Sauvetage des membres atteints de sarcome localement évolué. La triade innovante : perfusion de membre isolé sous CEC, TNFα, et transplant microchirurgical

Abstract

We retrospectively studied the benefits of isolated limb perfusion combined with TNFalpha administration and free flap reconstruction in locally advanced soft-tissue sarcomas of the limbs. Between 2000 and 2008, we treated 37 patients (22 women and 15 men) with locally advanced soft tissue sarcomas. The sarcomas were located in the lower and upper limbs in respectively 26 and 11 cases, and had a mean diameter of 15 cm and 12 cm, respectively. They were multifocal in 8 cases and recurrent in 15 cases. Seventeen patients received neoadjuvant chemotherapy. Sarcoma excision was combined with a complementary procedure in 10 patients (vascular graft or nerve anastomosis). Reconstruction was performed with free flaps of the latissimus dorsi (n = 31), transverse rectus abdominis myocutaneous flaps (n = 4) or free forearm flaps (n = 2). Early postoperative radiotherapy was administered in 25 cases. Three major improvements were made in recent years, namely isolated limb perfusion, TNFalpha administration, and free flap reconstruction two months after resection of residual sarcoma. There were no early postoperative deaths. The procedure lasted a median of 7 hours. Two free flaps necrotized, and a new free flap was created with success. Tumor excision was stage R0 in 29 cases (clean margins), R1 in 7 cases (microscopic residue), and R2 in one case (macroscopic residue). With a median follow-up of 5 years, there were no local recurrences in R0 patients, and the overall survival rate was 65%. The limb was preserved in 78% of cases. Thirteen patients developed pulmonary metastases and seven of them died between the first and fifth years of follow-up. Isolated limb perfusion and free flap reconstruction permitted more extensive tumor excision. Amputation was avoided in 78% of our 37 patients, and early postoperative radiotherapy was possible in 25 cases.