Preoperative Radiotherapy and Wide Resection for Soft Tissue Sarcomas: Achieving a Low Rate of Major Wound Complications with the Use of Flaps. Results of a Single Surgical Team.

Lester Wai Mon Chan,Peter Choong,Damien Glen Grinsell,Jungo Imanishi

doi:10.3389/fsurg.2017.00079

Lester Wai Mon Chan, Peter Choong + Show 2 more

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https://doi.org/10.3389/fsurg.2017.00079

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Abstract

Surgery in combination with radiotherapy (RT) has become the standard of care for most soft tissue sarcomas. The choice between pre- and postoperative RT is controversial. Preoperative RT is associated with a 32-35% rate of major wound complications (MWC) and 16-25% rate of reoperation. The role of vascularized soft tissue "flaps" in reducing complications is unclear. We report the outcomes of patients treated with preoperative RT, resection, and flap reconstruction. 122 treatment episodes involving 117 patients were retrospectively reviewed. All patients were treated with 50.4 Gy of external beam radiation. Surgery was performed at 4-8 weeks after completion of RT by the same combination of orthopedic oncology and plastic reconstructive surgeon. Defects were reconstructed with 64 free and 59 pedicled/local flaps. 30 (25%) patients experienced a MWC and 17 (14%) required further surgery. 20% of complications were exclusively related to the donor site. There was complete or partial loss of three flaps. There was no difference in the rate of MWC or reoperation for complications with respect to age, sex, tumor site, previous unplanned excision, tumor grade, depth, and type of flap. Tumor size ≥8 cm was associated with a higher rate of reoperation (11/44 vs 6/78; P = 0.008) but the rate of MWC was not significant (16/44 vs 14/78; P = 0.066). The use of soft tissue flaps is associated with a low rate of MWC and reoperation. Our results suggest that a high rate of flap usage may be required to observe a reduction in complication rates.

Highlights

Surgery in combination with radiotherapy (RT) has become the standard of care for soft tissue sarcomas (STSs) of the extremity and trunk [1,2,3], the choice between preoperative vs postoperative RT continues to be controversial [4, 5]
The main disadvantage of preoperative RT is the high rate of postoperative wound complications
The reported rates are variable and partially dependent on the definition used; the rate of major wound complications (MWCs) as defined by the Canadian Clinical Trials Group is around 32–35% with 16–25% of patients requiring further surgery for complications [4, 7,8,9,10,11,12,13]

Summary

Introduction

Surgery in combination with radiotherapy (RT) has become the standard of care for soft tissue sarcomas (STSs) of the extremity and trunk [1,2,3], the choice between preoperative vs postoperative RT continues to be controversial [4, 5]. All three factors are negatively affected in the preoperatively irradiated sarcoma wound All these factors can be improved with the use of vascularized soft tissue flaps [14]. While flaps are commonly used for the closure of soft tissue defects, only one historical series has demonstrated a reduction in the rate of wound complications [15] with the majority of the literature reporting no difference in outcomes [10, 11, 13, 16,17,18,19]. We report the outcomes of patients treated with preoperative RT, resection, and flap reconstruction

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