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Gudefin S, Weiss A, Ciucur E, Herlin C. [Rare case of reconstruction of the anterior thigh compartment after resection of high-grade sarcoma by hybrid technique: Latissimus dorsi free flap associated with a medial gastrocnemius pedicled flap]. ANN CHIR PLAST ESTH 2024; 69:207-211. [PMID: 37271656 DOI: 10.1016/j.anplas.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/06/2023]
Abstract
INTRODUCTION The soft tissue sarcomas of the limbs require extensive surgical excision. Reconstructive surgery plays an essential role in its management to preserve the limb, as exposed in a case of thigh sarcoma. CLINICAL CASE A 73-year-old patient has a large sarcoma within the quadriceps. Its excision requires resection of the entire anterior thigh compartment. Preservation of the limb is permitted by reconstruction by latissimus dorsi free flap and medial gastrocnemius pedicled flap. The patient resumed walking using an orthosis at 3 months. CONCLUSION Surgery to remove a sarcoma of a limb can threaten the integrity of the limb. Plastic surgery, with all the reconstruction techniques, contributes to the preservation of a functional limb.
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Affiliation(s)
- S Gudefin
- Service de chirurgie plastique, reconstructrice et esthétique, CHU de Carrémeau, place du Pr.-Robert-Debré, 30029 Nîmes, France.
| | - A Weiss
- Service de chirurgie orthopédique, traumatologique et chirurgie du rachis, CHU de Carrémeau, place du Pr.-Robert-Debré, 30029 Nîmes, France
| | - E Ciucur
- Service de chirurgie plastique, reconstructrice et esthétique, CHU de Carrémeau, place du Pr.-Robert-Debré, 30029 Nîmes, France
| | - C Herlin
- Chirurgie plastique reconstructrice et esthétique - brûlés, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France
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Krijgh DD, Smith JM, Tilney G, Lyu H, Traweek RS, Witt RG, Roubaud MJ, Correa AM, Roland CL, Mericli AF. Identifying risk factors and analyzing reconstructive outcomes in patients with lower-extremity soft-tissue sarcoma. J Plast Reconstr Aesthet Surg 2024; 89:174-185. [PMID: 38199219 DOI: 10.1016/j.bjps.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 01/12/2024]
Abstract
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.
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Affiliation(s)
- David D Krijgh
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, United States; Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J Michael Smith
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Gordon Tilney
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Heather Lyu
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Raymond S Traweek
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Russell G Witt
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Margaret J Roubaud
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Arlene M Correa
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Christina L Roland
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Alexander F Mericli
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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Generaal JD, Glas HH, Ubbels JF, Stevenson MG, Huijing MA, van Leeuwen BL, Been LB. Calculating Tumor Volume Using Three-Dimensional Models in Preoperative Soft-Tissue Sarcoma Surgical Planning: Does Size Matter? J Clin Med 2023; 12:7242. [PMID: 38068294 PMCID: PMC10871107 DOI: 10.3390/jcm12237242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/12/2023] [Accepted: 11/21/2023] [Indexed: 02/18/2024] Open
Abstract
This feasibility study aims to explore the use of three-dimensional virtual surgical planning to preoperatively determine the need for reconstructive surgery following resection of an extremity soft-tissue sarcoma. As flap reconstruction is performed more often in advanced disease, we hypothesized that tumor volume would be larger in the group of patients that had undergone flap reconstruction. All patients that were treated by surgical resection for an extremity soft-tissue sarcoma between 1 January 2016 and 1 October 2019 in the University Medical Center Groningen were included retrospectively. Three-dimensional models were created using the diagnostic magnetic resonance scan. Tumor volume was calculated for all patients. Three-dimensional tumor volume was 107.8 (349.1) mL in the group of patients that had undergone primary closure and 29.4 (47.4) mL in the group of patients in which a flap reconstruction was performed, p = 0.004. Three-dimensional tumor volume was 76.1 (295.3) mL in the group of patients with a complication following ESTS treatment, versus 57.0 (132.4) mL in patients with an uncomplicated course following ESTS treatment, p = 0.311. Patients who had undergone flap reconstruction had smaller tumor volumes compared to those in the group of patients treated by primary closure. Furthermore, a larger tumor volume did not result in complications for patients undergoing ESTS treatment. Therefore, tumor volume does not seem to influence the need for reconstruction. Despite the capability of three-dimensional virtual surgical planning to measure tumor volume, we do not recommend its utilization in the multidisciplinary extremity soft-tissue sarcoma treatment, considering the findings of the study.
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Affiliation(s)
- Jasmijn D. Generaal
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (B.L.v.L.); (L.B.B.)
| | - Haye H. Glas
- Department of Maxillofacial Surgery, 3D Lab, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Jan F. Ubbels
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Marc G. Stevenson
- Department of Surgery, Isala Hospital, Dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands;
| | - Marijn A. Huijing
- Department of Plastic Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Barbara L. van Leeuwen
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (B.L.v.L.); (L.B.B.)
| | - Lukas B. Been
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (B.L.v.L.); (L.B.B.)
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Tokumoto H, Akita S, Kosaka K, Kubota Y, Mitsukawa N. Do the Histological Differences of Soft Tissue Sarcomas Affect the Rate of Skin Defect Reconstruction? Ann Plast Surg 2023; 91:585-589. [PMID: 37638837 DOI: 10.1097/sap.0000000000003680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND In soft tissue sarcoma (STS) resection, flap reconstruction and/or skin grafting is frequently required. However, it is not clear whether the histological difference affects the rate of reconstruction. The present study aimed to investigate it. METHODS This study compared in 5 classifications (105 adipocytic tumors, 102 fibroblastic tumors, 39 muscle tumors, 31 peripheral nerve sheath tumors, and 178 tumors of uncertain differentiation). In addition, the reconstruction rates of detailed tumor sites were compared. The median and case number (percentage) were calculated. RESULTS Tumor size (adipocytic 112 mm vs fibroblastic 79 mm, muscle 72 mm, nerve 90 mm, uncertain 74 mm, P < 0.0001 in all comparisons), histological low-grade rates (adipocytic 43.8% vs uncertain 3.9%, P < 0.0001; fibroblastic 46.1% vs muscle 15.4%, P = 0.003; fibroblastic vs uncertain, P < 0.0001; nerve 19.4% vs uncertain, P = 0.003) and reconstruction rates (adipocytic 5.7% vs fibroblastic 42.2%, muscle 33.3%, nerve 32.3%, uncertain 25.8%, P < 0.0001 in all comparisons) were significantly different. In the region of lower extremity, the regions of thigh [adipocytic 1/62 (1.6%) vs fibroblastic 7/32 (21.9%), P = 0.002], and lower leg [adipocytic 1/16 (6.3%) vs fibroblastic 11/19 (57.9%), P = 0.002] were significantly different. CONCLUSIONS In adipocytic tumors, the tumor size was significantly large; however, the skin defect reconstruction rate was significantly lower than that of the other STS. Histologically, the reconstruction rate of STS derived from superficial tissue increases, whereas the reconstruction rate derived from deep tissue such as adipocytic tumor decreases.
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Affiliation(s)
- Hideki Tokumoto
- From the Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Chiba, Japan
| | - Kentaro Kosaka
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Chiba, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Chiba, Japan
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Lese I, Baesu C, Hoyos IA, Pais MA, Klenke F, Kollar A, Ionescu C, Constantinescu M, Olariu R. Flap Reconstruction Outcome Following Surgical Resection of Soft Tissue and Bone Sarcoma in the Setting of (Neo)adjuvant Therapy: A Sarcoma Center Experience. Cancers (Basel) 2023; 15:cancers15092423. [PMID: 37173890 PMCID: PMC10177579 DOI: 10.3390/cancers15092423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Soft tissue and bone sarcomas are heterogeneous groups of malignant tumors. The shift in their management, with an emphasis on limb salvage, has deemed the involvement of reconstructive surgeons an integral part of their multidisciplinary treatment. We present our experience with free and pedicled flaps in the reconstruction of sarcomas at a tertiary referral university hospital and major sarcoma center. MATERIALS AND METHODS All patients undergoing flap reconstruction after sarcoma resection over a 5-year period have been included in the study. Patient-related data and postoperative complications were collected retrospectively, ensuring a minimum follow-up of 3 years. RESULTS A total of 90 patients underwent treatment with 26 free flaps and 64 pedicled flaps. Postoperative complications occurred in 37.7% of patients, and the flap failure rate was 4.4%. Diabetes, alcohol consumption and male gender were associated with increased early necrosis of the flap. Preoperative chemotherapy significantly increased the occurrence of early infection and late dehiscence, while preoperative radiotherapy was associated with a higher incidence of lymphedema. Intraoperative radiotherapy was associated with late seromas and lymphedema. CONCLUSIONS Reconstructive surgery with either pedicled or free flaps is reliable, but it can be demanding in the setting of sarcoma surgery. A higher complication rate is to be expected with neoadjuvant therapy and with certain comorbidities.
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Affiliation(s)
- Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
| | - Crinu Baesu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
| | - Isabel Arenas Hoyos
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
| | - Michael-Alexander Pais
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
| | - Frank Klenke
- Department of Orthopedic Surgery, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
| | - Attila Kollar
- Department of Medical Oncology, Inselspital, Bern University Hospital, 3012 Bern, Switzerland
| | - Codruta Ionescu
- Department of Radiation Oncology, Inselspital, Bern University Hospital, 3012 Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, 3008 Bern, Switzerland
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Novak R, Nevin JL, Rowell PD, Griffin A, Mazin S, Hofer SOP, O'Neill AC, Tsoi K, Ferguson PC, Wunder JS. A Size-Based Criteria for Flap Reconstruction After Thigh-Adductor, Soft-Tissue Sarcoma Resection. Ann Surg Oncol 2023; 30:3701-3711. [PMID: 36840861 DOI: 10.1245/s10434-023-13261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/01/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Resection of soft-tissue sarcomas from the adductor compartment is associated with significant complications. Free/pedicled flaps often are used for wound closure, but their effect on healing is unclear. We compared wound complications, oncologic, and functional outcomes for patients undergoing flap reconstruction or primary closure following resection of adductor sarcomas. METHODS A total of 177 patients underwent resection of an adductor sarcoma with primary closure (PrC) or free/pedicled flap reconstruction (FR). Patient, tumor, and treatment characteristics were compared, as well as wound complications, oncologic, and functional outcomes (TESS/MSTS87/MSTS93). To examine the relative benefit of flap reconstruction, number needed to treat (NNT) was calculated. RESULTS In total, 143 patients underwent PrC and 34 had FR, 68% of which were pedicled. There were few differences in demographic, tumor, or treatment characteristics. No significant difference was found in the rate of wound complications. Length of stay was significantly longer in FR (18 days vs. PrC 8 days; p < 0.01). Oncologic and functional outcomes were similar over 5 years follow-up. Uncomplicated wound healing occurred more often in FR compared with PrC for tumors with ≥15 cm (NNT = 8.4) or volumes ≥ 800 ml (NNT = 8.4). Tumors ≤ 336 ml do not benefit from a flap, whereas those > 600 ml are 1.5 times more likely to heal uneventfully after flap closure. CONCLUSIONS Although flap use prolonged hospitalization, it decreased wound healing complications for larger tumors, and in all sized tumors, it demonstrated similar functional and oncologic outcomes to primary closure. Our size-based treatment criteria can help to identify patients with large adductor sarcomas who could benefit from flap reconstruction. LEVEL OF EVIDENCE III (Retrospective cohort study).
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Affiliation(s)
- Rostislav Novak
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.
| | - Jennifer L Nevin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Philip D Rowell
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Anthony Griffin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Sergey Mazin
- Department of Software Engineering, ORT Braude Academic College, Karmiel, Israel
| | - Stefan O P Hofer
- Division of Plastic and Reconstructive Surgery, University Health Network, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada
| | - Anne C O'Neill
- Division of Plastic and Reconstructive Surgery, University Health Network, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada
| | - Kim Tsoi
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada.,Department of Surgical Oncology, University Health Network, Toronto, Canada.,Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
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Thomas B, Bigdeli AK, Nolte S, Gazyakan E, Harhaus L, Bischel O, Lehner B, Egerer G, Mechtersheimer G, Hohenberger P, Horch RE, Andreou D, Schmitt J, Schuler MK, Eichler M, Kneser U. The Therapeutic Role of Plastic and Reconstructive Surgery in the Interdisciplinary Treatment of Soft-Tissue Sarcomas in Germany-Cross-Sectional Results of a Prospective Nationwide Observational Study (PROSa). Cancers (Basel) 2022; 14:cancers14174312. [PMID: 36077847 PMCID: PMC9454490 DOI: 10.3390/cancers14174312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The mainstay of soft-tissue-sarcoma treatment remains ablative surgery with complete tumor resection. In this context, reconstructive plastic surgery has become an important aspect of multidisciplinary sarcoma therapy aiming at limb preservation as an alternative to amputations. In this present study, cross-sectional data collected prospectively at 39 study centers across Germany were analyzed, focusing on both the inhouse availability of plastic surgery and external accessibility to plastic surgery in 621 cases. In summary, unplanned and incomplete primary tumor resections carried out at centers with lower degrees of specialization were associated with a significantly increased need for subsequent flap-based defect coverage. In line with this, a readily available team of plastic surgeons was independently associated with successful defect reconstruction, which in turn was associated with significantly higher chances of limb preservation. We conclude that easily accessible plastic surgery and a high degree of expertise in the field of sarcoma treatment are indispensable for limb preservation following sarcoma resection. Plastic and reconstructive surgery therefore plays a vital role in achieving the best possible outcomes in the interdisciplinary treatment of soft-tissue sarcomas. Abstract Although the involvement of plastic surgery has been deemed important in the treatment of sarcoma patients to avoid oncological compromises and ameliorate patient outcomes, it is not ubiquitously available. The accessibility of defect reconstruction and its therapeutic impact on sarcoma care is the subject of this analysis. Cross-sectional data from 1309 sarcoma patients were collected electronically at 39 German study centers from 2017 to 2019. A total of 621 patients with surgical treatment for non-visceral soft-tissue sarcomas were included. The associated factors were analyzed exploratively using multifactorial logistic regression to identify independent predictors of successful defect reconstruction, as well Chi-squared and Cochran–Mantel–Haenszel tests to evaluate subgroups, including limb-salvage rates in extremity cases. A total of 76 patients received reconstructive surgery, including 52 local/pedicled versus 24 free flaps. Sarcomas with positive margins upon first resection (OR = 2.3, 95%CI = 1.2–4.4) that were excised at centers with lower degrees of specialization (OR = 2.2, 95%CI = 1.2–4.2) were independently associated with the need for post-oncological defect coverage. In this context, the inhouse availability of plastic surgery (OR = 3.0, 95%CI = 1.6–5.5) was the strongest independent predictor for successful flap-based reconstruction, which in turn was associated with significantly higher limb-salvage rates (OR = 1.4, 95%CI = 1.0–2.1) in cases of extremity sarcomas (n = 366, 59%). In conclusion, consistent referral to specialized interdisciplinary sarcoma centers significantly ameliorates patient outcomes by achieving higher rates of complete resections and offering unrestricted access to plastic surgery. The latter in particular proved indispensable for limb salvage through flap-based defect reconstruction after sarcoma resection. In fact, although there remains a scarcity of readily available reconstructive surgery services within the current sarcoma treatment system in Germany, plastic and reconstructive flap transfer was associated with significantly increased limb-salvage rates in our cohort.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Steffen Nolte
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Oliver Bischel
- Department of Trauma and Orthopedics, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
| | - Burkhard Lehner
- Department of Orthopaedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Gerlinde Egerer
- Department of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | | | - Peter Hohenberger
- Division of Surgical Oncology, Department of Surgery, Mannheim University Medical Center, University of Heidelberg, 68167 Mannheim, Germany
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Dimosthenis Andreou
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Münster, 48149 Münster, Germany
- Department of Orthopedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Jochen Schmitt
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Center for Evidence-based Healthcare, University Hospital Carl Gustav Carus, Technical University Dresden, 01307 Dresden, Germany
| | - Markus K. Schuler
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Martin Eichler
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
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Nomogram Predicting the Risk of Postoperative Major Wound Complication in Soft Tissue Sarcoma of the Trunk and Extremities after Preoperative Radiotherapy. Cancers (Basel) 2022; 14:cancers14174096. [PMID: 36077636 PMCID: PMC9454623 DOI: 10.3390/cancers14174096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/21/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Preoperative radiotherapy increases the risk of postoperative wound complication in the treatment of soft tissue sarcoma (STS). This study aims to develop a nomogram for predicting major wound complication (MaWC) after surgery. Using the Oxford University Hospital (OUH) database, a total of 126 STS patients treated with preoperative radiotherapy and surgical resection between 2007 and 2021 were retrospectively reviewed. MaWC was defined as a wound complication that required secondary surgical intervention. Univariate and multivariate regression analyses on the association between MaWC and risk factors were performed. A nomogram was formulated and the areas under the Receiver Operating Characteristic Curves (AUC) were adopted to measure the predictive value of MaWC. A decision curve analysis (DCA) determined the model with the best discriminative ability. The incidence of MaWC was 19%. Age, tumour size, diabetes mellitus and metastasis at presentation were associated with MaWC in the univariate analysis. Age, tumour size, and metastasis at presentation were independent risk factors in the multivariate analysis. The sensitivity and specificity of the predictive model is 0.90 and 0.76, respectively. The AUC value was 0.86. The nomogram constructed in the study effectively predicts the risk of MaWC after preoperative radiotherapy and surgery for STS patients.
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9
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Li D, Wang C, Wei W, Li B, Liu H, Cheng A, Niu Q, Han Z, Feng Z. Postoperative Complications of Free Flap Reconstruction in Moderate-Advanced Head and Neck Squamous Cell Carcinoma: A Prospective Cohort Study Based on Real-World Data. Front Oncol 2022; 12:792462. [PMID: 35814388 PMCID: PMC9263716 DOI: 10.3389/fonc.2022.792462] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPostoperative complications (POCs) of moderate-advanced head and neck squamous cell carcinoma (HNSCC) after free flap reconstruction have received little attention. We investigated the risk factors that lead to POCs and their impact on management and prognosis.Patients and MethodsA single-center, prospective cohort study was conducted at Beijing Stomatological Hospital on primary HNSCC patients treated between 2015 and 2020.ResultsIn total, 399 consecutive HNSCC patients who underwent radical resection of the primary tumor and free flap reconstruction were enrolled in this study, 155(38.8%) experienced POCs. The occurrence of POCs directly led to worse short-term outcomes and poorer long-term overall survival (P=0.0056). Weight loss before the operation (P=0.097), Tumor site (P=0.002), stage T4b (P=0.016), an ACE-27 index of 2-3 (P=0.040), operation time≥8h (P=0.001) and Clindamycin as antibiotic prophylaxis (P=0.001) were significantly associated with POCs.ConclusionsThe occurrence of POCs significantly leads to worse short-term outcomes and increases the patients’ burden.
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Affiliation(s)
- Delong Li
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - Chong Wang
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - Wei Wei
- Clinical Epidemiology and EBM Unit, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Bo Li
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - Huan Liu
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - Aoming Cheng
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - Qifang Niu
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - Zhengxue Han
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - Zhien Feng
- Department of Oral and Maxillofacial-Head and Neck Oncology, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
- *Correspondence: Zhien Feng,
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10
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Utilité du pédicule épigastrique inférieur profond pour le branchement microchirurgical de lambeau libre pour la couverture de la racine de la cuisse controlatéral. ANN CHIR PLAST ESTH 2022; 67:162-166. [DOI: 10.1016/j.anplas.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/24/2021] [Accepted: 12/20/2021] [Indexed: 11/18/2022]
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11
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Samà L, Binder JP, Darrigues L, Couturaud B, Boura B, Helfre S, Chiche L, Nicolas N, Tzanis D, Bouhadiba T, Gentile D, Perlbarg-Samson J, Bonvalot S. Safe-margin surgery by plastic reconstruction in extremities or parietal trunk soft tissue sarcoma: A tertiary single centre experience. Eur J Surg Oncol 2021; 48:526-532. [PMID: 34702592 DOI: 10.1016/j.ejso.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Tertiary centers recruit a large proportion of locally advanced or recurrent soft tissue sarcomas (STSs) that may have been preoperatively irradiated. The objective of this study was to evaluate the results of oncoplastic surgery (OPS) for patients affected by extremities or parietal trunk STS. MATERIALS AND METHODS This retrospective study includes patients who underwent a flap reconstruction after sarcoma resection between January 2018 and December 2020 at Institut Curie. The primary endpoint was the evaluation of the impact of OPS on the quality of surgical margins. The secondary endpoint was to quantify the morbidity of OPS and identify predictive factors for wound complications. RESULTS Of 211 patients, 89 (42.2%) had a flap reconstruction. Surgery was realized on an irradiated field in 56 (62.9%) patients. Without OPS, all patients were candidates either for amputation (n = 9,10.1%) due to vessels/nerve infiltration, or R1/R2 resection (n = 80,89.9%). Seventy-two (80.0%) pedicle flaps and 18 (20.0%) free flaps were used. No R2 resections were performed. R0 and R1 margins were achieved in 82 (92.1%) and 7 (7.9%), respectively. The median closest margin was 3 mm (IQR 1-6 mm). Among R1 patients, 5 had positive margins along a preserved critical structure, 2 patients had well-differentiated liposarcomas. The surgical morbidity rate was 33.3% (30/90 flaps). The reoperation rate was 15.7% (14/89 patients). CONCLUSIONS In a referral sarcoma center, the collaboration between the surgical oncologist and the plastic surgery team should be considered upfront in the surgical plan, allowing the most adequate wide oncological resection with acceptable postoperative morbidity.
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Affiliation(s)
- Laura Samà
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy.
| | | | - Lauren Darrigues
- Division of Plastic and Reconstructive Surgery, Institute Curie, Paris, France
| | - Benoit Couturaud
- Division of Plastic and Reconstructive Surgery, Institute Curie, Paris, France
| | - Benoit Boura
- Department of Vascular Surgery, Hospital Saint Joseph, Paris, France
| | - Sylvie Helfre
- Department of Radiation Oncology, Institute Curie, Paris, France
| | | | - Nayla Nicolas
- Department of Radiology, Institute Curie, Paris, France
| | - Dimitri Tzanis
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France
| | - Toufik Bouhadiba
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France
| | - Damiano Gentile
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | | | - Sylvie Bonvalot
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France.
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12
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Perrault DP, Lee GK, Yu RP, Carre AL, Chattha A, Johnson MB, Gardner DJ, Carey JN, Tseng WW, Menendez LR, Wong AK. Risk Factors for Wound Complications After Soft Tissue Sarcoma Resection. Ann Plast Surg 2021; 86:S336-S341. [PMID: 33234885 DOI: 10.1097/sap.0000000000002592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Soft tissue sarcomas are a heterogenous group of malignant tumors that represent approximately 1% of adult malignancies. Although these tumors occur throughout the body, the majority involved the lower extremity. Management may involve amputation but more commonly often includes wide local resection by an oncologic surgeon and involvement of a plastic surgeon for reconstruction of larger and more complex defects. Postoperative wound complications are challenging for the surgeon and patient but also impact management of adjuvant chemotherapy and radiation therapy. To explore risk factors for wound complications, we reviewed our single-institution experience of lower-extremity soft tissue sarcomas from April 2009 to September 2016. We identified 127 patients for retrospective review and analysis. The proportion of patients with wound complications in the cohort was 43.3%. Most notably, compared with patients without wound complications, patients with wound complications had a higher proportion of immediate reconstruction (34.5% vs 15.3%; P = 0.05) and a marginally higher proportion who received neoadjuvant radiation (30.9% vs 16.7%; P = 0.06).
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Affiliation(s)
| | - Gene K Lee
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | - Roy P Yu
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | - Antoine Lyonel Carre
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Maxwell B Johnson
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Joseph N Carey
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Lawrence R Menendez
- Department of Orthopedic Surgery, Keck School of Medicine of USC, Los Angeles, CA
| | - Alex K Wong
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
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13
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Hasegawa H, Tsukamoto S, Honoki K, Shimizu T, Ferra L, Errani C, Sioutis S, Mavrogenis AF, Tanaka Y. Soft-tissue reconstruction after soft-tissue sarcoma resection: the clinical outcomes of 24 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1-10. [PMID: 33608754 DOI: 10.1007/s00590-021-02901-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/08/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Pedicle or free-flap reconstruction is important in surgical sarcoma management. Free flaps are indicated only when pedicle flaps are considered inadequate; however, they are associated with a higher risk of flap failure, longer surgical times, and technical difficulty. To determine the skin defect size that can be covered by a pedicle flap, we investigated the clinical outcomes and complications of reconstruction using pedicle flaps vs. free flaps after sarcoma resection. METHODS We retrospectively studied the medical records of 24 patients with soft-tissue sarcomas who underwent reconstruction using a pedicle (n = 20) or free flap (n = 4) following wide tumour resection. RESULTS All skin defects of the knee, lower leg, and ankle were reconstructed using a pedicle flap. Skin defects of the knee, lower leg, and ankle were covered by up to 525 cm2, 325 cm2, and 234 cm2, respectively. The amount of blood loss was significantly greater in the free-flap group than in the pedicle flap group (p = 0.011). Surgical time was significantly shorter in the pedicle flap group than in the free-flap group (p = 0.006). Total necrosis was observed in one (25%) patient in the free-flap group; no case of total necrosis was observed in the pedicle flap group. CONCLUSION Less blood loss, shorter surgical time, and lower risk of total flap necrosis are notable advantages of pedicle flaps over free flaps. Most skin defects, even large ones, of the lower extremities following sarcoma resection can be covered using a single pedicle flap or multiple pedicle flaps.
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Affiliation(s)
- Hideo Hasegawa
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan.
| | - Kanya Honoki
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Takamasa Shimizu
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Lorenzo Ferra
- Department of Orthopaedic Oncology, IRCCS Rizzoli Institute, Bologna, Italy
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Rizzoli Institute, Bologna, Italy
| | - Spyros Sioutis
- Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas F Mavrogenis
- Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
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14
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The Role of Plastic Reconstructive Surgery in Surgical Therapy of Soft Tissue Sarcomas. Cancers (Basel) 2020; 12:cancers12123534. [PMID: 33256182 PMCID: PMC7760015 DOI: 10.3390/cancers12123534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Soft tissue sarcoma (STS) treatment is an interdisciplinary challenge. Along with radio(chemo)therapy, surgery plays the central role in STS treatment. Little is known about the impact of reconstructive surgery on STS, particularly whether reconstructive surgery enhances STS resection success with the usage of flaps. Here, we analyzed the 10-year experience at a university hospital's Comprehensive Cancer Center, focusing on the role of reconstructive surgery. METHODS We performed a retrospective analysis of STS-patients over 10 years. We investigated patient demographics, diagnosis, surgical management, tissue/function reconstruction, complication rates, resection status, local recurrence and survival. RESULTS Analysis of 290 patients showed an association between clear surgical margin (R0) resections and higher-grade sarcoma in patients with free flaps. Major complications were lower with primary wound closure than with flaps. Comparison of reconstruction techniques showed no significant differences in complication rates. Wound healing was impaired in STS recurrence. The local recurrence risk was over two times higher with primary wound closure than with flaps. CONCLUSION Defect reconstructions in STS are reliable and safe. Plastic surgeons should have a permanent place in interdisciplinary surgical STS treatment, with the full armamentarium of reconstruction methods.
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15
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O'Neill AC, Roy M, Boucher A, Fitzpatrick AM, Griffin AM, Tsoi K, Ferguson PC, Wunder JS, Hofer SOP. The Toronto Sarcoma Flap Score: A Validated Wound Complication Classification System for Extremity Soft Tissue Sarcoma Flap Reconstruction. Ann Surg Oncol 2020; 28:3345-3353. [PMID: 33005992 DOI: 10.1245/s10434-020-09166-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/03/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Flap reconstruction plays an important role in limb preservation after wide resection of extremity soft tissue sarcoma (ESTS), but can be associated with high rates of postoperative wound complications. Currently, no standardized system exists for the classification of these complications. This study aimed to develop a standardized classification system for wound complications after ESTS flap reconstruction. METHODS Outcomes of ESTS flap reconstructions were analyzed in a retrospective cohort of 300 patients. All wound- and flap-related complications were identified and categorized. Based on these data, a scoring system was developed and validated with a prospective cohort of 100 patients who underwent ESTS flap reconstruction. RESULTS A 10-point scoring system was developed based on the level of intervention required to treat each complication observed in the retrospective cohort. Raters applied the scoring system to the prospective patient cohort. Validation studies demonstrated excellent inter-rater and intra-rater reliability (weighted Cohen's kappa range, 0.82 [95% CI, 0.5-1.0] to 0.99 [95% CI, 0.98-1.0] and 0.95 [95% CI, 0.84-1.0] to 0.97 [95% CI, 0.92-1.0], respectively). The majority of the raters reported the score to be simple, objective, and reproducible (respective mean scores, 4.76 ± 0.43, 4.53 ± 0.62, and 4.56 ± 0.56 on 5-point Likert scales). CONCLUSION The Toronto Sarcoma Flap Score (TSFS) is a simple and objective classification system with excellent inter- and intra-rater reliability. Universal adoption of the TSFS could standardize outcome reporting in future studies and aid in the establishment of clinical benchmarks to improve the quality of care in sarcoma reconstruction.
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Affiliation(s)
- Anne C O'Neill
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada. Anne.O'.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada. Anne.O'.,Department of Surgery, University of Toronto, Toronto, Canada. Anne.O'
| | - Mélissa Roy
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Amelia Boucher
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Aisling M Fitzpatrick
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Anthony M Griffin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Kim Tsoi
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Stefan O P Hofer
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, University Health Network, Toronto, ON, Canada.,University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
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16
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O'Neill AC. ASO Author Reflections: Standardizing Outcome Reporting in Extremity Soft Tissue Sarcoma Flap Reconstruction. Ann Surg Oncol 2020; 28:3354-3355. [PMID: 33000369 DOI: 10.1245/s10434-020-09189-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Anne C O'Neill
- Division of Plastic Surgery, Department of Surgery and Surgical Oncology, University Health Network, University of Toronto, Toronto, ON, Canada. Anne.O'
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17
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Frobert P, Vaucher R, Vaz G, Gouin F, Meeus P, Delay E. The role of reconstructive surgery after soft tissue sarcoma resection. ANN CHIR PLAST ESTH 2020; 65:394-422. [PMID: 32807533 DOI: 10.1016/j.anplas.2020.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/31/2020] [Indexed: 02/07/2023]
Abstract
Soft tissue sarcomas are rare malignant tumors with pejorative prognosis. They require a multidisciplinary approach in a specialized hospital belonging to the NetSarc network in France. In all cases treated with curative intent, the objective of excision surgery is to achieve wide, microscopically negative margins (R0 according to the UICC classification). When growing on a limb, sarcomas may threaten functionally relevant structures and even lead to amputation. Nowadays, when combined with radiation therapy, wide exeresis limb-sparing surgery is achievable in 90 to 95% of the cases, of which 25% will nevertheless require reconstructive surgery to preserve the limb, to limit postoperative complications and to manage possible sequelae. Progress in reparative surgery, particularly in microsurgery, has helped not only to improve limb salvage rates but also to create wider margins without altering oncologic goals of curative resection. After determining the range of resection, reconstructive surgery should be tailored to address the tissue defect. The converse is to be strongly discouraged. The extent of resection must not be compromised or reduced in order to facilitate reconstructive surgery. A plastic surgeon must master all the flap techniques, including microsurgery, while taking into account the impact of preoperative and postoperative radiation therapy on previously irradiated tissues or on wounds requiring adjuvant therapy. Recent developments, especially as regards perforator flaps, have helped to enhanced the quality of reconstruction procedure while reducing donor site morbidity. In our experience, perforator flaps are a workhorse in reconstructive surgeries subsequent to soft tissue sarcoma of the extremities. On a parallel track, lipofilling (otherwise known as fat grafting or fat transfer) has become the first-line treatment for patients with post-surgical functional or cosmetic sequalae. It is performed after long-term follow-up during disease-free survival. Strict clinical examination and MRI are mandatory prior to programming any local procedure. Usually, three to four sessions of fat grafting are needed to enhance local trophicity or the cosmetic aspect. Sequalae treatments are of great interest in terms of psychological as well as functional outcome.
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Affiliation(s)
- P Frobert
- Unité de chirurgie plastique et réparatrice, centre Léon-Bérard, 28, rue Laennec, Lyon, France.
| | - R Vaucher
- Unité de chirurgie plastique et réparatrice, centre Léon-Bérard, 28, rue Laennec, Lyon, France
| | - G Vaz
- Unité de chirurgie digestive et des sarcomes, centre Léon-Bérard, 28, rue Laennec, Lyon, France
| | - F Gouin
- Unité de chirurgie digestive et des sarcomes, centre Léon-Bérard, 28, rue Laennec, Lyon, France
| | - P Meeus
- Unité de chirurgie digestive et des sarcomes, centre Léon-Bérard, 28, rue Laennec, Lyon, France
| | - E Delay
- Unité de chirurgie plastique et réparatrice, centre Léon-Bérard, 28, rue Laennec, Lyon, France
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18
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Dadras M, Koepp P, Wallner C, Wagner JM, Sogorski A, Lehnhardt M, Harati K, Behr B. Predictors of oncologic outcome in patients with and without flap reconstruction after extremity and truncal soft tissue sarcomas. J Plast Reconstr Aesthet Surg 2020; 73:1239-1252. [PMID: 32245732 DOI: 10.1016/j.bjps.2020.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/25/2020] [Accepted: 03/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Soft tissue sarcomas (STS) of the extremities or trunk often require plastic reconstructive transfer of vital tissue for wound closure after resection. Literature on the oncologic outcome of patients receiving flap closure in comparison with patients receiving primary wound closure is very limited. METHODS Patients who underwent resection of a primary extremity or truncal STS without dissemination at our institution between January 2000 until December 2015 were eligible for the study. Patients were divided into two groups based on type of soft tissue closure (primary or flap) while patients receiving skin grafting were excluded. Characteristics, oncologic outcome and prognostic factors of both groups were compared. RESULTS 781 patients could be included, of these 200 had received flap closure and 581 primary wound closure. Tumors receiving flap closure were significantly smaller but were located in distal extremities and showed a trend towards prior neoadjuvant radiotherapy. Incidence of wound and general complications was similar in both groups. 5-year local recurrence free survival (LRFS, 71% vs. 69%) and 5-year disease specific survival (DSS, 84% vs. 88%) did not differ significantly between patients with primary closure and flap closure. Most important predictors in both groups were tumor size and grading with no major differences in analysis of predictors for both endpoints. CONCLUSION Plastic reconstructive surgery plays an important role in limb-conserving STS treatment. Complication rates of patients with flap coverage are not higher than of patients with primary wound closure and oncologic outcome is similar with no major differences in predictors of LRFS and DSS.
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Affiliation(s)
- Mehran Dadras
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany.
| | - Pascal Koepp
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Christoph Wallner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Johannes M Wagner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Alexander Sogorski
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Kamran Harati
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Björn Behr
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
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19
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Thirty-Day Outcomes after Surgery for Primary Sarcomas of the Extremities: An Analysis of the NSQIP Database. JOURNAL OF ONCOLOGY 2020; 2020:7282846. [PMID: 32411242 PMCID: PMC7201584 DOI: 10.1155/2020/7282846] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 12/24/2019] [Indexed: 02/07/2023]
Abstract
Background Primary bone and soft tissue sarcomas are rare tumors requiring wide surgical resection and reconstruction to achieve local control. Postoperative complications can lead to delays in adjuvant therapy, potentially affecting long-term oncologic outcomes. Understanding postoperative complication risks is essential; however, past studies are limited by small sample sizes. Purpose This study uses a large national registry to characterize the incidence of complications and mortality in the first thirty days following surgical management of primary bone and soft tissue sarcomas of the extremities. Methods A retrospective review of patients in the National Surgical Quality Improvement Program database was performed. Cases were identified using diagnosis codes for malignant neoplasm of soft tissue or bone and procedure codes for amputation and radical resection. The cohort was subdivided by bone versus soft tissue sarcoma, upper versus lower extremity, and amputation versus limb salvage. Results One thousand, one hundred eleven patients were identified. The most frequent complications were surgical site infections, sepsis, and venous thromboembolism. The overall incidence of complications was 14.0%. Unplanned readmission and reoperation occurred after 7.0% and 8.0% of cases, respectively. Thirty-day mortality was 0.3%, with one intraoperative death. Patient factors and complication rates varied by tumor location and surgical modality. Lower extremity cases were associated with higher rates of wound complications and infectious etiologies such as surgical site infections, urinary tract infections, and systemic sepsis. In contrast, patients undergoing amputation were more likely to experience major medical complications including acute renal failure, cardiac arrest, and myocardial infarction. Conclusion Approximately 1 in 7 patients will experience a complication in the first thirty days following surgery for primary bone and soft tissue sarcomas of the extremities. The unique risk profiles of lower extremity and amputation cases should be considered during perioperative planning and surveillance.
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20
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Martin E, Flucke UE, Coert JH, van Noesel MM. Treatment of malignant peripheral nerve sheath tumors in pediatric NF1 disease. Childs Nerv Syst 2020; 36:2453-2462. [PMID: 32494969 PMCID: PMC7575473 DOI: 10.1007/s00381-020-04687-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malignant peripheral nerve sheath tumors (MPNSTs) are rare yet highly aggressive soft tissue sarcomas. Children with neurofibromatosis type 1 (NF1) have a 10% lifetime risk for development of MPNST. Prognosis remains poor and survival seems worse for NF1 patients. METHODS This narrative review highlights current practices and pitfalls in the management of MPNST in pediatric NF1 patients. RESULTS Preoperative diagnostics can be challenging, but PET scans have shown to be useful tools. More recently, functional MRI holds promise as well. Surgery remains the mainstay treatment for these patients, but careful planning is needed to minimize postoperative morbidity. Functional reconstructions can play a role in improving functional status. Radiotherapy can be administered to enhance local control in selected cases, but care should be taken to minimize radiation effects as well as reduce the risk of secondary malignancies. The exact role of chemotherapy has yet to be determined. Reports on the efficacy of chemotherapy vary as some report lower effects in NF1 populations. Promisingly, survival seems to ameliorate in the last few decades and response rates of chemotherapy may increase in NF1 populations when administering it as part of standard of care. However, in metastasized disease, response rates remain poor. New systemic therapies are therefore desperately warranted and multiple trials are currently investigating the role of drugs. Targeted drugs are nevertheless not yet included in first line treatment. CONCLUSION Both research and clinical efforts benefit from multidisciplinary approaches with international collaborations in this rare malignancy.
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Affiliation(s)
- Enrico Martin
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, G04.126, PO Box 85060, 3508, AB, Utrecht, the Netherlands.
| | - Uta E. Flucke
- Department of Solid Tumors, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands ,Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J. Henk Coert
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, G04.126, PO Box 85060, 3508 AB Utrecht, the Netherlands
| | - Max M. van Noesel
- Department of Solid Tumors, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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21
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Negative Impact of Wound Complications on Oncologic Outcome of Soft Tissue Sarcomas of the Chest Wall. Cancers (Basel) 2019; 12:cancers12010101. [PMID: 31906053 PMCID: PMC7017132 DOI: 10.3390/cancers12010101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 12/25/2019] [Accepted: 12/29/2019] [Indexed: 12/17/2022] Open
Abstract
A link of complications with worse oncologic prognosis has been established for multiple malignancies, while the limited literature on soft-tissue sarcomas is inconclusive. The aim of this study was to examine risk factors and the oncologic impact of wound complications after curative resection of primary soft-tissue sarcomas of the chest wall. Patients with primary soft tissue sarcomas of the chest wall were identified. Groups with and without wound complications were compared by using univariate and multivariate analysis to identify risk factors. For patients with clear surgical margins (R0), univariate and multivariate analysis of factors associated with 5-year local recurrence free survival (LRFS), metastasis free survival (MFS), and disease specific survival (DSS) were performed. A total of 102 patients were included in the study. Wound complications occurred in 11 patients (10.8%) within 90 days. Cardiovascular morbidity and operation time represented independent risk factors for wound complications. In 94 patients with clear surgical margins, those with wound complications had an estimated 5-year LRFS of 30% versus 72.6% and a 5-year DSS of 58.3% versus 82.1%. Wound complications could be identified as an independent predictor for worse LRFS and DSS. Patients with a high risk of wound complications should be identified and strategies implemented to reduce surgical complications and possibly improve oncologic prognosis.
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Resuscitating extremities after soft tissue sarcoma resections: Are functional reconstructions an overlooked option in limb salvage? A systematic review. Eur J Surg Oncol 2019; 45:1762-1769. [DOI: 10.1016/j.ejso.2019.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 12/27/2022] Open
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Kito M, Ae K, Koyanagi H, Gokita T, Furuoka H, Okamoto M, Tanaka A, Suzuki S, Takazawa A, Aoki K, Yoshimura Y. Risk factor for wound complications following wide resection of soft tissue sarcoma in the adductor compartment of the thigh. Jpn J Clin Oncol 2019; 49:932-937. [DOI: 10.1093/jjco/hyz101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/03/2019] [Accepted: 06/19/2019] [Indexed: 12/14/2022] Open
Abstract
Abstract
Background
The purpose of this study was to investigate deep-seated soft tissue sarcoma (STS) occurring in the adductor compartment of the thigh that underwent wide resection and to clarify the high-risk group for wound complications.
Patients and methods
From 2000 to 2017, we reviewed 104 cases of deep-seated STS occurring in the adductor compartment of the thigh that were treated at four specialized facilities with expertise in sarcoma treatment.
Results
Wound complications occurred in 40 cases (38.5%), of which 23 cases (22.1%) were cases with major wound complications (MWC). In univariate analysis, BMI (P < 0.01), maximum tumor diameter (P < 0.01), operation time (P < 0.01), amount of intraoperative bleeding (P < 0.01), and intraoperative intervention to the femoral artery and vein (P < 0.01) were significantly associated with wound complications. In multivariate analysis, the associated parameters were BMI (P < 0.01), maximum tumor diameter (P = 0.02), and intraoperative intervention to the femoral artery and vein (P = 0.01). When limited to cases with MWC, univariate analysis showed that maximum tumor diameter (P < 0.01), diabetes mellitus (P = 0.03), operation time (P < 0.01), amount of intraoperative bleeding (P < 0.01), and intraoperative intervention to the femoral artery and vein (P = 0.02) were significantly associated parameters. In multivariate analysis, maximum tumor diameter (P = 0.02) and amount of intraoperative bleeding (P = 0.04) were associated parameters.
Conclusions
For patients with risk factors for wound complications, control of bleeding are crucial when resecting deep-seated STS in the adductor compartment of the thigh. In cases with large tumors, surgeons should be especially cautious of cases requiring interventions that surround the femoral artery and vein in order to attain an appropriate surgical margin.
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Affiliation(s)
- Munehisa Kito
- Department of Orthopaedic Surgery, Shinshu University School of Medicine
| | - Keisuke Ae
- Department of Orthopaedic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research
| | - Hirotaka Koyanagi
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University
| | - Tabu Gokita
- Department of Orthopaedic Surgery, Saitama Cancer Center
| | - Hideto Furuoka
- Department of Orthopaedic Surgery, Saitama Cancer Center
| | - Masanori Okamoto
- Department of Orthopaedic Surgery, Shinshu University School of Medicine
| | - Atsushi Tanaka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine
| | - Shuichiro Suzuki
- Department of Orthopaedic Surgery, Shinshu University School of Medicine
| | - Akira Takazawa
- Department of Orthopaedic Surgery, Shinshu Ueda Medical Center
| | - Kaoru Aoki
- Department of Orthopaedic Surgery, Shinshu University School of Medicine
| | - Yasuo Yoshimura
- Department of Orthopaedic Surgery, Shinshu Ueda Medical Center
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Kapoor T, Banuelos J, Adabi K, Moran SL, Manrique OJ. Analysis of clinical outcomes of upper and lower extremity reconstructions in patients with soft-tissue sarcoma. J Surg Oncol 2018; 118:614-620. [DOI: 10.1002/jso.25201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/19/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Trishul Kapoor
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Joseph Banuelos
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Kian Adabi
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Steven L. Moran
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Oscar J. Manrique
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
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Slump J, Hofer SO, Ferguson PC, Wunder JS, Griffin AM, Hoekstra HJ, Bastiaannet E, O'Neill AC. Flap choice does not affect complication rates or functional outcomes following extremity soft tissue sarcoma reconstruction. J Plast Reconstr Aesthet Surg 2018; 71:989-996. [DOI: 10.1016/j.bjps.2018.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 03/18/2018] [Accepted: 04/01/2018] [Indexed: 12/27/2022]
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Stevenson MG, Ubbels JF, Slump J, Huijing MA, Bastiaannet E, Pras E, Hoekstra HJ, Been LB. Identification of predictors for wound complications following preoperative or postoperative radiotherapy in extremity soft tissue sarcoma. Eur J Surg Oncol 2018; 44:816-822. [PMID: 29472042 DOI: 10.1016/j.ejso.2018.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/24/2018] [Accepted: 02/02/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION In extremity soft tissue sarcoma (ESTS), external beam radiotherapy (EBRT) has been used in addition to limb-sparing surgery (LSS). This study aims to identify predictors for major wound complication (MWC) development following EBRT and LSS in ESTS. METHODS This retrospective study includes ESTS patients treated with EBRT and LSS between 2005 and 2017. Two groups were formed; Group I included preoperatively irradiated patients, whereas Group II included patients who underwent postoperative EBRT. Multivariate logistic regression analyses were performed to create a prediction model for MWC development. RESULTS One hundred twenty-seven patients were included, 58 patients (45.7%) in Group I and 69 patients (54.3%) in Group II. Some differences in baseline characteristics were found between the groups, e.g. in tumor size and grade, histological subtype and total RT dose. Twenty-three patients (39.7%) in Group I and 14 patients (20.3%) in Group II developed a MWC (p = 0.02). Preoperative EBRT was identified as independent predictor for MWC development, OR 2.75 (95%CI 1.21-6.26), p = 0.02. Furthermore, a trend towards an increased MWC risk was shown for patients' age (OR 1.02 (0.99-1.04)), delayed wound closure (OR 3.20 (0.64-16.02)) and negative surgical margins (OR 2.26 (0.72-7.11)). The area under the curve (AUC) of the model was 0.68 (0.57-0.79). CONCLUSIONS This study corroborates the increased MWC risk following preoperative EBRT in ESTS. It remains important to carefully weigh the MWC risk against the expected long-term functional outcome, and to consider the liberal use of primary plastic surgical reconstructions in an individualized multidisciplinary tumor board prior to treatment.
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Affiliation(s)
- Marc G Stevenson
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan F Ubbels
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jelena Slump
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marijn A Huijing
- Department of Plastic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Esther Bastiaannet
- Department of Surgical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elisabeth Pras
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Harald J Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lukas B Been
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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