When to ditch the ladder and take the elevator: The Anderson SArcoma Risk of Complications (A-SARC) score to guide reconstructive decision-making in extremity soft tissue sarcoma patients

BACKGROUND

The reconstructive ladder relies mostly on defect size and depth to determine reconstructive technique, however, in actuality, many more variables ultimately inform reconstructive decision making, especially regarding extremity soft tissue sarcoma (eSTS) defects. The purpose of this study was to describe eSTS patients who will most optimally benefit from an advanced method of reconstruction (defined as a pedicled regional flap or free flap) and to create a simple risk assessment scale that can be employed in clinical practice.

STUDY DESIGN

A single-institution retrospective cohort study examined patients undergoing resection of soft tissue sarcoma affecting the upper or lower extremities between 2016 and 2021. We categorized patients who required a pedicled or free flap as having had advanced reconstruction, and all other techniques were considered simple reconstruction. A regression was used to create a risk scale to guide reconstructive decision-making.

RESULTS

The following variables were identified as independent predictors of complications and used to create our risk scale: lower extremity tumor location, preoperative radiotherapy, tumor bed excision, male sex, hypertension, and tumor volume. Intermediate and high-risk patients reconstructed using simple techniques had significantly greater overall complication rates compared to those reconstructed with advanced techniques. Major complications were significantly greater in low-risk patients reconstructed with advanced techniques.

CONCLUSIONS

To minimize postoperative wound complications, low-risk patients should receive simple methods of reconstruction, whereas high-risk patients should be reconstructed using advanced techniques.

Identifying risk factors and analyzing reconstructive outcomes in patients with lower-extremity soft-tissue sarcoma

PURPOSE

Reconstructing defects after resecting soft-tissue sarcoma (STS) can be challenging. The aim of this retrospective study was to analyze the reconstructive outcomes and identify the potential risk factors in patients undergoing reconstruction after excision of lower-extremity STS.

METHODS

Patients with lower-extremity STS were included. This database was compiled of patients from a single, large National Cancer Institute-accredited academic hospital. In total, 302 patients were included between January 2016 to January 2022. Univariate and multivariate analyses were performed to calculate odds ratios (ORs) for developing complications for each patient and surgical characteristic.

RESULTS

The following factors were independent predictors of any complication: benign pulmonary disease (OR = 4.2; p = 0.02), preoperative radiotherapy (RT; OR = 2.5; p = 0.047), a tumor in the medial thigh (OR = 1.9; p = 0.03), body mass index (BMI) > 30 kg/m2 (OR = 1.05; p = 0.037), and full-thickness skin graft (OR = 5.4; p = 0.01). In the preoperative RT subgroup, reconstructing a defect via undermining and layered closure alone was an independent predictor of dehiscence (OR = 2.1; p = 0.02) and seroma (OR = 3.1; p = 0.02), whereas pedicled flaps (OR = 0.08; p = 0.001) and free flaps (OR = 0.05; p = 0.001) were independent protectors against any complication.

CONCLUSION

Information derived from this analysis will assist with accurate preoperative patient counseling, which is crucial for informed decision-making and expectation management in lower-extremity STS. BMI and pulmonary function should be optimized to the extent possible to reduce postoperative complications. Patients treated preoperatively with RT should be reconstructed with a pedicled or free flap to optimize recovery.

Association of hypercoagulable states and increased platelet adhesion and aggregation with bacterial colonization of intravenous catheters

Bacterial adherence to intravenous catheters may be mediated, in part, by adherence to coagulation proteins and platelets. The possibility that catheter infection is associated with gene polymorphisms that cause hypercoagulability or increased platelet stickiness was examined. Among patients with infected catheters, there was no increase in the frequency of polymorphisms that increase coagulability, including factor V Leiden R506G, factor II (prothrombin) G20210A, and methylenetetrahydrofolate reductase C677T, compared with control subjects. The incidence of polymorphisms of the platelet beta(3) integrin among patients with infected catheters was also similar to that among control subjects. The C/D heterozygote of the variable number tandem repeat polymorphism and the C/T heterozygote of the KO polymorphism of glycoprotein Ibalpha were more frequent among patients with infected catheters than they were among control subjects. In a small proportion of patients, a genetic predisposition to platelet stickiness may be associated with infection of intravenous catheters, but in the majority, a recognized genetic tendency to hypercoagulability or platelet stickiness does not underlie infection.