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Pagnoni C, Zoccali G, Scotto di Uccio A, Sperati F, Favale L, Valeri S, Annovazzi A, Petrongari MG, Anelli V, Ferraresi V, Zoccali C. Soft tissue sarcomas of the proximal adductor area of the thigh: Indications, results and complications at medium follow-up in a series of 43 surgically treated patients. J Orthop 2024; 58:16-23. [PMID: 39035448 PMCID: PMC11259782 DOI: 10.1016/j.jor.2024.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 06/17/2024] [Indexed: 07/23/2024] Open
Abstract
Introduction When Soft Tissue Sarcomas are localized in the groin area, they pose specific challenges due to their proximity to important structures. These tumors exhibit elevated complication rates and a higher local recurrence rate compared to their locations in other limbs. The objective of this paper is to analyze a series of patients affected by soft tissue sarcomas in the adductor area of the proximal thigh. The analysis aims to elucidate the epidemiology, diagnostic and therapeutic approaches, complications, and outcomes. Additionally, the study seeks potential prognostic factors and to determine patients at a heightened risk of postoperative complications. Patients and methods all patients who underwent surgeries for primary soft tissue sarcomas of the adductor area between October 2006 and March 2022 in a tertiary research hospital were valued. Epidemiology, tumor characteristics and therapeutic approaches were analyzed to identify risk factors for complications and local recurrences; survival was considered a secondary outcome. Results The series comprised 43 patients, 26 males and 17 females, with an average age of 63.3 years. The most frequent histology was liposarcoma, followed by undifferentiated forms. All patients reported the presence of masses, with associated pain in 27.9% of cases. Limb-sparing surgery was performed in 86.0% of cases. Early and late complications were experienced by 34.9% and 20.0% of patients, respectively, with wound dehiscence being the most frequent problem. The recurrence rate was 9.3%, with no recurrences observed in low-grade patients. At an average follow-up of 51 months, 18 patients (41.9%) were alive, two of which with distant metastases. Conclusion The present series provides evidence that when Soft Tissue Sarcomas localized in the groin area are managed in specialized centers, the rates of recurrence and complications are not significantly different from those observed in other anatomical sites.
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Affiliation(s)
- Chiara Pagnoni
- Soft Tissue Sarcoma Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, 00128, Rome, Italy
| | - Giovanni Zoccali
- Plastic and Reconstructive Unit, IRCCS – Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Alessandra Scotto di Uccio
- General Surgery and Organ Transplantation Unit, School of General Surgery, Sapienza University of Rome, Umberto I Polyclinic of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesca Sperati
- Clinical Trial Center, Biostatistics and Bioinformatics Department, IRCCS San Gallicano Dermatological Institute, 00144, Rome, Italy
| | - Leonardo Favale
- Oncological Orthopedics Department, IRCCS – Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Sergio Valeri
- Soft Tissue Sarcoma Surgery Unit, Fondazione Policlinico Universitario Campus Bio-Medico, 00128, Rome, Italy
| | - Alessio Annovazzi
- Nuclear Medicine Unit, IRCCS – Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Maria Grazia Petrongari
- Radiotherapy Unit, IRCCS – Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Vincenzo Anelli
- Radiolgy Unit, IRCCS – Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Virginia Ferraresi
- Oncological Medica Unit A, IRCCS – Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Carmine Zoccali
- Oncological Orthopedics Department, IRCCS – Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy
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Aoki Y, Tome Y, Oshiro H, Kinjo M, Okubo H, Nakasone M, Nishida K. Veno-accompanying artery fasciocutaneous flaps following wide excision of soft tissue tumors in the lower legs. J Orthop Sci 2022; 27:1126-1131. [PMID: 34325954 DOI: 10.1016/j.jos.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Soft tissue defects following wide excision of malignant soft tissue tumors (STTs) are sometimes too large for primary closure, especially in the lower legs where available soft tissue is limited. This study aimed to determine the clinical outcomes of reconstruction of a defect after wide excision of an STT with a veno-accompanying artery fasciocutaneous (VAF) flap in the lower leg. METHODS This study comprised 9 patients with malignant STTs who had undergone reconstructive surgeries using VAF flaps after wide excisions, between October 2010 and September 2017. We retrospectively reviewed and collected data involving age, sex, follow-up period, histological diagnosis, surgical procedures, size and location of defects, size and location of the flaps, venous source of the flaps, direction of the pedicles, closing of donor sites, perioperative chemotherapies, postoperative complications, and the presence of postoperative local recurrence and metastasis. RESULTS The median follow-up period was 91.5 (range, 15.5-189.0) months. Four patients had defects located around the knee, 3 patients had defects located on the calf, and 2 patients had defects located around the ankle. The mean flap size was 95.6 × 119.4 (range, 50 × 100-130 × 140) mm. Six patients had venous sources from the small saphenous vein and 3 patients had venous sources from the great saphenous vein. The pedicles were proximally based in 4 patients and distally based in 5 patients. All flaps remained viable without any complications. CONCLUSIONS Our findings showed that the VAF flap was easily elevated and reliable. Furthermore, it was effective in reconstructing soft tissue defects following wide excisions of STTs in the lower leg.
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Affiliation(s)
- Yusuke Aoki
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Yasunori Tome
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.
| | - Hiromichi Oshiro
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Masaki Kinjo
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hirotaka Okubo
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Motoko Nakasone
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Kotaro Nishida
- Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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Dissemond J, Protz K, Erfurt-Berge C, Kröger K, Kottner J. [Wound treatment without curative intention: position paper of the Initiative Chronische Wunden (ICW) e. V.]. Hautarzt 2022; 73:550-555. [PMID: 35296922 DOI: 10.1007/s00105-022-04973-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/27/2022]
Abstract
Today, patients with chronic wounds are treated in many different fields of medicine. Despite this great interdisciplinary and interprofessional importance, there is still a lack of uniformly accepted definitions and classifications. Therefore, a group of experts from the professional society Initiative Chronische Wunden (ICW) e. V. translated and adapted the classification of chronic wounds into healable, maintenance and nonhealable wounds on the basis of the internationally published literature into German. This classification results in the aim of curative, limited respectively non-curative or palliative wound care, which are very important for everyday clinical practice. It thus becomes clear that complete wound closure is not always the central intention of wound treatment. For many patients with chronic wounds, other aspects such as the best possible quality of life and the promotion of health-related self-management as well as the avoidance of complications are important for treatment concepts. These therapy intentions should be differentiated and individually discussed with patients in order to facilitate shared decision making.
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Affiliation(s)
- Joachim Dissemond
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122, Essen, Deutschland.
| | - Kerstin Protz
- CompetenzzentrumVersorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg, Deutschland
| | | | - Knut Kröger
- Klinik für Angiologie, Helios Klinikum, Krefeld, Deutschland
| | - Jan Kottner
- Centrum für Human- und Gesundheitswissenschaften - Einheit Klinische Pflegewissenschaft, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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Bretschneider T, Michelitsch C, Frima H, Furrer M, Sommer C. Pathologic femur fractures following surgery and radiotherapy for soft tissue sarcomas: A case series. Int J Surg Case Rep 2021; 84:106062. [PMID: 34139424 PMCID: PMC8219744 DOI: 10.1016/j.ijscr.2021.106062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/30/2021] [Accepted: 06/03/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Combined limb-sparing surgery and radiation therapy are considered the standard of care for higher grade soft tissue sarcomas (STS) of the extremities. The risk of post-radiation fracture after this treatment modality is well known, but still underestimated, and can end in serious long-term secondary problems years later. Presentation of case We reviewed the records of three patients with pathological femur fractures years after wide local excision of an STS of the proximal lower extremity. All patients received more than 50 Gy (Gy) to the entire femur circumference. During surgery, all patients had bone exposure, and in two patients with stripping of the periosteum. The median time from surgery to fracture was 116 months (range from 84 to 156 months). The median age at the time of diagnosis was 66 years old. Despite standard operative fracture treatment, all three patients developed a non-union. One patient later died due to uncontrolled pulmonary metastasis independent from the femoral non-union. In the second case, an exarticulation at hip level due to an uncontrolled infected non-union had to be performed. The third patient finally achieved fracture union after two years of treatment. Discussion Our study confirms the high occurrence rate of postoperative complications and difficulties one encounters in treating these pathologic fractures. Only in one patient, following several revisions with intramedullary nailing, the fracture healed. In pathologic femur shaft fractures we recommend a minimal invasive procedure using intramedullary nailing devices. Conclusion The risk of pathological fractures at the former treatment site is high, even years later. The rate of non-unions after a difficult fracture treatment in this particular clinical situation seems to be very high and may be associated with severe complications. 3 patients with pathological femur fractures after excision of sarcoma are reviewed. Risk of post-radiation fracture after this treatment modality is underestimated. Despite standard operative fracture treatment, rate of non-unions is very high. We recommend a minimal invasive procedure using intramedullary nailing devices.
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Affiliation(s)
- Tobias Bretschneider
- Department of Surgery, Cantonal Hospital Graubünden, Loestrasse 170, 7000 Chur, Switzerland.
| | - Christian Michelitsch
- Department of Surgery, Cantonal Hospital Graubünden, Loestrasse 170, 7000 Chur, Switzerland
| | - Herman Frima
- Department of Trauma Surgery, Northwest Hospitalgroup, Wilhelminalaan 12, 1815 JD Alkmaar, the Netherlands
| | - Markus Furrer
- Department of Surgery, Cantonal Hospital Graubünden, Loestrasse 170, 7000 Chur, Switzerland
| | - Christoph Sommer
- Department of Surgery, Cantonal Hospital Graubünden, Loestrasse 170, 7000 Chur, Switzerland
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Resuscitating extremities after soft tissue sarcoma resections: Are functional reconstructions an overlooked option in limb salvage? A systematic review. Eur J Surg Oncol 2019; 45:1762-1769. [DOI: 10.1016/j.ejso.2019.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 12/27/2022] Open
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Bridgham KM, El Abiad JM, Lu ZA, Bhat D, Darrach H, Morris CD, Levin AS, Sacks JM. Reconstructive limb‐salvage surgery after lower extremity soft tissue sarcoma resection: A 20‐year experience. J Surg Oncol 2019; 119:708-716. [DOI: 10.1002/jso.25358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/16/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Kelly M. Bridgham
- Department of Plastic and Reconstructive SurgeryThe Johns Hopkins University School of MedicineBaltimore Maryland
| | - Jad M. El Abiad
- Department of Orthopaedic SurgeryThe Johns Hopkins University School of MedicineBaltimore Maryland
| | - Zhen A. Lu
- Department of Plastic and Reconstructive SurgeryThe Johns Hopkins University School of MedicineBaltimore Maryland
| | - Deepa Bhat
- Department of Plastic and Reconstructive SurgeryThe Johns Hopkins University School of MedicineBaltimore Maryland
| | - Halley Darrach
- Department of Plastic and Reconstructive SurgeryThe Johns Hopkins University School of MedicineBaltimore Maryland
| | - Carol D. Morris
- Department of Orthopaedic SurgeryThe Johns Hopkins University School of MedicineBaltimore Maryland
| | - Adam S. Levin
- Department of Orthopaedic SurgeryThe Johns Hopkins University School of MedicineBaltimore Maryland
| | - Justin M. Sacks
- Department of Plastic and Reconstructive SurgeryThe Johns Hopkins University School of MedicineBaltimore Maryland
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Fractures after multimodality treatment of soft tissue sarcomas with isolated limb perfusion and radiation; likely to occur and hard to heal. Eur J Surg Oncol 2018; 44:1398-1405. [PMID: 29789188 DOI: 10.1016/j.ejso.2018.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Treatment associated fractures (TAFs) are known severe side effects after surgery and radiotherapy for soft tissue sarcoma (STS). There is no literature about TAF after multimodality treatment with isolated limb perfusion (ILP) for locally advanced STS. This study aimed to analyze predictive factors, treatment and outcome for TAF after multimodality treatment with ILP. METHOD Out of 126 consecutive patients undergoing ILP after 1991 till now, 25 patients were excluded due to no surgery or direct amputation at initial surgery. Therefore, 101 patients were at risk and 12 developed a TAF (12%). RESULTS The majority of tumors was located at the upper leg and knee (N = 60), and 11 patients developed a TAF (18%) after median 28 (5-237) months. Twenty-five tumors were located at the lower leg, and 1 patient developed a TAF after 12 months (4%). No patients with a tumor at the upper extremities (N = 16) developed a TAF. Ten out of 12 patients with a fracture received adjuvant RT with a dose of 50 Gy, and a median boost dose of 18 (10-20) Gy. Predictive factors were periosteal stripping, age over 65 years at time of treatment and tumor size after ILP ≥10 cm. Multivariate analysis showed periosteal stripping and tumor size after ILP ≥10 cm as significant predictive factors. The majority of the fractures were treated with intramedullary nailing. Only one of 12 patients without radiotherapy reached bone union (8%). The median survival after developing TAF was 18 (1-195) months. CONCLUSION The overall risk of TAF after multimodality treatment with ILP was relatively high with 15% at ten years. The incidence of TAF for patients with tumors located at the thigh and knee after resection with periosteal stripping and radiotherapy was even >50%. The treatment of these fractures is challenging due to the high non-union rate, requiring an extensive orthopedic oncological TAF experience.
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Tsukahara T, Emori M, Murata K, Mizushima E, Shibayama Y, Kubo T, Kanaseki T, Hirohashi Y, Yamashita T, Sato N, Torigoe T. The future of immunotherapy for sarcoma. Expert Opin Biol Ther 2016; 16:1049-57. [PMID: 27158940 DOI: 10.1080/14712598.2016.1188075] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION The use of immunotherapeutic challenges for sarcoma has a long history. Despite the existence of objective responses, immunotherapy has been overshadowed by the results of chemotherapy, especially for osteosarcoma. However, the prognosis for non-responders to chemotherapy is still poor and immunotherapy is now focused on again. AREAS COVERED We reviewed the following types of clinical trials of immunotherapy for sarcoma: (i) vaccination with autologous tumor cells, (ii) vaccination with peptides derived from tumor-associated antigens, (iii) adoptive cell transfer using engineered T cells expressing T cell receptor directed at NY-ESO-1 and (iv) immune checkpoint inhibitors targeting CTLA-4 and PD1/PDL1. EXPERT OPINION The immunogenicity of sarcoma might be lower than that of melanoma. Patients with small lesions who have not received any chemotherapy are good candidates for peptide-based immunotherapy. Combining peptide vaccination and immune checkpoint inhibitors is an attractive option, and long-lived memory T cells are attracting attention. Memory T stem cells defined by CD95+ are long-lived and have the capacity for self-renewal and multidifferentiation. We also identified a novel memory T cell population, young memory T cells defined by CD73+CXCR3+. Regulation of such memory T stem cells will be useful for peptide vaccination and adoptive cell transfer.
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Affiliation(s)
- Tomohide Tsukahara
- a Department of Pathology , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Makoto Emori
- b Department of Orthopaedic Surgery , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Kenji Murata
- a Department of Pathology , Sapporo Medical University School of Medicine , Sapporo , Japan.,b Department of Orthopaedic Surgery , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Emi Mizushima
- a Department of Pathology , Sapporo Medical University School of Medicine , Sapporo , Japan.,b Department of Orthopaedic Surgery , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Yuji Shibayama
- a Department of Pathology , Sapporo Medical University School of Medicine , Sapporo , Japan.,b Department of Orthopaedic Surgery , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Terufumi Kubo
- a Department of Pathology , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Takayuki Kanaseki
- a Department of Pathology , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Yoshihiko Hirohashi
- a Department of Pathology , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Toshihiko Yamashita
- b Department of Orthopaedic Surgery , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Noriyuki Sato
- a Department of Pathology , Sapporo Medical University School of Medicine , Sapporo , Japan
| | - Toshihiko Torigoe
- a Department of Pathology , Sapporo Medical University School of Medicine , Sapporo , Japan
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