructive challenges. Frequently, primary closure is achievable; however, larger tumors often require specialist reconstruction. STUDY DESIGN A retrospective chart review of all referred patients from the London Sarcoma Unit requiring reconstruction between February 2006 and January 2015 was performed. Patients who underwent primary amputation were excluded. RESULTS The total number of operations performed was 298 and the mean follow-up was 16 months (12-46 months). 51% of patients had major comorbidities. Patients could be separated into early (0-1 week postoperatively, n = 167) and late reconstructions (>1 week postoperatively, n = 131). 32 patients were reconstructed with skin grafts, 137 patients were managed with regional flaps and 129 patients were treated with free flaps. CONCLUSIONS A patient with 3 or more major comorbidities resulted in a significantly increased risk of reconstructive failure (P < 0.05). Our experience has lead us to adhere to the following guidelines: (1) All patients should be reviewed in a multidisciplinary team meeting. (2) After primary excision, patients should be managed with a vacuum dressing until margins are clear. (3) Definitive reconstruction should be performed by a specialist reconstructive surgeon.
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Eloy G, Daveau C, Kreps S, Boudou-Rouquette P, Anract P, Biau D. Higher complications after previous external beam radiation for extremity soft-tissue sarcoma in the surgical treatment of a local recurrence: a comparative retrospective study of one hundred and three patients. INTERNATIONAL ORTHOPAEDICS 2018; 43:727-733. [PMID: 30046861 DOI: 10.1007/s00264-018-4064-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 07/16/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE The use of adjuvant radiation in the treatment of soft-tissue sarcoma (STS) is equivocal in selected cases. Our objective was to compare the short-term outcomes in patients operated on for a local recurrence who had radiation for the primary tumour to those who were spared radiation. METHODS This was a retrospective study of 103 patients treated for a local recurrence: 48 (47%) with previous radiation and 55 (53%) without. Our primary outcome criterion was to identify the differences in the local treatment provided. Secondary outcomes were the cumulative incidence of a surgical site infection/wound complication (SSI/WC), variables associated with SSI/WC, and local recurrence. RESULTS Amputation and the incidence of re-operation were significantly more frequent in patients who received previous radiation compared to patients without previous radiation (27% vs 9%, p = 0.02, for amputation; 26% vs 36% at 2 years for SSI/WC, p = 0.049). Multivariable regression models found previous radiation (p = 0.049), arteriopathy (p = 0.012), location at lower limb (p = 0.09), and use of a flap (0.0048) associated with the risk of SSI/WC. CONCLUSIONS Previous radiation is associated with an increased risk of amputation and reoperation for SSI/WC when treating a local recurrence. This information should be accounted for when deciding for the use of radiation.
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Affiliation(s)
- Gauthier Eloy
- Orthopedic Surgery, Hopital Cochin, Paris, Île-de-France, France.
| | - Caroline Daveau
- Radiotherapy, Hopital Europeen Georges Pompidou, Paris, Île-de-France, France
| | - Sarah Kreps
- Radiotherapy, Hopital Europeen Georges Pompidou, Paris, Île-de-France, France
| | | | - Philippe Anract
- Orthopedic Surgery, Hopital Cochin, Paris, Île-de-France, France
| | - David Biau
- Orthopedic Surgery, Hopital Cochin, Paris, Île-de-France, France
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Jacobson LK, Johnson MB, Dedhia RD, Niknam-Bienia S, Wong AK. Impaired wound healing after radiation therapy: A systematic review of pathogenesis and treatment. JPRAS Open 2017. [DOI: 10.1016/j.jpra.2017.04.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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15
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Chiang KT, Lee SY, Chu H. Dermatofibrosarcoma protuberans, a rare but locally aggressive tumor on finger: clinical and aeromedical considerations. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2015; 2:15-8. [PMID: 27252960 PMCID: PMC4623539 DOI: 10.3109/23320885.2014.995185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 10/09/2014] [Accepted: 12/02/2014] [Indexed: 12/02/2022]
Abstract
Dermatofibrosarcoma protuberans (DFSP) is a rare, slow growing, locally infiltrative tumor of intermediate malignancy. It is mostly found on the trunk and head, rarely on hands. The course of evaluation and treatment of a young pilot with DFSP on left middle finger is reported. The clinical issues and aeromedical considerations of this rare tumor is discussed.
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Affiliation(s)
- Kwo-Tsao Chiang
- Aviation Physiology Research Laboratory, Gangshan Branch of Armed Forces Kaohsiung General Hospital , Kaohsiung, Taiwan, Republic of China
| | - Shih-Yu Lee
- Institute of Aerospace and Undersea Medicine, School of Medicine , National Defense Medical Center , Taipei, Taiwan, Republic of China
| | - Hsin Chu
- Aviation Physiology Research Laboratory, Gangshan Branch of Armed Forces Kaohsiung General Hospital, Kaohsiung, Taiwan, Republic of China; Institute of Aerospace and Undersea Medicine, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Abstract
The treatment of musculoskeletal sarcomas has made vast strides in the last few decades. From an era where amputation was the only option to the current day function preserving resections and complex reconstructions has been a major advance. The objectives of extremity reconstruction after oncologic resection include providing skeletal stability where necessary, adequate wound coverage to allow early subsequent adjuvant therapy, optimising the aesthetic outcome and preservation of functional capability with early return to function. This article highlights the concepts of surgical margins in oncology, discusses the principles governing safe surgical resection in these tumors and summarises the current modalities and recent developments relevant to reconstruction after limb salvage. The rationale of choice of a particular resection modality, the unique challenges of reconstruction in skeletally immature individuals and the impact of adjuvant modalities like chemotherapy and radiotherapy on surgical outcomes are also discussed.
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Affiliation(s)
- Ajay Puri
- Department of Orthopaedic Oncology Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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Concomitant upper extremity soft tissue sarcoma limb-sparing resection and functional reconstruction: assessment of outcomes and costs of surgery. Hand (N Y) 2014; 9:196-204. [PMID: 24839421 PMCID: PMC4022960 DOI: 10.1007/s11552-013-9567-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
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