Plastic surgery for the oncological patient

Outcome of Surgery as Part of Palliative Care of Patients with Symptomatic Advanced or Metastatic Extra-Abdominal High-Grade Soft Tissue Sarcoma

Background

The modern multimodal treatment of malignant tumors has increased disease-specific survival and decreased the burden of tumor-associated complications. The main focus of palliative surgery is not based primarily on quantitative success parameters of tumor response but is instead mainly on the question of quality of life.

Aim

The current study was conducted to analyze the clinical and oncological outcomes of palliative patients with soft tissue sarcoma.

Design

Of 309 patients with extra-abdominal high-grade soft tissue sarcoma treated between August 2012 and December 2014, our retrospective analysis revealed 33 palliative patients for this study. All patients were evaluated and managed by a multidisciplinary team with expertise and experience in sarcoma treatment. The survival analysis was made using the Kaplan-Meier method.

Results

The main sarcoma symptoms were pain (27.3%) and ulcerated tumors or shortly before ulceration (24.2%). Thirteen patients (39.4%) were operated on with negative margins, 15 (45.5%) with positive margins, 2 with tumor debulking (6.1%), and 3 patients (9.1%) were treated only with palliative hyperthermic isolated limb perfusion. Ten pedicle flaps were performed after sarcoma resection. The median operation time was 85 minutes (range, 37-216 minutes). The median hospitalization stay was 9.5 days (range, 3-27 days). No patients died during hospitalization. Twelve-month disease-free survival was 48.5% (95% confidence interval: 45.4-51.6).

Conclusions

Palliative surgery of metastatic or advanced soft tissue sarcoma can improve the wound care and quality of life. Closed noninfected wounds enable further treatment options, such as chemotherapy, immunotherapy, and radiotherapy. This surgery should be considered during the discussion on interdisciplinary tumor boards.

Palliative Free Flap Surgery for Plantar Sarcoma: A Case Report and Literature Review

We report a case of palliative surgery in a 73-year-old patient with metastatic plantar sarcoma. The patient underwent resection and irradiation of an undifferentiated spindle cell sarcoma in the right plantar region. The wound was not closed and systemic metastases were observed. The chief complaint of the patient on his first visit to our department was difficulty walking due to pain in the right plantar region. Since we were unsuccessful in relieving the pain with conservative treatment, we decided to perform a palliative free tissue transfer to the right plantar. The surgery was successful, the skin ulcer healed, and the pain was relieved after the surgery. When performing palliative surgery, more detailed preoperative management and planning are necessary to achieve a successful outcome. The selection of the flaps according to the local lesion and metastatic lesions and changes in the local hemodynamics should be considered when planning.

Current Surgical Therapy of Locally Advanced cSCC: From Patient Selection to Microsurgical Tissue Transplant. Review

Among the non-melanoma skin cancers (NMSC) the squamous cell carcinoma (SCC) is one of the most challenging for the surgeon. Local aggressiveness and a tendency to metastasize to regional lymph nodes characterize the biologic behavior. The variants locally advanced and metastatic require wide excision and node dissection. Such procedures can be extremely detrimental for patients. The limit of the surgery can be safely pushed forward with a multidisciplinary approach. The concept of skin oncoplastic surgery, the ablative procedures and the reconstructive options (skin graft, pedicled flap, microsurgical free flap) are discussed together with a literature review.

[Soft tissue defects following tumor resection in the limbs and trunk : Plastic reconstructive soft tissue and revision concepts]

BACKGROUND

Tissue defects of the trunk and limbs after oncologic surgery and radiation require plastic reconstructive tissue coverage. Depending on the location and size of the wound as well as the interdisciplinary treatment concept, different reconstructive procedures are performed. These range from skin transplantation to local and pedicle flaps, to perforator flaps and free microsurgical tissue transfer.

METHODS

The modern "reconstructive ladder" can be regarded as an orientation for the sequence of the reconstructive options. Considering the patient's wishes and risk profile, an individual reconstructive concept must be devised. The best functional and simultaneously safest procedure with the smallest secondary defect is to be chosen. Wound preconditioning via vacuum-assisted closure can precede definitive tissue coverage in order to optimize local conditions.

CONCLUSION

Safe tissue coverage can be achieved even in advanced stages of oncologic disease and after extensive surgery by performing wound preconditioning and arteriovenous loop grafting to induce safe de novo recipient vessels for two-stage free tissue transfer. The choice between maximum plastic reconstructive options for a curative approach or limited palliative surgery is to be harmonized and balanced with therapeutic goals and the patient's biologic resources. Preservation and restoration of quality of life and functionality is the plastic surgeon's dictum.

Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases

PURPOSE

The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects.

PATIENTS AND METHODS

179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques.

RESULTS

In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps.

CONCLUSIONS

Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.

Microsurgical Reconstruction of Extensive Oncological Scalp Defects

Although most small to medium defects of the scalp can be covered by local flaps, large defects or complicating factors, such as a history of radiotherapy, often require a microsurgical reconstruction. Several factors need to be considered in such procedures. A sufficient preoperative planning is based on adequate imaging of the malignancy and a multi-disciplinary concept. Several flaps are available for such reconstructions, of which the latissimus dorsi and anterior-lateral thigh flaps are the most commonly used ones. In very large defects, combined flaps, such as a parascapular/latissimus dorsi flaps, can be highly useful or necessary. The most commonly used recipient vessels for microsurgical scalp reconstructions are the superficial temporal vessels, but various other feasible choices exist. If the concomitant veins are not sufficient, the jugular veins represent a safe back-up alternative but require a vessel interposition or long pedicle. Post-operative care and patient positioning can be difficult in these patients but can be facilitated by various devices. Overall, microsurgical reconstruction of large scalp defects is a feasible undertaking if the mentioned key factors are taken into account.