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Borghi A, Gronchi A. Extremity and Truncal Soft Tissue Sarcoma: Risk Assessment and Multidisciplinary Management. Semin Radiat Oncol 2024; 34:147-163. [PMID: 38508780 DOI: 10.1016/j.semradonc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Extremity and truncal soft tissue sarcomas are a heterogeneous group of rare cancers that arise from mesenchymal tissues. Hence, the adoption of tailored risk assessment and prognostication tools plays a crucial role in optimizing the decision-making for which of the many possible treatment strategies to select. Management of these tumors requires a multidisciplinary strategy, which has seen significant development in recent decades. Surgery has emerged as the primary treatment approach, with the main goal of achieving microscopic negative tumor margins. To reduce the likelihood of local recurrence, loco-regional treatments such as radiation therapy and isolated limb perfusion are often added to the treatment regimen in combination with surgery. This approach also enables surgeons to perform limb-sparing surgery, particularly in cases where a positive tumor margin is expected. Chemotherapy may also provide a further benefit in decreasing the probability of local recurrence or reducing distant metastasis in selected patients. Selecting the optimal treatment strategy for these rare tumors is best accomplished by an experienced multi-disciplinary team.
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Affiliation(s)
- Alessandra Borghi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy..
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2
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Ghimire S, Pokhrel P, Thapa S. Limb conservation surgery in biphasic synovial sarcoma of thigh with vascular involvement: A race against time. Int J Surg Case Rep 2023; 109:108646. [PMID: 37566986 PMCID: PMC10432812 DOI: 10.1016/j.ijscr.2023.108646] [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: 07/04/2023] [Revised: 08/03/2023] [Accepted: 08/05/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION Synovial sarcomas are malignant soft tissue neoplasm representing 5 to 10 % of all Soft tissue sarcoma with incidence of 2.75 per 100,000. It is presented in particular along with extra articular location with no as such relation to synovial structures. Among various histological pattern biphasic synovial sarcoma (SS) is considered classical type. Involvement of neurovascular structures in synovial sarcoma is least noted and such invasion by malignant cells is considered an indication for amputation. However vessel reconstructive surgeries have also resulted in conservation of limb hence providing good quality of life. CASE PRESENTATION 13 years old Asian female presented with complaint of exposed synthetic vessel graft from her previous surgical site where femoral vessel reconstruction was carried out for SS of thigh with femoral vessel involvement. Following her (wide local excision) WLE and femoral vessel reconstruction in another center she suffered thrombosis of her femoral vessel following which emergency thrombectomy was also carried out. Later in our center vertical rectus abdominis myocutaneous flap (VRAM) flap was used to manage her exposed synthetic graft. At subsequent follow up patient was ambulating well with no signs of radiological metastasis. CLINICAL DISCUSSION Surgical resections of mass along with synthetic graft placement of the concomitant vascular bundle have also shown significant improvement in reducing the burden of the severe diseases such as synovial sarcoma. CONCLUSION SS with its malignant pathophysiology have impacted severely the quality of life of even among the pediatrics group of population. It is utmost need to set up proper and definitive muscular oncological care to reduce the morbidity and mortality associated with such malignancies.
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Affiliation(s)
- Sagun Ghimire
- KIST Medical College and Teaching Hospital, Lalitpur, Nepal.
| | | | - Samir Thapa
- KIST Medical College and Teaching Hospital, Lalitpur, Nepal
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3
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Wiffen J, Mah E. Determining functional outcomes after resection and reconstruction of primary soft tissue sarcoma in the lower extremity: A review of current subjective and objective measurement systems. J Surg Oncol 2023; 127:862-870. [PMID: 36683344 DOI: 10.1002/jso.27202] [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: 07/06/2022] [Revised: 11/27/2022] [Accepted: 01/02/2023] [Indexed: 01/24/2023]
Abstract
The surgical management of soft-tissue sarcoma has evolved significantly over the last two decades due to the routine use of adjunct therapies, with an increased focus on postoperative functional outcome. The literature suffers from methodological inconsistency and use of low quality outcome measures to assess an already heterogeneous population. This article aims to review the most frequently used subjective and objective methods of functional outcome assessment and highlight the current benefits and limitations of these.
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Affiliation(s)
- James Wiffen
- St Vincent's Hospital, The University of Melbourne, Melbourne, Australia
| | - Eldon Mah
- Department of Plastic & Reconstructive Surgery, St Vincent's Hospital, Melbourne, Australia
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4
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Pedicled Functional Latissimus Flaps for Reconstruction of the Upper Extremity following Resection of Soft-Tissue Sarcomas. Curr Oncol 2023; 30:3138-3148. [PMID: 36975450 PMCID: PMC10047364 DOI: 10.3390/curroncol30030237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/09/2023] Open
Abstract
(1) Background: Resection of soft-tissue sarcomas (STS) of the upper extremity can result in substantial functional impairment with limited options for functional reconstruction. Free functional latissimus flaps have been utilized to restore function of the thigh; however, there is limited data on the use of latissimus flaps for functional reconstruction in the upper extremity. As such, we sought to evaluate our institutional experience with these flaps. (2) Methods: We reviewed ten (seven male; three female; and a mean age of 63 years) patients undergoing soft-tissue sarcoma resection involving the triceps (n = 4), biceps (n = 4), and deltoid (n = 2) reconstructed with a pedicled functional latissimus flap. All surviving patients had at least 1 year of follow-up, with a mean follow-up of 5 years. (3) Results: The mean elbow range of motion and shoulder elevation were 105° and 150°. The mean Musculoskeletal Tumor Society score was 88%, and the muscle strength was four. Four patients had a recipient site wound complication. There were no flap losses. One patient sustained a radiation-associated humerus fracture 5 years postoperatively, treated nonoperatively. (4) Conclusions: Although early complications are high, pedicled functional latissimus flaps allow for wound coverage, potential space obliteration, and restoration of function in the upper extremity following resection of large soft tissue sarcomas.
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Novak R, Nevin JL, Rowell PD, Griffin A, Mazin S, Hofer SOP, O'Neill AC, Tsoi K, Ferguson PC, Wunder JS. A Size-Based Criteria for Flap Reconstruction After Thigh-Adductor, Soft-Tissue Sarcoma Resection. Ann Surg Oncol 2023; 30:3701-3711. [PMID: 36840861 DOI: 10.1245/s10434-023-13261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/01/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Resection of soft-tissue sarcomas from the adductor compartment is associated with significant complications. Free/pedicled flaps often are used for wound closure, but their effect on healing is unclear. We compared wound complications, oncologic, and functional outcomes for patients undergoing flap reconstruction or primary closure following resection of adductor sarcomas. METHODS A total of 177 patients underwent resection of an adductor sarcoma with primary closure (PrC) or free/pedicled flap reconstruction (FR). Patient, tumor, and treatment characteristics were compared, as well as wound complications, oncologic, and functional outcomes (TESS/MSTS87/MSTS93). To examine the relative benefit of flap reconstruction, number needed to treat (NNT) was calculated. RESULTS In total, 143 patients underwent PrC and 34 had FR, 68% of which were pedicled. There were few differences in demographic, tumor, or treatment characteristics. No significant difference was found in the rate of wound complications. Length of stay was significantly longer in FR (18 days vs. PrC 8 days; p < 0.01). Oncologic and functional outcomes were similar over 5 years follow-up. Uncomplicated wound healing occurred more often in FR compared with PrC for tumors with ≥15 cm (NNT = 8.4) or volumes ≥ 800 ml (NNT = 8.4). Tumors ≤ 336 ml do not benefit from a flap, whereas those > 600 ml are 1.5 times more likely to heal uneventfully after flap closure. CONCLUSIONS Although flap use prolonged hospitalization, it decreased wound healing complications for larger tumors, and in all sized tumors, it demonstrated similar functional and oncologic outcomes to primary closure. Our size-based treatment criteria can help to identify patients with large adductor sarcomas who could benefit from flap reconstruction. LEVEL OF EVIDENCE III (Retrospective cohort study).
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Affiliation(s)
- Rostislav Novak
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.
| | - Jennifer L Nevin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Philip D Rowell
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Anthony Griffin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Sergey Mazin
- Department of Software Engineering, ORT Braude Academic College, Karmiel, Israel
| | - Stefan O P Hofer
- Division of Plastic and Reconstructive Surgery, University Health Network, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada
| | - Anne C O'Neill
- Division of Plastic and Reconstructive Surgery, University Health Network, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada
| | - Kim Tsoi
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
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6
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Hauguel A, Goueffic Y, Tzanis D, Bouhadiba T, Perlbarg-Samson J, Bonvalot S, Boura B. Arterial Reconstruction for En-Bloc Resection of Soft Tissue Sarcoma: A Single Tertiary Center Experience. Ann Vasc Surg 2022:S0890-5096(22)00884-6. [PMID: 36549475 DOI: 10.1016/j.avsg.2022.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/29/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Tertiary centers recruit a number of locally advanced or recurrent soft tissue sarcomas (STSs) that require large tissue loss including vessels. Arterial reconstruction (AR) in the context of patients with cancer who may receive radiotherapy (RT) and chemotherapy (CT) is challenging. METHODS This retrospective single centre cohort study includes patients affected by extremities or trunk STS who underwent an AR during sarcoma resection, between October 2015 and February 2021 at Institut Curie. The endpoints of this study were to analyze the morbidity, the patency, and the impact on surgical margins of such associations. RESULTS Of 976 patients operated, 21 (2.15%) had AR. Seventeen (81%) had American Society of Anesthesiologists (ASA) scores ≥2. Locations were as follows: intra-abdominal n = 9 (43%), lower limb n = 8 (38%), upper limb n = 3 (14%), and cervical n = 1 (5%). N = 11 (52.3%) and n = 5 (23.8%) received RT or were operated on a preirradiated field, respectively. N = 7 (34%) patients received CT. Vein graft was used in n = 12 (57%). Musculo-cutaneous flaps were associated in n = 13 (62%) patients. Margins of resection were R0 n = 19 (90.4%), R1 n = 2, and R2 n = 0. The median follow-up was 16 months [6-44]. No postoperative death occurred. Two patients died of metastasis. At 1, 6, 12, and 24 months the primary patency was 80.9%, 71.4%, 87.5%, and 88.9%, respectively. Seven patients (33%) presented perioperative infection. Reoperation rate at 1, 6, and 12 months were 38%, 14%, and 5%, respectively. Ten patients (48%) presented persistent lymphoedema during follow-up. CONCLUSIONS AR enlarges the possibilities of STS excision with healthy margins and achieves good patency. Majority of patients were ASA ≥ 2 and received adjuvant treatments. In this particular context, morbidity is high and requires an upfront multidisciplinary management taking into account all these specific issues.
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Affiliation(s)
- Alexandra Hauguel
- Vascular center, Groupe hospitalier Paris Saint Joseph, Paris, France; LadHyX, Laboratoire d'Hydrodynamique de l'Ecole polytechnique, CNRS UMR-7646, Institut Polytechnique de Paris, Paris, France.
| | - Yann Goueffic
- Vascular center, Groupe hospitalier Paris Saint Joseph, Paris, France
| | - Dimitri Tzanis
- Department of Surgery, Institut Curie, Paris University, Paris, France
| | - Toufik Bouhadiba
- Department of Surgery, Institut Curie, Paris University, Paris, France
| | | | - Sylvie Bonvalot
- Department of Surgery, Institut Curie, Paris University, Paris, France
| | - Benoit Boura
- Vascular center, Groupe hospitalier Paris Saint Joseph, Paris, France
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7
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Mughal M, Rose V, Sindali K, Farhadi J, Havard H, Pollock R, Roblin P. Dual pedicle epiphyseal transfer for paediatric bony sarcoma reconstruction: Technique and review of outcomes. J Plast Reconstr Aesthet Surg 2022; 75:2466-2473. [PMID: 35504788 DOI: 10.1016/j.bjps.2021.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 05/14/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2022]
Abstract
Skeletal reconstruction after tumour resection in paediatric patients is challenging. The resultant reconstruction needs to meet the demands of graft incorporation as well as the potential for growth. The vascularised fibular epiphyseal transfer (VFET) offers the potential for both. We retrospectively reviewed eight paediatric patients treated with VFET after bony tumour resection. All patients underwent a dual pedicle transfer with the peroneal artery for the diaphyseal blood supply and the recurrent branch of the anterior tibial artery for the physis. This is the largest series in literature for dual pedicle transfers for bony reconstruction. We present our surgical technique and outcomes in terms of functional limb salvage and growth.
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Affiliation(s)
- Maleeha Mughal
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK; Department of Plastic Surgery, University Health Network, Toronto, ON, CA.
| | - Victoria Rose
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK
| | - Katia Sindali
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK
| | - Jian Farhadi
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK
| | - Heledd Havard
- Department of Orthopaedics, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Robin Pollock
- Department of Orthopaedics, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Paul Roblin
- Department of Plastic Surgery, Guy's & St. Thomas Hospital, London, UK
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8
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Homsy P, Kantonen I, Salo J, Albäck A, Tukiainen E. Reconstruction of the superficial femoral vessels with muscle flap coverage for soft tissue sarcomas of the proximal thigh. Microsurgery 2022; 42:568-576. [PMID: 35730696 PMCID: PMC9543357 DOI: 10.1002/micr.30932] [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: 12/27/2021] [Revised: 05/02/2022] [Accepted: 06/10/2022] [Indexed: 11/24/2022]
Abstract
Background Surgical resection of soft tissue sarcoma with a margin of healthy tissue may necessitate resection and reconstruction of major blood vessels together with soft tissues of the proximal thigh to preserve the limb. The long‐term functional outcomes of these reconstructions remain unestablished. The aim of this report was to assess the vascular and functional outcomes of soft tissue sarcoma patients with femoral vessel reconstructions. Patients and Methods Patients who had undergone oncovascular reconstruction during the treatment of proximal thigh soft tissue sarcoma in 2014–2020 were reviewed for details of the vascular and soft tissue reconstructions, and the oncological and functional outcomes. This included eight patients of a median age 59 (range 19–77) years. All had a reconstruction of at least the superficial femoral artery and vein as well as soft tissue reconstruction with a muscle flap. All vessel reconstructions were done with either autologous vein (six grafts/four patients) or allograft (10 grafts/six patients). A microvascular latissimus dorsi flap, with a skin island, was incorporated to cover the vascular grafts in five patients. A pedicled sartorius or gracilis muscle flap was used to fill the defect in three patients. Results Graft patency was assessed in seven patients with a median follow‐up of 48 (1–76) months. The arterial graft was patent in 6/8 and the vein graft in 2/8 patients. The gait had returned to normal in five of the six patients assessed. The median MTSS was 70 (43–87)% and the TESS 90 (75–100)%. No local recurrence of the sarcoma was detected. Conclusions Vascular reconstruction combined with soft tissue reconstruction enables limb‐sparing surgery in patients with soft tissue sarcoma involving proximal femoral vessels. Although the surgeries are complex with high early morbidity, the achieved long‐term functional outcomes are worthwhile.
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Affiliation(s)
- Pauliina Homsy
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Kantonen
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juho Salo
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anders Albäck
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erkki Tukiainen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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9
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Kekeç AF, Günaydın İ, Öztürk R, Güngör BŞ. Outcomes of Planned Marginal and Wide Resection of Sarcomas Associated with Major Vascular Structures in Extremities. Indian J Surg Oncol 2022; 13:395-402. [DOI: 10.1007/s13193-021-01476-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/04/2021] [Indexed: 11/30/2022] Open
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10
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Samà L, Binder JP, Darrigues L, Couturaud B, Boura B, Helfre S, Chiche L, Nicolas N, Tzanis D, Bouhadiba T, Gentile D, Perlbarg-Samson J, Bonvalot S. Safe-margin surgery by plastic reconstruction in extremities or parietal trunk soft tissue sarcoma: A tertiary single centre experience. Eur J Surg Oncol 2021; 48:526-532. [PMID: 34702592 DOI: 10.1016/j.ejso.2021.10.010] [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: 08/02/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Tertiary centers recruit a large proportion of locally advanced or recurrent soft tissue sarcomas (STSs) that may have been preoperatively irradiated. The objective of this study was to evaluate the results of oncoplastic surgery (OPS) for patients affected by extremities or parietal trunk STS. MATERIALS AND METHODS This retrospective study includes patients who underwent a flap reconstruction after sarcoma resection between January 2018 and December 2020 at Institut Curie. The primary endpoint was the evaluation of the impact of OPS on the quality of surgical margins. The secondary endpoint was to quantify the morbidity of OPS and identify predictive factors for wound complications. RESULTS Of 211 patients, 89 (42.2%) had a flap reconstruction. Surgery was realized on an irradiated field in 56 (62.9%) patients. Without OPS, all patients were candidates either for amputation (n = 9,10.1%) due to vessels/nerve infiltration, or R1/R2 resection (n = 80,89.9%). Seventy-two (80.0%) pedicle flaps and 18 (20.0%) free flaps were used. No R2 resections were performed. R0 and R1 margins were achieved in 82 (92.1%) and 7 (7.9%), respectively. The median closest margin was 3 mm (IQR 1-6 mm). Among R1 patients, 5 had positive margins along a preserved critical structure, 2 patients had well-differentiated liposarcomas. The surgical morbidity rate was 33.3% (30/90 flaps). The reoperation rate was 15.7% (14/89 patients). CONCLUSIONS In a referral sarcoma center, the collaboration between the surgical oncologist and the plastic surgery team should be considered upfront in the surgical plan, allowing the most adequate wide oncological resection with acceptable postoperative morbidity.
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Affiliation(s)
- Laura Samà
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy.
| | | | - Lauren Darrigues
- Division of Plastic and Reconstructive Surgery, Institute Curie, Paris, France
| | - Benoit Couturaud
- Division of Plastic and Reconstructive Surgery, Institute Curie, Paris, France
| | - Benoit Boura
- Department of Vascular Surgery, Hospital Saint Joseph, Paris, France
| | - Sylvie Helfre
- Department of Radiation Oncology, Institute Curie, Paris, France
| | | | - Nayla Nicolas
- Department of Radiology, Institute Curie, Paris, France
| | - Dimitri Tzanis
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France
| | - Toufik Bouhadiba
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France
| | - Damiano Gentile
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | | | - Sylvie Bonvalot
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France.
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11
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Cruz SM, Basmaci UN, Bateni CP, Darrow MA, Judge SJ, Monjazeb AM, Thorpe SW, Humphries MD, Canter RJ. Surgical and oncologic outcomes following arterial resection and reconstruction for advanced solid tumors. J Surg Oncol 2021; 124:1251-1260. [PMID: 34495553 DOI: 10.1002/jso.26665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/16/2021] [Accepted: 08/28/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Although arterial involvement for advanced tumors is rare, vascular resection may be indicated to achieve complete tumor resection. Given the potential morbidity of this approach, we sought to evaluate perioperative outcomes, vascular graft patency, and survival among patients undergoing tumor excision with en bloc arterial resection and reconstruction. METHODS From 2010 to 2020, we identified nine patients with tumors encasing or extensively abutting major arterial structures for whom en bloc arterial resection and reconstruction was performed. RESULTS Mean age was 53 ± 20 years, and 89% were females. Diagnoses were primary sarcomas (5), recurrent gynecologic carcinomas (3), and benign retroperitoneal fibrosis (1). Tumors involved the infrarenal aorta (2), iliac arteries (6), and superficial femoral artery (1). Three patients (33%) had severe perioperative morbidity (Grade III + ) with no mortality. At a median follow-up of 23 months, eight patients (89%) had primary graft patency, and five patients (56%) had no evidence of disease. CONCLUSIONS Arterial resection and reconstruction as part of the multimodality treatment of regionally advanced tumors is associated with acceptable short- and long-term outcomes, including excellent graft patency. In appropriately selected patients, involvement of major arterial structures should not be viewed as a contraindication to attempted curative surgery.
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Affiliation(s)
- Sylvia M Cruz
- Department of Surgery, UC Davis School of Medicine, Sacramento, California, USA
| | - Ugur N Basmaci
- Department of Surgery, UC Davis School of Medicine, Sacramento, California, USA
| | - Cyrus P Bateni
- Division of Musculoskeletal Radiology, UC Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Morgan A Darrow
- Department of Pathology and Laboratory Medicine, UC Davis Medical Center, Sacramento, California, USA
| | - Sean J Judge
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California, USA
| | - Arta M Monjazeb
- Department of Radiation Oncology, UC Davis Medical Center, Sacramento, California, USA
| | - Steven W Thorpe
- Department of Orthopedic Surgery, UC Davis Medical Center, Sacramento, California, USA
| | - Misty D Humphries
- Division of Vascular and Endovascular Surgery, UC Davis Medical Center, Sacramento, California, USA
| | - Robert J Canter
- Division of Surgical Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California, USA
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12
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Blight TJ, Choong PFM. The need for improved patient reported outcome measures in patients with extremity sarcoma: A narrative review. ANZ J Surg 2021; 91:2021-2025. [PMID: 34227237 DOI: 10.1111/ans.17028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 06/05/2021] [Accepted: 06/06/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Extremity sarcoma causes impairments to functionality and quality of life. Patient-reported outcome measures (PROMS) assess patient perspectives relating to domains of health and quality of life. METHODS To describe PROMs utilised in extremity sarcoma, the available literature was screened for studies that utilised PROMs to evaluate outcomes in extremity sarcoma following surgery. RESULTS Seventy articles met eligibility criteria; six PROMs were identified. The Toronto Extremity Salvage Score, The Short-Form 36, The EORTC QLQ-C30, The Disabilities of the Arm, Shoulder and Hand questionnaire, the Reintegration to Normal Living index and the Patient-Reported Outcomes Measurement Information System. Most sarcoma patients score well in these tools, with bone sarcoma, and extent of resection being predictors of poor outcomes. CONCLUSION TESS is the only sarcoma-specific PROM, and though a valid assessment of functionality, it has difficulty differentiating patients with minor functional impairments. The absence of a disease-specific measure of health is concerning, as generic tools do not account for the unique experiences sarcoma patients face and may impair their accuracy in analysing intervention effectiveness.
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Affiliation(s)
- Thomas J Blight
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.,Clinical School, St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Peter F M Choong
- Department of Surgery, University of Melbourne, Melbourne, Australia.,Bone and Soft Tissue Sarcoma Unit, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Orthopaedics, St. Vincent's Hospital Melbourne, Melbourne, Australia
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13
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The Orthopedic-Vascular Multidisciplinary Approach Improves Patient Safety in Surgery for Musculoskeletal Tumors: A Large-Volume Center Experience. J Pers Med 2021; 11:jpm11060462. [PMID: 34073954 PMCID: PMC8225121 DOI: 10.3390/jpm11060462] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/03/2021] [Accepted: 05/20/2021] [Indexed: 12/27/2022] Open
Abstract
Objective: Wide-margin resection is mandatory for malignant bone and soft tissue tumors. However, this increases the complexity of resections, especially when vessels are involved. Patients in this high-risk clinical setting could be surgically treated using the multidisciplinary orthopedic-vascular approach. This study was carried out in this healthcare organization to evaluate patient safety in term of oncologic outcomes and reduction of the complication rate. Materials and Methods: We retrospectively reviewed 74 patients (37 males, 37 females; mean age 46 years, range 9–88) who underwent surgical excision for bone/soft tissue malignant tumors closely attached to vascular structures from October 2015 to February 2019. Vascular surgery consisted of isolation of at least one vessel (64 patients), bypass reconstruction (9 patients), and end-to-end anastomosis (1 patient). Mean follow-up was 27 months. Patients’ demographics, tumor characteristics, adjuvant treatments, type of orthopedic and vascular procedures, and oncologic and functional outcomes and complications were recorded. Results: Overall survival was 85% at 3 years follow-up. In total, 22 patients experienced at least one major complication requiring further surgery and 13 patients experienced at least one minor complication, whereas 17 reported deviations from the normal postoperative course without the need for pharmacological or interventional treatment. Major complications were higher in pelvic resections compared to limb-salvage procedures (p = 0.0564) and when surgical time was more than 4 h (p = 0.0364) at univariate analysis, whereas the most important multivariate independent predictors for major complications were pelvic resection (p = 0.0196) and preoperative radiotherapy (p = 0.0426). Conclusions: A multidisciplinary ortho-vascular approach for resection of malignant bone and soft tissue tumors tightly attached to important vascular structures should be considered a good clinical practice for patient safety.
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14
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Abstract
Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.
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15
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Noebauer-Huhmann IM, Chaudhary SR, Papakonstantinou O, Panotopoulos J, Weber MA, Lalam RK, Albtoush OM, Fueger BJ, Szomolanyi P, Grieser T, Bloem JL. Soft Tissue Sarcoma Follow-up Imaging: Strategies to Distinguish Post-treatment Changes from Recurrence. Semin Musculoskelet Radiol 2020; 24:627-644. [PMID: 33307581 DOI: 10.1055/s-0040-1721464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Soft tissue sarcomas encompass multiple entities with differing recurrence rates and follow-up intervals. The detection of recurrences and their differentiation from post-therapeutic changes is therefore complex, with a central role for the clinical radiologist. This article describes approved recommendations. Prerequisite is a precise knowledge of the current clinical management and surgical techniques. We review recurrence rates and treatment modalities. An adequate imaging technique is paramount, and comparison with previous imaging is highly recommended. We describe time-dependent therapy-related complications on magnetic resonance imaging compared with the spectrum of regular post-therapeutic changes. Early complications such as seromas, hematomas, and infections, late complications such as edema and fibrosis, and inflammatory pseudotumors are elucidated. The appearance of recurrences and radiation-associated sarcomas is contrasted with these changes. This systematic approach in follow-up imaging of soft tissue sarcoma patients will facilitate the differentiation of post-therapeutic changes from recurrences.
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Affiliation(s)
- Iris-M Noebauer-Huhmann
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Snehansh R Chaudhary
- Department of Clinical Radiology, Aintree University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | | | - Joannis Panotopoulos
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Radhesh K Lalam
- Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom
| | - Omar M Albtoush
- Department of Radiology, University of Jordan, and Department of Radiology, King Hussein Cancer Center, Amman, Jordan
| | - Barbara J Fueger
- Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Pavol Szomolanyi
- High Field MR Center, Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Grieser
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Johan L Bloem
- Department of radiology, Leiden University Medical Center, Leiden, The Netherlands
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Kumar S, Manjunath NML, Manoj Gowda S, Kumar N, Bharati S, Deo SVS. Limb Preservation Using Vascular Reconstruction in Patients with Large Extremity Soft Tissue Sarcomas: Results of Multi-Modality Therapy. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02161-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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17
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Nooromid MJ, Thomas MA, Yoon DY, Eskandari MK, Peabody TD, Rodriguez HE. Outcomes of Sarcoma Resections Requiring Vascular Surgical Assistance: A Single-Center Experience. Vasc Endovascular Surg 2020; 54:579-585. [PMID: 32744174 DOI: 10.1177/1538574420942334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: To describe the types of intervention and determine patency and survival after arterial and venous reconstruction after surgical excision of sarcomas. Methods: Between November 2001 and July 2015, 42 patients with sarcomas and vascular involvement underwent surgical oncologic resection followed by arterial or venous reconstruction or preservation of the native vascular bundle. Univariate, multivariate, and Kaplan-Meier survival analyses were performed on abstracted data, which included demographics, risk factors, oncologic and vascular treatment modalities, postoperative complications, graft patency, and survival outcomes. Results: A total of 42 sarcomas required vascular assistance for oncologic removal. The majority of sarcomas were malignant fibrous histiocytoma (23.8%), and the most common anatomic location was the retroperitoneum (48%). A total of 12 revascularizations procedures were performed, including 5 arterial, 3 venous, and 2 concomitant arterial and venous. In 32 cases, a vascular surgeon was needed for vessel ligation, repair, or mobilization. The overall 2- and 5-year survival was 77.7% and 26.2%, respectively, with no significant survival difference between patients who underwent revascularization compared to those without revascularization. There was a 100% patency rate in all cases at last follow-up, regardless of the type of vascular reconstruction (median 18 months, range 1-29 months). On multivariate analysis, chronic obstructive pulmonary disease (COPD; P = .002) and positive surgical margins (P = .003) were associated with decreased survival. Most cases were performed in the last 5 years of the study (n = 27, 64.3%). Conclusions: Vascular reconstruction is feasible after surgical oncologic resection of sarcomas with good mid-term patency and limb preservation. Factors independently associated with mortality included COPD and positive surgical margins.
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Affiliation(s)
- Michael J Nooromid
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael A Thomas
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dustin Y Yoon
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark K Eskandari
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Terrance D Peabody
- Department of Orthopedic Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Heron E Rodriguez
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Abstract
Although the vast majority of soft tissue extremity masses are benign, approximately 13,000 people in the United States were diagnosed with soft tissue sarcoma in 2019. This article focuses on the optimal workup of soft tissue masses including the indications for ultrasound and MRI, as well as use of preoperative core needle biopsy. Current AJCC staging, surgical principles of soft tissue sarcoma management, and data regarding indications for radiation therapy and chemotherapy are reviewed. As up to 50% of patients with soft tissue sarcoma will develop recurrent disease, surgical management of locally recurrent and distant metastatic disease is discussed.
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Affiliation(s)
- Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, TX 77030, USA.
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19
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Fujiki M, Kimura T, Takushima A. Limb‐salvage surgery with vascular reconstruction after lower extremity sarcoma resection: A systematic review and meta‐analysis. Microsurgery 2020; 40:404-413. [DOI: 10.1002/micr.30553] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/26/2019] [Accepted: 12/26/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Masahide Fujiki
- Department of Plastic Surgery Kyorin University School of Medicine Tokyo Japan
| | - Takeichiro Kimura
- Department of Plastic Surgery Kyorin University School of Medicine Tokyo Japan
| | - Akihiko Takushima
- Department of Plastic Surgery Kyorin University School of Medicine Tokyo Japan
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20
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Ahmed F, Pounds R, Teo HG, Nevin J, Singh K, Yap J. En bloc resection of the external iliac vein along with broad ligament leiomyosarcoma: A case report. Case Rep Womens Health 2019; 23:e00131. [PMID: 31360641 PMCID: PMC6639561 DOI: 10.1016/j.crwh.2019.e00131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/17/2019] [Accepted: 06/24/2019] [Indexed: 10/28/2022] Open
Abstract
Outcomes following the excision of the external iliac vein during gynaecological oncology surgery are poorly documented. This is because most gynaecological oncologists consider tumours with vascular involvement inoperable. We describe a patient whose right external iliac vein was transected during the removal of a large broad ligament leiomyosarcoma invading the right external iliac vein. The patient's recovery following surgery was uneventful, and she remained disease-free 6 months postoperatively, with minimal morbidity. In describing this case, we hope to educate and inform other gynaecological oncologists facing a similar surgical challenge. We also propose that resection of the external iliac vessels in such cases is safe and feasible, and summarise the anatomical course of venous collaterals, which develop when the external iliac veins are obstructed.
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Affiliation(s)
- Fatima Ahmed
- Birmingham Women's NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham B15 2TG, UK
| | - Rachel Pounds
- Birmingham Cancer Research UK Cancer Centre, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK.,Pan Birmingham Gynaecological Cancer Centre, City Hospital, Dudley Road, B18 7QH, UK
| | - Hong-Giap Teo
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Dudley Road, B18 7QH, UK
| | - James Nevin
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Dudley Road, B18 7QH, UK
| | - Kavita Singh
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Dudley Road, B18 7QH, UK
| | - Jason Yap
- Birmingham Cancer Research UK Cancer Centre, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK.,Pan Birmingham Gynaecological Cancer Centre, City Hospital, Dudley Road, B18 7QH, UK
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21
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Twenty years of experience in vascular reconstructions associated with resection of malignant neoplasms in a single cancer center. J Vasc Surg 2019; 69:1880-1888. [DOI: 10.1016/j.jvs.2018.08.196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 08/16/2018] [Indexed: 02/07/2023]
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22
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Cetinkaya OA, Celik SU, Kalem M, Basarir K, Koksoy C, Yildiz HY. Clinical Characteristics and Surgical Outcomes of Limb-Sparing Surgery with Vascular Reconstruction for Soft Tissue Sarcomas. Ann Vasc Surg 2018; 56:73-80. [PMID: 30500640 DOI: 10.1016/j.avsg.2018.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/25/2018] [Accepted: 09/10/2018] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Omer Arda Cetinkaya
- Division of Vascular Surgery, Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
| | - Suleyman Utku Celik
- Department of Surgery, Ankara University School of Medicine, Ankara, Turkey.
| | - Mahmut Kalem
- Department of Orthopedics and Traumatology, Ankara University School of Medicine, Ankara, Turkey
| | - Kerem Basarir
- Department of Orthopedics and Traumatology, Ankara University School of Medicine, Ankara, Turkey
| | - Cuneyt Koksoy
- Division of Vascular Surgery, Department of Surgery, Ankara University School of Medicine, Ankara, Turkey
| | - Huseyin Yusuf Yildiz
- Department of Orthopedics and Traumatology, Ankara University School of Medicine, Ankara, Turkey
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23
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Akgül T, Sormaz İC, Aksoy M, Uçar A, Özger H, Eralp L. Results and functional outcomes of en-bloc resection and vascular reconstruction in extremity musculoskeletal tumors. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2018; 52:409-414. [PMID: 30274704 PMCID: PMC6318543 DOI: 10.1016/j.aott.2018.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/14/2018] [Accepted: 08/29/2018] [Indexed: 01/28/2023]
Abstract
Objectives This paper aims to evaluate the extremity function and vascular outcome after limb-sparing surgery for extremity musculoskeletal tumors invading vascular structure required reconstruction. Methods Of the 507 patients with musculoskeletal tumors, who underwent surgery between 2004 and 2007, 17 (3,3%) patients with major vessel involvement were included in the study. The mean age was 37.8 ± 14.5, with a female/male ratio of 8/9. Thirteen (76.4%) patients had Stage IIb disease, and 2 (11,7%) patients had Stage III disease. In 2 (11,7%) patients have locally aggressive tumor that had Stage 3. Fifteen (88.2%) of the cases involved lower extremity, whilst 2 (11.8%) of them involved upper extremity. An arterial reconstruction was carried out in all patients. Wide tumor resection and endoprosthetic reconstruction were performed in 6 (35.2%) patients. Other 11 (65.8%) patients were treated with wide resection and soft tissue reconstruction. Postoperative data included; perioperative morbidities such as bleeding, infection, graft thrombosis, rupture, metastatic local recurrence and mortality. Ankle brachial index (ABI) and color-flow-duplex-scan (CFDS) were done at the final follow-up of the study, in order to prove the efficacy of reconstruction. Functional outcome was evaluated with International Society of Limb Salvage (ISOLS) criteria. Results The mean follow-up was of 39 months (range 3–120). Perioperative complications were arterial graft thrombosis occurred in 3 (17.6%) patients treated acutely with thrombectomy, uncontrolled deep wound infection occurred in 2 patients whom extremities were amputated. The most frequent complication after surgery was limb edema according to possibly venous and lymphatic obstruction, staged as C1, C2 and C3 disease was established in 6 patients (two patients in each group), and 1 patient was classified as C6 disease. Three (17.6%) patients had local recurrence (1/3 patient died and 2/3 (11.7%) patients underwent transfemoral amputation). At the last follow-up, 9 (52.9%) patients were alive without evidence of disease, 8 (47.1%) patients were died due to primary disease. There were 8 (47.1%) patients alive with an intact limb. Although functional outcome scores were satisfactory, emotional acceptance scores were low. The limb salvage probability was 74.0%. Conclusion Limb-sparing oncological surgery in musculoskeletal tumors with vascular invasion provides a satisfactory limb function, which may lead to an improved life quality. Arterial reconstruction has a high rate of patency in the long term. The surgeon should be aware of early perioperative complication related to vascular reconstruction and infection that effect on the rate of extremity survival. Level of evidence Level IV, Therapeutic study
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Affiliation(s)
- Turgut Akgül
- Department of Orthopedics and Traumatology, Istanbul Medical Faculty, Istanbul, Turkey.
| | - İsmail Cem Sormaz
- Department of General Surgery, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Murat Aksoy
- Department of General Surgery, Bahcesehir University, Liv Hospital, Istanbul, Turkey.
| | - Adem Uçar
- Department of Radiology, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Harzem Özger
- Department of Orthopedics and Traumatology, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Levent Eralp
- Department of Orthopedics and Traumatology, Istanbul Medical Faculty, Istanbul, Turkey.
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24
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Kask G, Barner-Rasmussen I, Repo J, Blomqvist C, Tukiainen E. Functional Outcome After Lower Extremity Soft Tissue Sarcoma Treatment: A Pilot Study Based on Translated and Culturally Adapted Measures. Scand J Surg 2018; 108:164-171. [PMID: 30187826 DOI: 10.1177/1457496918798210] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS The present standard of care in treating lower extremity soft tissue sarcomas is function-sparing, limb-preserving resection and reconstruction with or without oncological therapy. The aim of this pilot study was to test the suitability and adequacy of the Finnish translations of two functional outcome questionnaires (Toronto Extremity Salvage Score and Musculoskeletal Tumor Society score) and to perform a preliminary investigation of functional outcomes of Finnish lower-limb soft tissue sarcoma patients after operative treatment. MATERIALS AND METHODS Between June 2015 and December 2015, consecutive surgically treated outpatients were asked to participate in the study. Demographic, clinical, surgical, and oncological outcome data were collected. Two functional outcome questionnaires were used (Toronto Extremity Salvage Score and Musculoskeletal Tumor Society scores). A comparative analysis is presented. RESULTS A total of 19 lower-limb soft tissue sarcoma patients with a mean follow-up time of 2 years and 10 months were included. All (n = 19) invited patients participated in the study. Mean age was 62.3 years. In total, 13 had high-grade sarcomas. Eight wounds were closed directly, four used skin grafts, and five required flap reconstructions. One patient required a tumor prosthesis, and one required a rotationplasty. A total of 14 patients received oncological therapy. No problems or difficulties were reported in using and completing the Finnish versions of the Toronto Extremity Salvage Score or Musculoskeletal Tumor Society questionnaires. The overall Toronto Extremity Salvage Score and Musculoskeletal Tumor Society scores were 88 and 76, respectively. CONCLUSION This pilot study suggests that the Finnish versions of the Toronto Extremity Salvage Score and Musculoskeletal Tumor Society questionnaires are suitable for measuring functional outcome after lower extremity soft tissue sarcomas treatment. Functional outcomes vary from moderate to excellent.
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Affiliation(s)
- G Kask
- 1 Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - I Barner-Rasmussen
- 1 Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - J Repo
- 1 Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland.,2 Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | - C Blomqvist
- 2 Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | - E Tukiainen
- 1 Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
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25
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Nakamura T, Kusuzaki K, Matsubara T, Murata H, Hagi T, Asanuma K, Sudo A. Long-term clinical outcome in patients with high-grade soft tissue sarcoma who were treated with surgical adjuvant therapy using acridine orange after intra-lesional or marginal resection. Photodiagnosis Photodyn Ther 2018; 23:165-170. [PMID: 29885811 DOI: 10.1016/j.pdpdt.2018.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/01/2018] [Accepted: 06/01/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND We investigated the long-term clinical efficacy of acridine orange (AO) therapy on the inhibition of local recurrence after marginal or intra-lesional tumor resection in high-grade soft tissue sarcomas (STSs). METHODS Our study consisted of 48 patients with STSs who received AO therapy after marginal or intra-lesional resection. The median and mean follow-up durations were 76 and 78 months, respectively. Our AO therapy procedure was combined with photodynamic surgery, photodynamic therapy, and radiodynamic therapy. RESULTS There were 25 men and 23 women, with a mean age of 46 years. The average tumor size at surgery was 8.5 cm. At the last follow-up, 11 patients developed local recurrence. The 5- and 10-year local recurrence-free rates were 78.9% and 73.3%, respectively. In multivariate analysis, tumor size remained significant for local control. None of the patients developed systemic or local complications. All patients recovered activities of daily life before AO therapy. CONCLUSION AO therapy can be performed in safety and may be a useful therapy for acquiring long-term local control in patients with high-grade STSs. Tumor size is an important factor for the indication of AO therapy.
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Affiliation(s)
- Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Postgraduate School of Medicine, Edobashi 2-174, Tsu-city, 514-8507, Japan.
| | - Katsuyuki Kusuzaki
- Department of Musculoskeletal Oncology, Takai Hospital, Kuranosho 470-8, Tenri, 632-0006, Japan
| | - Takao Matsubara
- Matsubara Orthopaedic Clinic. Shiroyama 3-4-25, Tsu-city, 514-0818, Japan
| | - Hiroaki Murata
- Department of Orthopaedic Surgery, Matsushita Memorial Hospital, Moriguchi-City, 570-8540, Japan
| | - Tomohito Hagi
- Department of Orthopaedic Surgery, Mie University Postgraduate School of Medicine, Edobashi 2-174, Tsu-city, 514-8507, Japan
| | - Kunihiro Asanuma
- Department of Orthopaedic Surgery, Mie University Postgraduate School of Medicine, Edobashi 2-174, Tsu-city, 514-8507, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Postgraduate School of Medicine, Edobashi 2-174, Tsu-city, 514-8507, Japan
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26
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Weichteilsarkome: Wie lassen sich posttherapeutische Veränderungen von Rezidiven unterscheiden? Radiologe 2017; 57:923-937. [DOI: 10.1007/s00117-017-0310-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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The risk of postoperative complications and functional impairment after multimodality treatment for limb and trunk wall soft-tissue sarcoma: Long term results from a monocentric series. Eur J Surg Oncol 2017; 43:1117-1125. [DOI: 10.1016/j.ejso.2017.01.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/15/2017] [Accepted: 01/24/2017] [Indexed: 01/27/2023] Open
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28
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Ramu EM, Houdek MT, Isaac CE, Dickie CI, Ferguson PC, Wunder JS. Management of soft-tissue sarcomas; treatment strategies, staging, and outcomes. SICOT J 2017; 3:20. [PMID: 28287387 PMCID: PMC5347369 DOI: 10.1051/sicotj/2017010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/03/2017] [Indexed: 12/20/2022] Open
Abstract
Soft-tissue sarcomas (STS) are a rare group of malignant tumors which can affect any age group. For the majority of patients who present with a localized STS, treatment involves a multidisciplinary team decision-making approach ultimately relying on surgical resection with or without adjuvant radiation for successful limb salvage. The goals of treatment are to provide the patient with a functional extremity without local tumor relapse. The purpose of this article is to review the treatment of extremity STS, with a focus on staging, treatment options, and outcomes.
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Affiliation(s)
- Eyal M Ramu
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Matthew T Houdek
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Christian E Isaac
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Colleen I Dickie
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Peter C Ferguson
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
| | - Jay S Wunder
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, M5G 1X5 Ontario, Canada - Department of Surgical Oncology, Princess Margaret Cancer Center, University of Toronto, Toronto, M5G 2C4 Ontario, Canada - Division of Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, M5G 2C4 Ontario, Canada
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29
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Slump J, Ferguson PC, Wunder JS, Griffin AM, Hoekstra HJ, Liu X, Hofer SOP, O'Neill AC. Patient, tumour and treatment factors affect complication rates in soft tissue sarcoma flap reconstruction in a synergistic manner. Eur J Surg Oncol 2017; 43:1126-1133. [PMID: 28222969 DOI: 10.1016/j.ejso.2017.01.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/11/2017] [Accepted: 01/24/2017] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Flap reconstruction plays an essential role in the management of soft tissue sarcoma, facilitating wide resection while maximizing preservation of function. The addition of reconstruction increases the complexity of the surgery and identification of patients who are at high risk for post-operative complications is an important part of the preoperative assessment. This study examines predictors of complications in these patients. METHODS 294 patients undergoing flap reconstruction following sarcoma resection were evaluated. Data on patient, tumour and treatment variables as well as post-operative complications were collected. Bivariate and multivariate regression analysis was performed to identify independent predictors of complications. Analysis of synergistic interaction between key patient and tumour risk factors was subsequently performed. RESULTS A history of cerebrovascular events or cardiac disease were found to be the strongest independent predictors of post-operative complications (OR 14.84, p = 0.003 and OR 5.71, p = 0.001, respectively). Further strong independent tumour and treatment-related predictors were high grade tumours (OR 1.91, p = 0.038) and the need for additional reconstructive procedures (OR 2.78, p = 0.001). Obesity had significant synergistic interaction with tumour resection diameter (RERI 1.1, SI 1.99, p = 0.02) and high tumour grade (RERI 0.86, SI 1.5, p = 0.01). Comorbidities showed significant synergistic interaction with large tumour resections (RERI 0.91, SI 1.83, p = 0.02). CONCLUSION Patient, tumour and treatment-related variables contribute to complications following flap reconstruction of sarcoma defects. This study highlights the importance of considering the combined effect of multiple risk factors when evaluating and counselling patients as significant synergistic interaction between variables can further increase the risk of complications.
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Affiliation(s)
- J Slump
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - P C Ferguson
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - J S Wunder
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - A M Griffin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - H J Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - X Liu
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - S O P Hofer
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada
| | - A C O'Neill
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Department of Surgery, University of Toronto, Toronto, Canada. Anne.O'
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Hussain ON, Sabbagh MD, Carlsen BT. Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities. Clin Plast Surg 2017; 44:299-311. [PMID: 28340664 DOI: 10.1016/j.cps.2016.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.
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Affiliation(s)
- Omar N Hussain
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - M Diya Sabbagh
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Brian T Carlsen
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA.
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Wortmann M, Alldinger I, Böckler D, Ulrich A, Hyhlik-Dürr A. Vascular reconstruction after retroperitoneal and lower extremity sarcoma resection. Eur J Surg Oncol 2017; 43:407-415. [DOI: 10.1016/j.ejso.2016.10.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/16/2016] [Accepted: 10/31/2016] [Indexed: 12/17/2022] Open
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Miyamoto S, Fujiki M, Setsu N, Kawai A. Simultaneous reconstruction of the bone and vessels for complex femoral defect. World J Surg Oncol 2016; 14:291. [PMID: 27863500 PMCID: PMC5116157 DOI: 10.1186/s12957-016-1037-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/04/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Shimpei Miyamoto
- Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 1040045, Japan.
| | - Masahide Fujiki
- Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Nokitaka Setsu
- Division of Orthopedic Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
| | - Akira Kawai
- Division of Orthopedic Surgery, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 1040045, Japan
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McGoldrick NP, Butler JS, Lavelle M, Sheehan S, Dudeney S, O'Toole GC. Resection and reconstruction of pelvic and extremity soft tissue sarcomas with major vascular involvement: Current concepts. World J Orthop 2016; 7:293-300. [PMID: 27190757 PMCID: PMC4865719 DOI: 10.5312/wjo.v7.i5.293] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 02/16/2016] [Accepted: 03/07/2016] [Indexed: 02/06/2023] Open
Abstract
Soft tissue sarcoma accounts for approximately 1% of all cancers diagnosed annually in the United States. When these rare malignant mesodermal tumours arise in the pelvis and extremities, they may potentially encase or invade large calibre vascular structures. This presents a major challenge in terms of safe excision while also leaving acceptable surgical margins. In recent times, the trend has been towards limb salvage with vascular reconstruction in preference to amputation. Newer orthopaedic and vascular reconstructive techniques including both synthetic and autogenous graft reconstruction have made complex limb-salvage surgery feasible. Despite this, limb-salvage surgery with concomitant vascular reconstruction remains associated with higher rates of post-operative complications including infection and amputation. In this review we describe the initial presentation and investigation of patients presenting with soft tissue sarcomas in the pelvis and extremities, which involve vascular structures. We further discuss the key surgical reconstructive principles and techniques available for the management of these complex tumours, drawn from our institution's experience as a national tertiary referral sarcoma service.
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Radaelli S, Fiore M, Colombo C, Ford S, Palassini E, Sanfilippo R, Stacchiotti S, Sangalli C, Morosi C, Casali PG, Gronchi A. Vascular resection en-bloc with tumor removal and graft reconstruction is safe and effective in soft tissue sarcoma (STS) of the extremities and retroperitoneum. Surg Oncol 2016; 25:125-31. [PMID: 27566012 DOI: 10.1016/j.suronc.2016.05.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 04/04/2016] [Accepted: 05/06/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND To analyze the outcome of a series of patients who underwent vascular resection as part of an excision of a soft tissue sarcoma (STS). STUDY DESIGN All consecutive patients affected by localized STS of an extremity or retroperitoneum treated between January 2000 and December 2013 with surgery including vascular resection were considered. Overall survival (OS), crude cumulative incidence (CCI) of local recurrence (LR) and distant metastases (DM) were estimated by Kaplan-Meier. Long-term vascular graft patency rate was assessed. RESULTS 2692 patients received an operation for localized disease with 105 (3.9%) cases undergoing vascular resection. Median FU was 32 months. 5-year OS, CCI of LR and DM were 62%, 12% and 58% respectively. Vascular reconstructions consisted of 52 arterial and 16 venous grafts in extremities; 12 arterial and 33 venous grafts in the retroperitoneum. Graft thrombosis occurred in 16 patients (7/64 arterial and 9/49 venous reconstructions). Arterial occlusions occurred at a median of 36 months after surgery and were treated by prosthesis replacement (3), Fogarty catheter embolectomy (2), percutaneous angioplasty (1) and observation (1). One patient eventually required amputation. Venous occlusions occurred at a median of 4 months post surgery and were all treated conservatively. Overall arterial and venous reconstruction patency rates were 89% and 82% respectively. CONCLUSIONS Vascular resection to facilitate resection of STS has an acceptable long term patency rate. However it was associated to a high risk of distant spread. Although the encasement of the vascular bundle does not represent a contraindication to surgery there is an association with a high metastatic risk by virtue of the locally advanced nature of the disease and this should be considered when planning treatment.
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Affiliation(s)
- Stefano Radaelli
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Marco Fiore
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Chiara Colombo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Samuel Ford
- Department of Surgery, University Hospital, Birmingham, United Kingdom.
| | - Elena Palassini
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Roberta Sanfilippo
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Silvia Stacchiotti
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Claudia Sangalli
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Carlo Morosi
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Paolo G Casali
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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Poultsides GA, Tran TB, Zambrano E, Janson L, Mohler DG, Mell MW, Avedian RS, Visser BC, Lee JT, Ganjoo K, Harris EJ, Norton JA. Sarcoma Resection With and Without Vascular Reconstruction: A Matched Case-control Study. Ann Surg 2015; 262:632-40. [PMID: 26366542 PMCID: PMC4657732 DOI: 10.1097/sla.0000000000001455] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the impact of major vascular resection on sarcoma resection outcomes. SUMMARY BACKGROUND DATA En bloc resection and reconstruction of involved vessels is being increasingly performed during sarcoma surgery; however, the perioperative and oncologic outcomes of this strategy are not well described. METHODS Patients undergoing sarcoma resection with (VASC) and without (NO-VASC) vascular reconstruction were 1:2 matched on anatomic site, histology, grade, size, synchronous metastasis, and primary (vs. repeat) resection. R2 resections were excluded. Endpoints included perioperative morbidity, mortality, local recurrence, and survival. RESULTS From 2000 to 2014, 50 sarcoma patients underwent VASC resection. These were matched with 100 NO-VASC patients having similar clinicopathologic characteristics. The rates of any complication (74% vs. 44%, P = 0.002), grade 3 or higher complication (38% vs. 18%, P = 0.024), and transfusion (66% vs. 33%, P < 0.001) were all more common in the VASC group. Thirty-day (2% vs. 0%, P = 0.30) or 90-day mortality (6% vs. 2%, P = 0.24) were not significantly higher. Local recurrence (5-year, 51% vs. 54%, P = 0.11) and overall survival after resection (5-year, 59% vs. 53%, P = 0.67) were similar between the 2 groups. Within the VASC group, overall survival was not affected by the type of vessel involved (artery vs. vein) or the presence of histology-proven vessel wall invasion. CONCLUSIONS Vascular resection and reconstruction during sarcoma resection significantly increases perioperative morbidity and requires meticulous preoperative multidisciplinary planning. However, the oncologic outcome appears equivalent to cases without major vascular involvement. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma resection.
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Affiliation(s)
| | - Thuy B. Tran
- Division of Surgical Oncology, Department of Surgery, Stanford University
| | | | | | | | - Matthew W. Mell
- Division of Vascular Surgery, Department of Surgery, Stanford University
| | | | - Brendan C. Visser
- Division of Surgical Oncology, Department of Surgery, Stanford University
| | - Jason T. Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University
| | - Kristen Ganjoo
- Division of Oncology, Department of Medicine, Stanford University
| | - E. John Harris
- Division of Vascular Surgery, Department of Surgery, Stanford University
| | - Jeffrey A. Norton
- Division of Surgical Oncology, Department of Surgery, Stanford University
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Abstract
BACKGROUND Advanced pelvic cancers involving the lateral pelvic compartment, and particularly the iliac vasculature, are difficult to manage. Common or external iliac vessel involvement has traditionally been considered a contraindication for curative surgery. OBJECTIVE The purpose of this study was to investigate pathological and surgical outcomes, particularly postoperative morbidity of pelvic exenteration with en bloc major iliac vascular excision and reconstruction. DESIGN This study was a case series. SETTINGS The study was conducted at a quaternary referral center for pelvic exenteration in Sydney. PATIENTS Patients included those undergoing en bloc iliac vessel excision as part of their pelvic exenteration for a locally advanced pelvic malignancy. MAIN OUTCOME MEASURES Over the study period, 336 patients underwent pelvic exenteration. Twenty-one patients (6.3%) underwent en bloc vascular excision of 29 vessels for tumor involvement. Twenty-four vessels required reconstruction. The primary outcomes were postoperative complications and pathologic outcomes. Survival rates were estimated using the Kaplan-Meier technique. RESULTS Operating time for patients who underwent vascular excision and reconstruction was longer, but this did not reach significance (631 vs 531 minutes; p = 0.052). Mean blood loss was significantly higher in the vascular excision and reconstruction group (6.8 vs 3.4 L; p < 0.001). Patients who required en bloc vascular excision were less likely to have R0 margins compared with patients who did not (38% vs 78%; p < 0.001). There was no intraoperative or 30-day mortality. Overall graft patency and limb loss at 1 year were 96% and 0%. A total of 52% of patients had at least 1 vascular related complication. Median overall and disease-free survival times were 34 and 26 months. LIMITATIONS This study is limited by a relatively small number of heterogeneous patients. CONCLUSIONS En bloc vascular resection and reconstruction for contiguous tumor involvement is feasible and safe in selected patients. Advanced pelvic tumors involving iliac vessels should not be precluded from curative surgery in specialized institutions.
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Abstract
It was estimated that more than 3000 people would be diagnosed with a primary bone or joint malignancy and more than 11,000 people would be diagnosed with a soft tissue sarcoma in 2013. Although primary bone and soft tissue tumors of the upper extremity are infrequent, it is imperative that the clinician be familiar with a systematic approach to the diagnosis and treatment of these conditions to prevent inadvertently compromising patient outcome. With advances in chemotherapy, radiotherapy, tumor imaging, and surgical reconstructive options, limb salvage surgery is estimated to be feasible in 95% of extremity bone or soft tissue sarcomas.
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Affiliation(s)
- Justin C Wong
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1025 Walnut Street, Room 516, College Building, Philadelphia, PA 19107, USA
| | - John A Abraham
- The Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA.
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Bains R, Magdum A, Bhat W, Roy A, Platt A, Stanley P. Soft tissue sarcoma - A review of presentation, management and outcomes in 110 patients. Surgeon 2014; 14:129-35. [PMID: 25261278 DOI: 10.1016/j.surge.2014.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 03/09/2014] [Accepted: 06/07/2014] [Indexed: 01/09/2023]
Abstract
UNLABELLED Soft tissue sarcomas are a rare group of mesenchymal tumours the treatment of which poses oncological and reconstructive challenges. Limb-salvage surgery aims to balance adequate excision margins for disease control and preservation of important structures to retain function. Reported here is the review of the Hull Plastic surgery sarcoma service over a twelve year period. METHOD We performed a review of the Hull sarcoma database over a twelve year period between 1997 and 2009. Demographic data, tumour grade, operative details complications and outcomes were recorded. RESULTS The database contained a total of 435 patients with a diagnosis of sarcoma. 110 were treated at the Plastic Surgery department over a period of 12 years between 1997 and 2009. The patients treated in our department consisted of 67 males and 43 females (median age 70 years). The most common histological type was leiomyosarcoma (n = 23). Distribution of anatomical sites affected were head and neck (n = 15), upper limb (n = 17), lower limb (n = 56), trunk (n = 22). Large tumours (greater than 8 cm) n = 30, deep tumours n = 48, and high grade (Trojani 3) n = 33. Patients were treated with surgical excision and postoperative radiotherapy in the high grade groups (2 and 3). A range of reconstructive procedures were required from skin grafting, functional muscle transfer and free flap reconstruction. Nine patients developed regional recurrence, six patients had grade 3 tumours. Three were not resectable. Fourteen patients developed distant metastases, seven had grade 3 tumours, six underwent chemotherapy, two were treated palliatively. There were twenty deaths in this group, of which sixteen were sarcoma related. Deaths in the high risk groups was seven (high grade), nine (deep tumours) and eight (tumour size >8 cm). There were six survivors from eleven in the group with all three of these risk factors. CONCLUSION This study summarises the management of sarcoma form one unit over a twelve year period and lends further evidence to the fact that the principles of limb-salvage surgery are applicable to a wide range of tumour-types and grades, to all patient age groups and anatomical sites with good functional results and that local and free flap reconstruction provides wound cover robust enough to withstand courses of radiotherapy. Early recurrence of high-grade disease and the development of metastasis carry a worse prognosis, especially if adjuvant therapy cannot be given. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Robert Bains
- Department of Plastic and Reconstructive Surgery, Castle Hill Hospital, Cottingham, Hull, UK
| | - Ashish Magdum
- Department of Plastic and Reconstructive Surgery, Castle Hill Hospital, Cottingham, Hull, UK
| | - Waseem Bhat
- Department of Plastic and Reconstructive Surgery, Castle Hill Hospital, Cottingham, Hull, UK.
| | - Anu Roy
- Department of Plastic and Reconstructive Surgery, Castle Hill Hospital, Cottingham, Hull, UK
| | - Alastair Platt
- Department of Plastic and Reconstructive Surgery, Castle Hill Hospital, Cottingham, Hull, UK
| | - Paul Stanley
- Department of Plastic and Reconstructive Surgery, Castle Hill Hospital, Cottingham, Hull, UK
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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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O'Donnell PW, Griffin AM, Eward WC, Sternheim A, Catton CN, Chung PW, O'Sullivan B, Ferguson PC, Wunder JS. The effect of the setting of a positive surgical margin in soft tissue sarcoma. Cancer 2014; 120:2866-75. [PMID: 24894656 DOI: 10.1002/cncr.28793] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/17/2014] [Accepted: 02/03/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objectives of this study were to evaluate the risk of local recurrence and survival after soft tissue sarcoma (STS) resection with positive margins and to evaluate the safety of sparing adjacent critical structures. METHODS One hundred sixty-nine patients with localized STS who had positive resection margins were identified from a prospective database. Patients who had positive margins were stratified into 3 groups, each representing a specific clinical scenario: critical structure positive margin (eg major nerve, vessel, or bone), tumor bed resection positive margin, and unexpected positive margin. The rates of local recurrence-free survival (LRFS) and cause-specific survival (CSS) were calculated and compared with relevant control patients who had negative margins after STS resection. RESULTS After planned close dissection to preserve critical structures, the 5-year LRFS and CSS rates both depended on the quality of the surgical margins (97% and 80.3%, respectively, for those with negative margins vs 85.4% and 59.4%, respectively, for those with positive margins; P = .015 and P = .05, respectively). Negative margins achieved through resection of critical structures because of tumor invasion or encasement only slightly improved the 5-year rates of LRFS (91.2%) and CSS (63.6%; P = .8 and P = .9, respectively). The lowest 5-year LRFS and CSS rates were 63.4% and 59.2%, respectively, after an unexpected positive margin during primary surgery. CONCLUSIONS After patients undergo resection of STS with positive margins, oncologic outcomes can be predicted based on the clinical context. Sparing adjacent critical structures in this setting is safe and contributes to improved functional outcomes.
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Affiliation(s)
- Patrick W O'Donnell
- Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Surgical Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada; Division of Orthopedic Surgery, University of Toronto, Toronto, Ontario, Canada
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Cipriano CA, Wunder JS, Ferguson PC. Surgical Management of Soft Tissue Sarcomas of the Extremities. ACTA ACUST UNITED AC 2014. [DOI: 10.1053/j.oto.2014.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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O’Donnell PW, Biau DJ. The Evolving Concept of Margins in Musculoskeletal Oncology. ACTA ACUST UNITED AC 2014. [DOI: 10.1053/j.oto.2013.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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[Long-term functional results after sarcoma resection]. Chirurg 2014; 85:215-20, 222-3. [PMID: 24595478 DOI: 10.1007/s00104-013-2603-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Multimodal treatment of malignant tumors of the musculoskeletal system with R0 in sano resection plays a key role in prevention of local recurrence in soft tissue and bone sarcoma. In cases of unavoidable neuromuscular or osseous defects, current plastic and orthoplastic reconstruction techniques avoid limb amputation in the majority of patients. Clinical long-term results demonstrate that large resection defects do not necessarily result in impaired limb function if multidisciplinary procedures are integrated. In oncologically necessary major limb amputation, segmental resection and replantation of distal limb parts should be considered which provide end-bearing long stump formation. The functional conditions of long-term surviving elderly patients should be integrated into surgical decision-making and rehabilitation efforts.
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Gronchi A, Olmi P, Casali PG. Combined modalities approach for localized adult extremity soft-tissue sarcoma. Expert Rev Anticancer Ther 2014; 7:1135-44. [DOI: 10.1586/14737140.7.8.1135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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45
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Lun DX, Hu YC, Huang HC. Management of great vessels and nerves in limb-salvage surgery for bone and soft tissue tumors. Orthop Surg 2013; 5:233-8. [PMID: 24254445 DOI: 10.1111/os.12066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 08/25/2013] [Indexed: 01/13/2023] Open
Abstract
In recent years, limb-salvage surgery has gradually replaced amputations and become one of the main treatment strategies for patients with bone and soft tissue tumors of the extremities. The goals of tumor resection in limb-salvage surgery are to reduce the recurrence rate and preserve as much limb function as possible. However, depending on the size and specific location of the tumor, large neurovascular bundles may be involved. In addition, management of large nerves and vessels can make wide marginal resection more difficult. Sites where these problems commonly arise include the sciatic and tibial common peroneal nerve, artery and vein in the lower limbs.
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Affiliation(s)
- Deng-xing Lun
- Department of Spine Surgery, Weifang People's Hospital, Weifang City, Shandong Province, China
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Reconstruction of sarcoma defects following pre-operative radiation: free tissue transfer is safe and reliable. J Plast Reconstr Aesthet Surg 2013; 66:1575-9. [PMID: 23831122 DOI: 10.1016/j.bjps.2013.06.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 06/12/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neoadjuvant radiotherapy followed by surgical resection and soft tissue reconstruction provides the best possibility of achieving superior limb function in soft tissue sarcomas. The aim of this study was to report our experience of free flap microsurgical reconstruction of recently irradiated soft tissue sarcoma defects. METHODS A retrospective study of microsurgical outcome in consecutively treated extremity and trunk sarcoma patients undergoing free tissue transfer between 2007 and 2012 was conducted from a prospectively collected database. Outcomes in pre-operatively irradiated patients were compared with non-irradiated patients. Demographic data, operative details, limb salvage rate, post-operative including microsurgical complications, and long-term limb function (Toronto Extremity Salvage score, TESS; Musculoskeletal Tumour Society Rating Scale, MSTS) were recorded and analysed for differences between the two study groups. RESULTS Forty-six patients underwent 46 free flaps (pre-irradiated n = 32, non-irradiated n = 14) over the study period. Microvascular complications (intra-operative revision, flap re-exploration, flap loss) were uncommon and similar between the two groups (4/32 and 2/14 respectively, p > 0.05). Recipient site wound healing complications (i.e. not flap related) occurred more frequently in pre-irradiated patients (16 events) compared with the control group (2 events, p = 0.03). There was no significant difference in limb salvage rate, or TESS/MSTS functional outcome scores between the two patient groups. CONCLUSIONS Free tissue transfer is safe and effective in patients undergoing surgical resection and reconstruction following neoadjuvant radiotherapy.
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Planned preservation surgery for soft tissue sarcomas adjacent to critical structures. Arch Orthop Trauma Surg 2013; 133:481-6. [PMID: 23381296 DOI: 10.1007/s00402-013-1690-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Whether to preserve or sacrifice critical structures (bone, major vessels and major nerves) adjacent to soft tissue sarcomas is still controversial. Referring to characteristic imaging and intraoperative findings, we perform planned preservation surgery for these critical structures. The aim of this study was to investigate the clinical outcome of soft tissue sarcomas adjacent to critical structures and to validate this procedure. METHODS Of 202 cases of soft tissue sarcomas surgically treated at our department of orthopedic surgery from 2004 to 2010, 57 cases (28 %) whose tumors were adjacent to the critical structures were studied. There were 36 men and 21 women. In 32 cases critical structures were preserved, and in 25 resected together with the tumor. The oncological outcome and histological surgical margin were analyzed. RESULTS The overall survival and local recurrence-free survival rates at 5 years were 75.9 and 83.2 %. In 26 of the 32 (81 %) preserved cases histologically the surgical margin was negative, and in 17 (53 %) radiotherapy could be avoided. Neither overall survival (p = 0.9669) nor local recurrence-free survival (p = 0.7819) differed significantly between two groups. CONCLUSIONS When soft tissue sarcomas are located adjacent to bone or major vessels, by meticulously detaching the periosteum or neurovascular sheath referring to characteristic imaging and intraoperative findings, a histologically negative surgical margin can be achieved in the majority, allowing avoidance of postoperative radiotherapy. Planned preservation surgery provided no significant adverse effect on survival or local recurrence rates, validating this procedure.
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Matsubara T, Kusuzaki K, Matsumine A, Nakamura T, Sudo A. Can a less radical surgery using photodynamic therapy with acridine orange be equal to a wide-margin resection? Clin Orthop Relat Res 2013; 471:792-802. [PMID: 23008027 PMCID: PMC3563805 DOI: 10.1007/s11999-012-2616-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Wide-margin resections are an accepted method for treating soft tissue sarcoma. However, a wide-margin resection sometimes impairs function because of the lack of normal tissue. To preserve the normal tissue surrounding a tumor, we developed a less radical (ie, without a wide margin) surgical procedure using adjunctive photodynamic therapy and acridine orange for treating soft tissue sarcoma. However, whether this less radical surgical approach increases or decreases survival or whether it increases the risk of local recurrence remains uncertain. QUESTIONS/PURPOSES We determined the survival, local recurrence, and limb function outcomes in patients treated with a less radical approach and adjunctive acridine orange therapy compared with those who underwent a conventional wide-margin resection. METHODS We treated 170 patients with high-grade soft tissue sarcoma between 1999 and 2009. Fifty-one of these patients underwent acridine orange therapy. The remaining 119 patients underwent a conventional wide-margin resection for limb salvage surgery. We recorded the survival, local recurrence, and functional score (International Society of Limb Salvage [ISOLS]) score) for all the patients. RESULTS The 10-year overall survival rates in the acridine orange therapy group and the conventional surgery group were 68% and 63%, respectively. The 10-year local recurrence rate was 29% for each group. The 5-year local recurrence rates for Stages II, III, and IV were 8%, 36%, and 40%, respectively, for the acridine orange group and 13%, 27%, and 33%, respectively, for the conventional surgery group. The average ISOLS score was 93% for the acridine orange group and 83% for the conventional therapy group. CONCLUSION Acridine orange therapy has the potential to preserve limb function without increasing the rate of local recurrence. This therapy may be useful for eliminating tumor cells with minimal damage to the normal tissue in patients with soft tissue sarcoma. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of the levels of evidence.
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Affiliation(s)
- Takao Matsubara
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu City, Mie 514-8507, Japan.
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Payne CE, Hofer SOP, Zhong T, Griffin AC, Ferguson PC, Wunder JS. Functional outcome following upper limb soft tissue sarcoma resection with flap reconstruction. J Plast Reconstr Aesthet Surg 2013; 66:601-7. [PMID: 23434111 DOI: 10.1016/j.bjps.2013.01.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 01/27/2013] [Accepted: 01/28/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Upper limb preservation after soft tissue sarcoma resection often requires flap reconstruction. The aim of this study was to compare pre- and post-operative upper limb function following shoulder, elbow or wrist/hand sarcoma resection and soft tissue reconstruction with a pedicled or free flap. PATIENTS Between 1989 and 2008, 113 patients underwent resection of an upper limb soft tissue sarcoma and required flap reconstruction. Perioperative morbidity, mortality and flap loss were studied. Functional outcome was assessed pre and postoperatively using the Toronto Extremity Salvage Score (TESS), a measure of disability, and the Musculoskeletal Tumour Society Rating Scale (MSTS), a measure of impairment. Statistical analyses were performed to evaluate the relationship between flap type and functional outcome scores. RESULTS Patients underwent soft tissue sarcoma excision in the shoulder (n = 64), elbow (n = 27) or wrist/hand (n = 22) region with soft tissue reconstruction using either a pedicled (n = 76) or free flap (n = 37). Comparison of the post-operative MSTS (n = 88) and TESS (n = 84) revealed no significant differences between the free and pedicled flap groups. A significant pre- to post-operative difference was identified in MSTS 87 scores for patients in both the pedicled (p < 0.02) and free flap groups (p < 0.04). Comparison of the pre- and post-operative MSTS 93 scores also revealed a significant difference (p < 0.01) but this was limited to the free flap group. The most notable post-operative score reductions in these patients were due to major joint, nerve, tendon or muscle group resection. CONCLUSION Reconstruction of the soft tissue defect following sarcoma resection in the upper limb maintains a similar satisfactory level of upper limb activity with either pedicled or free flap reconstructions. Based on TESS scores, patients rated themselves as having better function compared to impairment measures such as MSTS.
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Affiliation(s)
- Caroline E Payne
- Division of Plastic Surgery, University Health Network, University of Toronto, Toronto, Canada
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Umezawa H, Sakuraba M, Miyamoto S, Nagamatsu S, Kayano S, Taji M. Analysis of immediate vascular reconstruction for lower-limb salvage in patients with lower-limb bone and soft-tissue sarcoma. J Plast Reconstr Aesthet Surg 2013; 66:608-16. [PMID: 23391538 DOI: 10.1016/j.bjps.2013.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 12/05/2012] [Accepted: 01/03/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Limb amputation has historically been the first choice of treatment for patients with bone or soft-tissue sarcomas involving major blood vessels. However, recent advances in surgical technique have allowed limb-salvage surgery. We reviewed our experiences with limb-salvage surgery and immediate vascular reconstruction following en bloc resection of bone or soft-tissue sarcomas of the lower extremity. MATERIALS AND METHOD We reviewed 23 patients (15 male and eight female; mean age, 43.6 years) who underwent limb-salvage surgery and immediate vascular reconstruction. Details of surgical factors and postoperative complications were evaluated. RESULTS Reconstructed vessels remained patent in 21 cases. The rate of limb oedema was higher in patients who underwent only arterial reconstruction after arteriovenous resection. Twenty patients could walk well without crutches a few months after reconstructive surgery. All patients avoided amputation. Two patients died of disseminated disease within 3 years after surgery. CONCLUSION The high rate of limb oedema suggests that venous reconstruction is necessary after arteriovenous resection. Vascular reconstruction and musculocutaneous flap techniques are useful in limb-salvage surgery and are indicated for patients who have achieved good disease control. Evidence Rating Scale for Therapeutic Studies: Level III.
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Affiliation(s)
- Hiroki Umezawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan.
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