Resection Of Extremity Soft Tissue Sarcomas Research Articles

Comparison of the incidence of wound complications with preoperative and postoperative radiotherapy in patients with extremity soft tissue sarcoma resection: A meta-analysis.

We performed a meta-analysis to compare the effect of preoperative and postoperative radiotherapy on wound complications after resection of extremity soft tissue sarcoma (ESTS). A comprehensive computerised search of the PubMed, Cochrane Library, Web of Science, EMBASE, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang databases was conducted from their inception to August 2023 to identify studies comparing the effect of preoperative and postoperative radiotherapy on wound complications after ESTS resection. Two investigators independently screened the literature, extracted the data, and assessed the quality of the articles. The meta-analysis was performed using RevMan 5.4 software. Nine studies with 1271 patients were included, with 631 and 640 patients in the preoperative and postoperative radiotherapy groups, respectively. The results showed that the incidence of postoperative wound complications after ESTS resection was significantly higher with preoperative radiotherapy than with postoperative radiotherapy (27.26% vs. 12.03%, odds ratio [OR]: 2.88, 95% confidence interval [CI]: 2.12-3.91, p < 0.001). However, the rate of local recurrence of ESTS was significantly lower with preoperative radiotherapy than with postoperative radiotherapy (8.75% vs. 14.81%, OR: 0.57, 95% CI: 0.36-0.91, p = 0.02), and the 3-year overall survival was significantly higher in the preoperative radiotherapy group than in the postoperative radiotherapy group (82.24% vs. 70.04%, OR: 1.97, 95% CI: 1.05-3.71, p = 0.03). This pooled analysis suggests that although preoperative radiotherapy increases the rate of wound complications in ESTS compared with postoperative radiotherapy, it significantly reduces the rate of local recurrence after ESTS resection and improves the overall survival of patients. Owing to the limitations in the number and quality of the included studies, additional prospective cohort studies or randomised controlled trials are required to confirm these findings.

Venous Reconstruction in Extremity Soft Tissue Sarcoma Is Not Essential.

Limb salvage is an important concern following complete oncologic resection for extremity soft tissue sarcoma (STS). Vascular reconstruction is essential for limb salvage. The purpose of this study was to evaluate the outcomes of vascular reconstruction in patients with extremity STS. This is a retrospective, multi-center, case series of consecutive patients who underwent vascular reconstruction during extremity STS resection at 2 major centers in Korea. Demographics, reconstruction methods, type of conduit, surgical complications, graft patency, limb salvage rate, and patient survival were reviewed. From March 2005 to December 2020, 43 patients underwent vascular reconstructions during STS resection. Among the patients, 22 (51.2%) received arterial only, and 21 (48.8%) received simultaneous arterial and venous reconstructions. For the types of conduits, autologous saphenous veins (56.2%), artificial grafts (26.3%), and cryopreserved allografts (15.8%) were used. During a median follow-up of 23.8 months (interquartile range; 7.7-54.5), the overall primary patency of the reconstructed vessels was significantly higher in arteries than in veins (82.5% vs 56.3% at 12 months, P < .001). According to the type of conduit, the primary patency rate of autogenous vein seemed higher in venous reconstruction, however, there was no statistical significance in both arterial and venous reconstruction. There was no significant difference in primary arterial patency rate (P = .132) or incidence of surgical complications including postoperative edema or wound problem whether or not simultaneous venous reconstruction was performed with arterial reconstruction. The overall limb salvage rate and patient survival were 97.4%, 95.1%, and 89.4% and 91.9%, 81.7%, and 65.4% at 12, 24, and 36 months, respectively. Patency rates were poorer in venous reconstruction than in arterial reconstruction. In terms of arterial patency and postoperative complication, the role of simultaneous arterial and venous reconstruction seems not essential, however, it needs to be evaluated in future studies.

Reconstruction of Soft Tissue Defect With a Free Vascularized Anterolateral Thigh Flap After Resection of Soft Tissue Sarcoma in Extremities.

ObjectiveThis study aims to determine outcomes and complications in functional reconstruction of soft tissue defects after surgical resection for soft tissue sarcomas (STSs) of extremities.MethodsA retrospective chart review was performed on patients with STSs of extremities from May 2015 to April 2019 who underwent radical resection of STSs and reconstruction of soft tissue defect with free vascularized anterolateral thigh flap (FVALTP). A minimum 3‐month follow‐up was required for all the patients. Patient demographics and comorbidities, flap characteristics, postoperative complications, and time to heal were recorded. The functional outcomes of the reconstructed limbs were assessed by the Musculoskeletal Tumour Society（MSTS） scoring system.ResultsA total of 11 patients (four males and seven females) were included in the study. The mean age was 62 years (range: 29–84 years). The mean surface area was 151.4 cm2 (range: from 64 cm2 to 418cm2). The mean operation time was 126 min (range: 95–296 min). The mean follow‐up was 17.5 months (range: 6–34 months). The mean score of MSTS at last follow‐up was 26.2 (range: 12–29). Incision healed by first intention in eight patients. Incision healed by second intention in three patients. A patient who had received preoperative radiotherapy experienced delayed union. After debridement, the patient successfully got union. Another two patients experienced marginal necrosis of flap due to vascular crisis. After 3‐week dressing changes, the patients also got satisfactory union. One case suffered from vascular crisis during surgery in which the procedure was changed into skin grafting to cover resection site.ConclusionFVALTP technique can be effectively applied to the reconstruction of soft tissue defect after STSs resection. The short‐term follow‐up indicated satisfactory functional outcome and low incidence of previously known complications. It was necessary to further validate its efficacy in reconstruction of soft tissue defect after malignant extremity soft tissue sarcoma resection.

Vascular reconstruction using autologous vs synthetic graft for patients with extremity soft-tissue sarcoma involving the major vessels.

Arterial reconstruction after radical limb-sparing resection of extremity soft-tissue sarcoma (STS) involving great vessels is necessary. However, there is no agreement upon the optimal vascular substitute. This study prospectively evaluated the major vascular reconstructions in extremity STS surgery with vascular involvement. Between June 2017 and August 2019, 29 patients having extremity STS with major vascular reconstruction were enrolled. Recurrent, metastatic STSs or STSs of vascular origin were excluded. Patients were non-randomly divided into two groups according to the type of arterial substitute: group I, autologous graft (16 patients) and group II, synthetic graft (13 patients). Graft patency, postoperative morbidity, and patient and limb survival were analyzed. The mean follow-up was 12 months (range, 6-26). Early postoperative complications and overall survival were nonsignificantly different between groups. The 1-year primary patency was 92.85% vs 90% in groups I vs II, respectively, P = .704. Graft occlusion was nonsignificantly greater in the synthetic group, P = .107. Limb salvage was 93.75% in group I compared with 92.3% in group II, P = .87. Graft choice should be based on autologous vein suitability regarding its length and caliber. If such requirements are not available, synthetic substitutes can be used with close surveillance of patency.

Morbid Obesity Is Associated With an Increased Risk of Wound Complications and Infection After Lower Extremity Soft-tissue Sarcoma Resection.

Obesity is associated with wound complications after lower extremity surgery. Excision of soft-tissue sarcomas is urgent, and unlike the elective surgery, obesity cannot be modified preoperatively. The purpose of this study was to evaluate the effect of obesity on treatment outcome. Six hundred fifty-three patients (343 men; mean age, 56 ± 18 years) with a lower extremity soft-tissue sarcoma were reviewed. The mean body mass index (BMI) was 27.1 ± 5.7 kg/m, with 189 obese patients (29%) having a BMI of ≥30 kg/m and 27 morbidly obese patients (4%) having a BMI of ≥40 kg/m. Complications and functional and oncologic outcomes were compared between groups. Two hundred eighty-five patients (40%) sustained a postoperative complication, most commonly a dehiscence (n = 175; 24%) and infection (n = 147; 21%). On multivariate analysis, morbid obesity was associated with wound complications (P = 0.002) and infection (P = 0.01). Morbid obesity was not associated with local tumor recurrence (P = 0.56). No difference was found in the mean Toronto Extremity Salvage Score (P = 0.11) or Musculoskeletal Tumor Society (P = 0.41) scores between the groups. Morbid obesity was associated with postoperative wound complications and infection. However, after surgery, obese patients can expect no difference in oncologic outcome, with an excellent functional result.

Reconstructive limb-salvage surgery after lower extremity soft tissue sarcoma resection: A 20-year experience.

Reconstructive surgery is often required following lower extremity soft tissue sarcoma resection. The relationship between the method of plastic surgery reconstruction and postoperative wound healing or functional oncologic outcomes in this patient population is poorly understood. We performed a retrospective review on all adult patients that underwent soft tissue reconstruction following resection of lower extremity soft tissue sarcomas between 1996 and 2016 at our institution. One hundred and thirty-six patients were identified. Wound complications occurred within 6-months postoperatively in 72 patients (52.9%). Average time to heal was 13.0 weeks. Limb survival was 94.9%. 16.9% and 36.8% of patients had evidence of local recurrence or metastatic disease, respectively. There was no significant difference in the incidence of overall wound complications, time to heal, limb survival, local recurrence, or metastatic disease between the different reconstructive methods. In our cohort, the utilization of different reconstructive techniques did not correlate with a difference in postoperative wound complications or oncologic outcomes. Local flaps can effectively reconstruct the majority of lower extremity sarcoma defects that cannot be closed primarily. However, alternative reconstructive techniques may be utilized when indicated without a significant increase in postoperative morbidity in this patient population.

Abstract: Outcomes of Reconstructive Limb-Salvage Surgery in Lower Extremity Soft Tissue Sarcomas: A 20-Year Experience

INTRODUCTION: Extremity sarcoma management follows a multidisciplinary approach involving orthopedic oncologists, plastic surgeons, medical oncologists, and radiation oncologists. Surgical resection of lower extremity soft tissue sarcomas often leads to large, complex defects with exposure of underlying neurovascular structures, tendons, and/or bone. Subsequent reconstructive surgery is often required in order to provide adequate soft tissue coverage and allow for functional preservation of the limb. We report our 20-year experience with limb-salvage surgery following lower extremity soft tissue sarcoma resection. METHODS: We performed a retrospective review on all patients 18 years or older at the time of operation that underwent soft tissue reconstructive surgery following resection of lower extremity soft tissue sarcomas between 1996 and 2016 at our institution. Medical records were reviewed for patient demographics, tumor characteristics, details of tumor resection and plastic surgery reconstruction, administration and timing of chemo/radiation therapy, and postoperative outcomes. RESULTS: 136 patients underwent plastic surgery reconstruction following tumor resection. The average age was 55.7 years. The majority of tumors were high grade (47.1%), greater than 5 cm (66.9%), AJCC stage 3 (38.2%) and located in the proximal thigh (41.2%). 93.4% of reconstructive procedures were performed in the same operative setting as the oncologic resection. Approximately 90% of the advanced plastic surgery reconstructions involved a flap for coverage. Local flap reconstruction was most common for proximal thigh wounds (69.6%) and microvascular free flap reconstruction was most common for distal leg wounds (60.9%) (p=0.013). Skin grafts alone were most common for tumors ≤5cm (p=0.043), superficial wounds (p=0.001), and re-excisions (p=0.029) due to incomplete margins or recurrent disease. In conjunction with surgery, seventy-two patients (52.9%) received neoadjuvant radiation and twenty-six patients (19.1%) received neoadjuvant chemotherapy. The utilization of neoadjuvant radiation or neoadjuvant chemotherapy was not associated with the type of reconstruction utilized following tumor resection. Wound complications occurred within 6-months postoperatively in 52.9% of patients. The most common complication was wound dehiscence (26.4%), followed by infection (18.4%), and seroma (15.4%). Thirty-two patients (23.5%) required a re-operation for wound complications. Average time to healing was 13.0 weeks. Limb survival was 94.9%. There was no significant difference in the incidence of overall wound complications, re-operations, time to heal, or limb survival, between patients receiving local flap, free flap, or skin graft coverage. 16.9% and 36.8% of patients had evidence of local recurrence or metastatic disease through last known follow up, respectively. There was no significant difference in local recurrence or metastatic disease between the different reconstructive techniques. CONCLUSION: Patients with extensive lower extremity soft tissue defects often require plastic surgery soft tissue reconstruction after sarcoma resection. Based on our results, in patients that cannot undergo primary closure, local flaps can effectively reconstruct the majority of lower extremity sarcoma defects. However, microvascular free tissue transfer may be warranted for large wounds, areas of previous irradiation damage, or in the distal lower extremity. The post-operative management of sarcoma patients remains challenging due to high rates of wound complications. Local recurrence and metastatic disease confer additional morbidity and mortality in this patient population.

Patient Reported Outcomes Following Lower Extremity Soft Tissue Sarcoma Resection with Microsurgical Preservation of Ambulation.

Lower extremity soft tissue sarcoma treatment has evolved from primarily amputation procedures toward limb salvage. This series assesses whether soft tissue sarcoma tissue defects, extensive enough to require microsurgical reconstruction, can reliably result in preservation of ambulation, as well as objectively evaluate functional outcomes utilizing a patient-reported validated scale. It will also look at whether immediate functional muscle reconstructions and tendon transfers can be successful at restoring ambulation, potentially expanding the indications for limb salvage procedures. A retrospective review of all microsurgical reconstructions for limb salvage in lower extremity sarcoma patients was completed at our institution (2009-2013). Patients were additionally asked to complete the Toronto Extremity Salvage Score(TESS) quality of life survey. Over a 5-year period, 23 patients (mean age: 53 years) underwent free flap reconstructions for 23 sarcomas (mean follow-up: 14 months). Seventy-eight percent of patients received neoadjuvant radiation. The thigh was the most common tumor site (61%) and three muscles were resected on average. Perforator flaps were most frequently used (61%), and functional muscle transfers or immediate tendon transfers were used in four patients. There were no flap take-backs or failures, and 22 patients achieved independent ambulation. Three patients in the series died, two from metastatic disease found postoperatively and one from local recurrence. A 74% response rate was achieved for the TESS survey, with a mean score of 83. Microsurgical reconstruction of lower extremity sarcoma defects enables preservation of independent ambulation. Restoration of function utilizing immediate functional microsurgical reconstructions and tendon transfers should be considered.

Flap choice does not affect complication rates or functional outcomes following extremity soft tissue sarcoma reconstruction

Flap reconstruction plays an essential role in facilitating limb preservation in patients with extremity soft tissue sarcoma (ESTS). However, the effect of flap choice on the rates of postoperative complications and functional outcomes has not been clearly established. This study directly compares the outcomes of free and pedicled flap reconstructions in patients with ESTS. Two hundred sixty-six patients who underwent flap reconstruction following ESTS resection were included. Associations between flap type and complications were determined using logistic regression analyses. Functional outcome was evaluated using the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumor Society Scales (MSTS). There was no significant difference between complication rates in the pedicled and free flap groups (32% vs. 38%, p = 0.38). In the lower limb, pedicled flaps had complication rates similar to those of free flaps on univariate analysis (odds ratio [OR] = 1.12, 95% confidence interval [CI] = 0.56-2.26, p = 0.75). Conversely, in the upper limb, pedicled flaps were associated with fewer complications on univariate analysis (OR = 0.31, 95% CI = 0.11-0.86, p = 0.03), but this was not significant on multivariate analysis (OR = 0.45, 95% CI = 0.13-1.59, p = 0.22). Obesity was a strong predictor of complications in the upper limb group on multivariate analysis (body mass index [BMI] ≥ 30 kg/m2, OR = 7.01, 95% CI = 1.28-38.51, p = 0.03). There was no significant difference in functional outcomes between both flap groups in either upper or lower limbs. Postoperative complications and functional outcomes for patients undergoing free and pedicled flaps are similar in ESTS reconstruction. Selecting the most suitable reconstructive option in each individual case is paramount to preserving function while minimizing postoperative morbidity.

Therapeutic options and postoperative wound complications after extremity soft tissue sarcoma resection and postoperative external beam radiotherapy.

Soft tissue sarcomas occur most commonly in the lower and upper extremities. The standard treatment is limb salvage surgery combined with radiotherapy. Postoperative radiotherapy is associated with wound complications. This systematic review aims to summarise the available evidence and review the literature of the last 10 years regarding postoperative wound complications in patients who had limb salvage surgical excision followed by direct closure vs flap coverage together with postoperative radiotherapy and to define the optimal timeframe for adjuvant radiotherapy after soft tissue sarcomas resection and flap reconstruction. A literature search was performed using PubMed. The following keywords were searched: limb salvage, limb-sparing, flaps, radiation therapy, radiation, irradiation, adjuvant radiotherapy, postoperative radiotherapy, radiation effects, wound healing, surgical wound infection, surgical wound dehiscence, wound healing, soft tissue sarcoma and neoplasms. In total, 1045 papers were retrieved. Thirty-seven articles were finally selected after screening of abstracts and applying dates and language filters and inclusion and exclusion criteria. Plastic surgery provides a vast number of reconstructive flap procedures that are directly linked to decreasing wound complications, especially with the expectant postoperative radiotherapy. This adjuvant radiotherapy is better administered in the first 3-6 weeks after reconstruction to allow timely wound healing and avoid local recurrence.

Use of negative pressure wound therapy as an adjunct to the treatment of extremity soft-tissue sarcoma with ulceration or impending ulceration.

Major wound complications of the extremities, following wide tumor resection and reconstruction for soft-tissue sarcomas (STSs), remain a challenge for limb-sparing surgery. Furthermore, STSs with ulceration or impending ulceration predispose patients to an increased risk of post-operative infection. The present study was conducted to assess the efficacy of negative pressure wound therapy (NPWT) in preventing wound complications associated with surgical treatment of STSs with ulceration or impending ulceration, in patients treated between February 2012 and January 2013. A total of 5 patients, with a mean age of 48 years (range, 24-68 years), were enrolled in the present study. The diagnoses consisted of undifferentiated pleomorphic sarcoma (n=2), leiomyosarcoma (n=1), synovial sarcoma (n=1) and epithelioid sarcoma (n=1). According to American Joint Committee on Cancer criteria, 3 cases were stage III tumors, and the remaining 2 cases were of stages IIA and IIB, respectively. A total of 3 patients exhibited ulceration at diagnosis, and the remaining patients demonstrated impending ulceration. The mean wound area following wide resection of the tumor was 73 cm2 (range, 45-110 cm2). A continuous suction mode, with pressures measuring -200 to -300 mmHg, was used for 7-10 days on the soft-tissue defects as preparation for wound closure. Soft-tissue reconstruction included muscle flaps (n=2) and skin grafts (n=5). No major wound complications occurred. Post-operative functional and cosmetic outcomes were acceptable. A single patient demonstrated local recurrence 12 months after surgery and re-excision of the tumor was performed. All patients remained alive at the conclusion of follow-up, with a mean follow-up time of 26 months (range, 12-36 months). The present study demonstrated that NPWT is effective and safe when used as an adjunct to wound closure following resection of extremity STS with ulceration/impending ulceration.

Concomitant upper extremity soft tissue sarcoma limb-sparing resection and functional reconstruction: assessment of outcomes and costs of surgery.

The purpose of this study is to investigate functional outcomes and cost impacts of immediate functional reconstruction performed in conjunction with limb-sparing resection of upper extremity soft tissue sarcomas. Patients undergoing simultaneous limb-sparing upper extremity soft tissue sarcoma resection and functional reconstruction between December 1998 and March 2004 were retrospectively identified, their medical records reviewed, and costs of surgery analyzed. Functional outcomes and patient satisfaction were assessed via patient surveys and the Toronto Extremity Salvage Score (TESS). Thirteen patients met the inclusion criteria. Average follow-up was 43.3months. Reconstructions included rotational innervated muscle flaps (n = 6), free innervated myocutaneous flaps (n = 1), and tendon transfers or grafts (n = 6). Overall survival was 85% (n = 11) and disease-free survival was 77% (n = 10). Average total cost of surgery was $26,655. Patients undergoing reconstruction for hand and forearm sarcomas had significantly higher total costs of surgery than those undergoing reconstruction for elbow and upper arm sarcomas. Survey response rate was 91% (n = 10). Average TESS score was 76. Of the patients who worked preoperatively, 88% returned to work postoperatively, and all patients who returned to work currently use their affected limb at work. Patients undergoing immediate functional reconstruction for upper extremity soft tissue sarcoma resection achieved very good to excellent functional outcomes with quick recovery times and a high return-to-work rate following immediate functional reconstruction, thereby minimizing surgical cost impacts. Immediate functional reconstruction in the same surgical setting is thus a viable strategy following upper extremity soft tissue sarcoma resection.

The Effect of Preoperative Radiotherapy and Reconstructive Surgery on Wound Complications after Resection of Extremity Soft-Tissue Sarcomas

The Effect of Preoperative Radiotherapy and Reconstructive Surgery on Wound Complications after Resection of Extremity Soft-Tissue Sarcomas

The Effect of Preoperative Radiotherapy and Reconstructive Surgery on Wound Complications after Resection of Extremity Soft-Tissue Sarcomas

Major wound complications (MWCs) are frequent after preoperative radiotherapy (RT) for extremity soft-tissue sarcoma (STS). We examined the rate of MWCs at a single institution with readily available reconstructive surgery. The medical records of consecutively treated extremity STS patients treated with preoperative external-beam RT and surgical resection from June 1996 through February 2003 were reviewed. Patients underwent RT (median 50 Gy), followed by resection 4-8 weeks later. Patients believed to be at higher risk for MWC underwent wound closure by the reconstructive surgery service (RSS). MWCs included secondary operation, invasive procedure, hospital readmission, or persistent deep packing or dressing changes. A total of 173 patients underwent preoperative RT. Median age was 54 years; 51% were female; 80% had lower extremity STS. Wound closure was performed by the primary surgeon in 91 cases (53%). The RSS performed wound closure in the remaining 82 patients (47%). One or more MWCs occurred in 55 patients (32%). Wound complications were more likely in patients with lower extremity (49/138, 36%) than upper extremity (6/35, 17%) STS (P = 0.03). Among patients with lower-risk wounds closed by the primary surgical team, 29 (32%) experienced MWC, whereas in the higher-risk patients closed by the RSS, MWC occurred in 26 (32%). MWCs are frequent after preoperative RT and occur more commonly in patients with lower extremity tumors. The MWC rate observed in a single-institution setting was comparable to that observed in the preoperative therapy arm of a multicenter Canadian trial. Patients believed to be at higher risk for MWCs undergoing RSS closure have MWC rates comparable to those with lower-risk wounds closed by the primary team.