Management of great vessels and nerves in limb-salvage surgery for bone and soft tissue tumors

Clinical Characteristics and Surgical Outcomes of Limb-Sparing Surgery with Vascular Reconstruction for Soft Tissue Sarcomas

BACKGROUND

The standard treatment for lower extremity soft tissue sarcoma (STS) is limb-sparing surgery. For a small subset of patients, concomitant vascular reconstruction may be required to preserve limb viability and function while completely excising the tumor with an adequate resection margin. The aim of this study was to evaluate the surgical outcomes and clinical characteristics of patients with STS of the extremities requiring vascular reconstructions.

METHODS

From January 2002 through December 2014, 13 patients with limb STS presenting with vascular invasion underwent surgical resection, followed by vascular reconstruction. The medical records such as demographics, histopathological findings, complications, success of vascular reconstruction, and clinical and oncological outcomes were retrospectively reviewed from a prospectively collected clinical database.

RESULTS

With a mean follow-up period of 80.6 months, a total of 24 vascular reconstruction procedures (1 only arterial, 1 only venous, and 11 both arterial and venous) were performed. Contralateral great saphenous vein graft was the conduit of choice for vascular replacement. Five graft thromboses were observed in 4 patients. Arterial occlusion occurred in two cases, and venous bypasses occluded in three patients. The overall five-year patency for arterial and venous reconstructions was 84.6% and 75.2%, respectively. The mean survival period of patients was 105.5 months, with a 5-year disease-free survival rate and overall survival rate of 59.3% and 68.4%, respectively.

CONCLUSIONS

Vascular resection and reconstruction for STSs of extremity can be safely performed with acceptable short- and long-term surgical and oncological outcomes. Regardless of the surgical procedure, amputation or limb-sparing surgery, the primary focus should be to adhere to strict oncological principles. In addition, because of the complexity of these tumors, an appropriate preoperative planning and meticulous multidisciplinary approach are also crucial.

Limb-Salvage Surgery of Soft Tissue Sarcoma with Sciatic Nerve Involvement

Background

The surgical resection of soft tissue sarcomas (STS) with sciatic nerve involvement presents a significant surgical and oncological challenge. Current treatment strategies pursue a multimodal approach with the aim of limb preservation. We aim to evaluate the outcomes of limb-sparing surgery of STS in a patient cohort and to propose a classification for STS with sciatic nerve involvement.

Methods

Patients receiving limb-preserving resections for STS with sciatic nerve involvement between 01/2010 and 01/2017 were included. Clinical and oncological data were prospectively collected in a computerized database and retrospectively analyzed. Sciatic nerve involvement in STS was classified preoperatively as follows: type A for nerve encasement; type B for nerve contact; and type C for no nerve involvement.

Results

A total of 364 patients with STS were treated, of which 27 patients had STS with sciatic nerve involvement. Eight patients with type A tumors (29.6%) underwent sciatic nerve resection, and 19 patients with type B tumors (70.4%) received epineural dissections. Disease progression was observed in 8 patients (29.6%) with a local recurrence of 11.1% and distant metastasis in 29.6%. The type of nerve resection significantly influenced leg function but had no impact on disease recurrence or overall survival.

Conclusion

In a cohort of carefully selected patients with STS and sciatic nerve involvement, the extent of sciatic nerve resection had no significant impact on disease recurrence or survival. Precise classification of neural involvement may therefore be useful in selecting the appropriate degree of nerve resection, without compromising oncological outcome or unnecessarily sacrificing leg function.

Simultaneous reconstruction of the bone and vessels for complex femoral defect

Background

Several methods have been reported for intercalary reconstruction of femoral defects. Of these, free vascularized fibula grafts (FVFG) are preferred because of their durability, bone-healing potential, and tolerance to infection. If the bone tumor invades the femoral vessels, simultaneous vascular reconstruction also becomes necessary and significant technical hurdles make limb salvage difficult.

Case presentation

We present a 10-year-old girl who underwent limb-sparing surgery for a distal femur osteosarcoma. The femoral defect was 15 cm long, and the femoral vessel defect was 10 cm long. The femur was reconstructed with bilateral FVFG, and the femoral vessels were reconstructed with saphenous vein grafts. The grafts survived without vascular compromise, and the affected limb was preserved successfully.

Conclusions

Combined use of bilateral FVFG and autologous vein grafts makes limb-sparing surgery for a large osteosarcoma of the femur possible.