Journal of Surgical Oncology 2015;111:540–545
Surgical Management of Soft Tissue Sarcomas: Extremity Sarcomas ALBERT H. CHAO,
MD,
1
JOEL L. MAYERSON, MD,2 RAJIV CHANDAWARKAR, THOMAS J. SCHARSCHMIDT, MD2
1 MD,
AND 1
Department of Plastic Surgery, The Ohio State University, Columbus, Ohio Department of Orthopaedics, The Ohio State University, Columbus, Ohio
2
Wide surgical resection is the recommended treatment for extremity soft tissue sarcomas. Chemotherapy and/or radiotherapy may improve local control, but with marginal effect on overall survival. Advanced reconstructive techniques and multidisciplinary care, including plastic surgery, may allow a higher rate of limb salvage. This report focuses on surgical and reconstructive aspects in the multimodality care of extremity sarcomas.
J. Surg. Oncol. 2015;111:540–545. ß 2014 Wiley Periodicals, Inc.
KEY WORDS: extremity sarcoma; reconstruction; limb preservation
INTRODUCTION Surgical resection is the mainstay and cornerstone of treatment for extremity soft tissue sarcomas. Although radiation and/or chemotherapy often play a role in the multimodality treatment of these malignancies, they are almost always used in conjunction with surgical resection of the mass. This report will focus on surgical and reconstructive aspects in the multimodality care of extremity sarcomas.
SURGICAL INDICATIONS Surgery in indicated in the treatment algorithm of nearly all soft tissue sarcomas. The only exception to this is in the diffusely metastatic setting, where systemic options may be explored first. The optimal surgical procedure is a wide surgical resection. This terminology and classification of oncologic procedures was originally described by Enneking and is as follows: intralesional, marginal, wide, and radical. Intralesional excisions are those typically performed by entering the substance of the tumor and removing it in a piece‐meal fashion. Intralesional excisions are reserved for benign conditions such as evacuation of a hematoma. Marginal excisions refer to en bloc excision through what is called the reactive zone. The reactive zone is equivalent to the thin capsule around a lipoma or the signal changes seen surrounding a mass on MRI. Marginal excisions are usually reserved for benign tumors such as neurofibromas, lipomas, and giant cell tumors of tendon sheath. Marginal excisions are not indicated for most malignancies as there can be tumor cells within the reactive zone [1]. A marginal resection may also be considered for a low‐grade malignant tumor if it abuts a vital structure and sacrifice of the structure leads to unacceptable or unwanted morbidity. The biologic aggressiveness of the tumor should be considered in this instance. Wide excisions are most commonly performed for primary malignant masses. In a wide excision, a cuff of normal tissue as taken as the margin as to ensure complete removal of the tumor is accomplished. More than 90% of extremity sarcomas can be widely excised preserving the limb. In an attempt to formalize the surgical intent and subsequent resection specimen, a new terminology has gained acceptance. The International Union Against Cancer (UICC) definitions of residual disease quantify the quality of the surgical resection. This contemporary classification of surgical margins includes: R0, R1, and R2. R0 refers to negative margins (no tumor at the inked surface upon histologic analysis), R1 is used to define microscopic tumor at the inked margin, and R2 is gross tumor at the inked margin. The goal of surgery in sarcomas is achievement of negative surgical
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margins (R0). Positive margins are a risk factor for local recurrence, but the overall effect on survival is controversial and unproven [2,3]. What constitutes an adequate anatomic margin deserves discussion and is controversial. For intra‐muscular locations, 1 cm of muscle is generally considered an appropriate wide margin [4]. When the tumor extends outside of the muscle or lies in inter‐fascial planes, the adequacy of the margin is more difficult to define. Other non‐muscular margins that may be pertinent depending on the location of the tumor that are considered to be adequate (i.e., tumor rarely invades) include fascia, peri‐neurium, periosteum, and vascular adventitia. A 1 mm margin where one of these structures represents the inked portion on histologic analysis is usually considered a R0 equivalent resection. The caveat to the preservation of the underlying structures (nerve, vessel, or bone) is that there is no microscopic violation on histologic analysis. In general, because positive margins and local recurrence have not been convincingly correlated with overall survival or the development of metastatic disease, an attempt to salvage vital structures with close margins is favored [5]. However, if there is gross invasion or encasement of the tissue, then re‐resection including the involved structure (nerve, bone, vessel) is generally recommended. Again, the biologic aggressiveness of the tumor should also be taken into consideration in these cases. In general, it is reasonable to accept closer margins in low‐grade tumors than it is in high‐grade lesions. A majority of sarcomas (>90%) can be treated with a limb salvage resection [6]. The considerations for whether to attempt limb salvage or to consider amputation is that the limb salvage result should: (1) achieve R0 resection, (2) have acceptable functional results, and (3) be associated with acceptable and manageable complications. If these goals cannot be accomplished then amputation should be considered [7]. The indications for amputation vary. Amputation should be considered when an R0 resection would leave the patient with a poorly functional limb, or not achieve the goals as described above. It should be noted that what is considered a functional limb will vary
*Correspondence to: Albert H. Chao, MD, Department of Plastic Surgery, The Ohio State University, Columbus, OH. Fax: (614) 293‐3381. E‐mail: [email protected] Received 10 June 2014; Accepted 8 July 2014 DOI 10.1002/jso.23810 Published online 21 October 2014 in Wiley Online Library (wileyonlinelibrary.com).
Surgical Management of Soft Tissue Sarcomas greatly depending on the person and requires individual conversation with discussion of the predicted functional result. In general, the main factor leading to amputation is direct invasion or encasement of a major nerve that will result in a functional deficit that is not acceptable to the patient. Other potential indications in which to consider an ablative procedure include infiltrative tumors of the hand or foot and sarcomas with ipsilateral skip or regional metastasis. In the authors’ opinion, although the involvement of vascular structures or bone may also be problematic, these can often be reconstructed after resection. The same is not true for nerve, and sacrifice often leads to profound functional deficit. The decision to undergo limb salvage versus ablative procedure must be discussed on an individual basis with the patient and family. The other role for surgery in sarcomas, and one that is often not discussed nor well defined is in the palliative setting. Palliative surgery is defined as resection without curative intent. This is generally considered if R0 resection cannot be accomplished due to anatomic constraints or in the setting of metastatic disease. It is controversial, and each case should be considered independently with the patient’s goals in mind. Because of their painless growth, aggressive nature, presentation at an advanced stage, varied anatomic location, and relatively young mean patient age (56 years old), cure is often not an achievable goal in soft tissue sarcomas. In approximately 20% of high‐grade tumors, the patient will have distant metastatic disease discovered at the time of their initial presentation. In those patients a palliative approach must be undertaken or considered early in the treatment course. It should be stressed that palliative surgery without curative intent is distinctly different from a non‐curative procedure performed in an asymptomatic patient that results in residual disease [8]. The success of palliation is almost entirely dependent upon appropriate selection of patients. In contrast to curative therapy where the goal is prolongation of life, palliation focuses on quality of the remainder of life, and measures of success should focus on this. Therefore, consequences of treatment such as toxicity, discomfort, and mortality need to be carefully considered in patients for whom no additional survival benefit exists [9]. Open discussions with the patient and family outlining all treatment options and what to expect from each palliative intervention is paramount. The surgeon should attempt to provide an estimation of prolonged survival as a result of the proposed surgical procedure. In this context, it should be realized that prolonged survival and palliative interventions are not mutually exclusive; a palliative resection may indeed prolong the patient’s survival but this is not the primary goal of the procedure. In a report from the Roswell Park Cancer Institute, selection of patients for palliative procedures was based on four distinct criteria: (1) The patient’s debilitating symptoms can be relieved by surgical intervention; (2) The patient is assessed to determine whether the procedure will give him a better quality of life, after thoughtful consideration of risk‐to‐benefit ratio; (3) The estimation of the patient’s post treatment survival and whether a surgical intervention would justify the risk and morbidity of the procedure; and (4) If the patient can undergo an operation, that surgery is the most effective treatment for their specific problem [8]. These again are difficult principles to define, but the impact on a patient’s quality of life is great. In summary, the palliative approach should be considered after careful consideration with the family and multidisciplinary review of the individual case. Surgical management of an incompletely excised or unplanned excision with subsequent positive postoperative margins deserves mention. Benign soft tissue masses are much more common than malignant soft tissue sarcomas and therefore 50% of soft tissue sarcomas are excised non‐surgical oncologists. Many of these masses are presumed benign and only recognized as sarcoma at definitive pathology. These “whoops” procedures do not necessarily confer inferior survival, but mandate referral to a tertiary sarcoma cancer center Journal of Surgical Oncology
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given the need for radical re‐excisions, radiation and soft tissue reconstructions [10]. The mainstay of treatment remains the same: achievement of negative (R0) surgical margins. In the setting of a re‐ resection, this often requires a larger resection and more complex reconstruction, including all tissues that were manipulated and any resulting hematoma. Any tissue involved during the index procedure is considered contaminated [11]. However, in the absence of metastatic disease and the ultimate achievement of negative margins at the time of re‐resection, overall survival is not impacted by the initial unplanned procedure. All series agree that the re‐excisions are associated with increased cost and morbidity from complex soft tissue coverage [12,13]. The preference of the authors is to perform re‐resections that will require skin graft or flap reconstruction in a staged fashion with the plastic surgery team. The resection is performed, temporized with a wound vacuum, and the reconstruction is undertaken after the margin status is confirmed to be R0. Postoperative radiation is performed, as we have found is it often easier to define the contaminated tissues before radiation. Other large centers however, advocate for preoperative radiotherapy in this scenario [13]. Modern techniques of reconstruction have made limb salvage a more realistic and functional option for many patients. Multi‐disciplinary care and advances with our plastic surgery colleagues has fostered this collaboration. Plastic surgery is an essential part of the multidisciplinary care of patients with extremity sarcomas. In the extremities, the relative paucity of local tissues and the high concentration of structures (tendons, bone, vessels, nerves), result in a frequent need for soft tissue reconstruction following tumor resections. Soft tissue reconstruction may be necessary to attain wound closure, cover critical structures, salvage a limb, and restore function. This can have greater implications in patients who will receive multimodality treatment, where reconstructive surgery may facilitate wound healing and reduce surgical complications.
PLASTIC AND RECONSTRUCTIVE SURGERY Method of Reconstruction The reconstructive ladder is a familiar concept in plastic surgery, where simpler techniques (primary closure, skin grafts) are considered prior to escalating to more complex methods (pedicled flaps, free flaps). In patients with extremity sarcomas, flap reconstructions may be necessary in many cases due to the margins that are required, limited local tissues and high concentration of structures, especially in the distal extremities. The most commonly utilized pedicled flap options for reconstruction following resection of extremity sarcomas are presented in Table I. Primary closure is sometimes possible, particularly for small tumors in proximal locations. Split‐thickness skin grafts (STSG) may be performed for defects with a vascularized wound bed when no vital structures are exposed, but should be avoided over joints due to secondary contraction, or in patients who have received or will be receiving radiation therapy [14,15]. In previously irradiated wounds, skin grafting has traditionally been associated with a high rate of complications [16,17]. Although there is some recent evidence suggesting that skin grafts can be successful in this setting [18], this remains controversial, and therefore a backup plan should be in place in case of graft failure. In our experience, negative pressure wound therapy (NPWT) dressings, such as the V.A.C.1 (Kinetic Concepts, Inc., San Antonio, TX), function as effective bolster dressings for STSGs. In these cases, we place a non‐adherent gauze between the STSG and the dressing sponge, and then apply a splint to immobilize the recipient site. We typically remove the bolster on postoperative days 4–5, after which splint immobilization is performed for an additional 1 week during which twice daily dressing changes with a non‐adherent gauze are performed.
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TABLE I. Commonly Used Pedicled Flap Options for Reconstruction Following Extremity Sarcoma Resection Flap Upper Extremity
Latissimus dorsi flap
Blood supply
Indications
Thoracodorsal artery
Shoulder
Arm
Radial forearm flap
Elbow Elbow
Radial artery
Forearm
Hand
Lower Extremity
Rectus abdominis flap
Deep inferior epigastric artery
Anterolateral thigh flap
Descending branch of lateral circumflex femoral artery
Gastrocnemius flap
Sural artery
Groin
Thigh (proximal) Groin
Thigh Knee
Leg (proximal third)
Soleus flap Reverse sural flap
Popliteal, posterior tibial, and peroneal arteries Sural artery perforator
Leg (middle third) Leg (distal third)
Ankle
Medial plantar artery flap
Medial plantar artery
Myocutaneous, fasciocutaneous, and muscle flaps that are skin grafted can all be effective in reconstructing defects following extremity sarcoma resections, both as pedicled and free flaps. While there are many options for pedicled flaps (as discussed below), free flaps may become necessary especially for large defects, recurrent disease that has been Journal of Surgical Oncology
Foot Foot (plantar)
Pearls/pitfalls Typically performed as a myocutaneous flap; however, for larger defects the muscle may be skin grafted Division of the humeral muscle insertion can increase arc of rotation The antegrade flap is utilized for proximal defects, and the reverse flap for distal defects A preoperative Allen’s test should be performed to confirm an intact palmar arch; if not intact, vein grafting of the radial artery may be necessary The paratenon of the brachioradialis and flexor carpi radialis tendons should be preserved to ensure successful skin grafting of the donor site Usually performed as a myocutaneous flap with a vertical skin paddle Effective as both a perforator skin flap, or as a myocutaneous flap that includes vastus lateralis muscle for dead space obliteration The medial and lateral heads have separate vascular pedicles and can be transferred independently The medial gastrocnemius tends to confer more tissue and have a wider arc of rotation Typically performed as a muscle flap that is skin grafted Typically performed as a muscle flap that is skin grafted The flap blood supply is based on reverse flow through perforator vessels from the peroneal artery located within 7 cm of the lateral malleolus Venous congestion can be a problem with this flap and should be used with caution in patients with peripheral vascular disease and smokers Preoperatively the posterior tibial artery circulation should be assessed The flap should be harvested only within the confines of the non‐weight‐bearing portion of the foot, which is skin grafted following flap transfer
previously resected/reconstructed, or in irradiated fields. When thin supple soft tissues are desired for reconstruction, such as in the distal extremities, preference should be given to thinner flaps, such as perforator flaps, that confer skin without muscle bulk and have no need for skin grafting [19]. In patients undergoing amputation, distal tissue
Surgical Management of Soft Tissue Sarcomas should be considered for possible use as a fillet flap for reconstruction [20]. Structured postoperative protocols are essential to ensure successful wound healing following flap reconstructions. In general, patients who undergo pedicled flap reconstructions may bear weight without immobilization immediately postoperatively. Exceptions to this are cases involving flaps located on the weight‐ bearing surface of the foot, where we typically wait at least 6 weeks prior to full weight‐bearing, or muscle flaps with STSGs where we will splint immobilize the site for 2 weeks to prevent shearing of the STSG. When free flap reconstructions are performed, we typically employ a more conservative postoperative protocol due the presence of microvascular anastomoses. Patients are instructed to strictly elevate the involved extremity for 1 week, after which we implement a dangling protocol. During this period, patients are permitted to dangle the extremity in a dependent position for 5 min every 2 hr, and increase the duration by 5 min every 2 days. Once patients are able to do this for 30 min without any evidence of an abnormality of the flap (e.g., discoloration or excessive edema), they are released from the dangling protocol and may also bear weight as tolerated.
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Fig. 1. A: An 18 cm 12 cm posterior arm defect. B: Reconstruction of the posterior arm defect with a pedicled latissimus dorsi myocutaneous flap.
Timing of Reconstruction Soft tissue reconstruction may be performed either immediately following sarcoma resection, or in delayed fashion once final pathologic margin status is known. Although delayed reconstruction obligates a patient to a second operation, it may be beneficial in cases where there is uncertainty about margin status, especially when a flap reconstruction is planned. In most cases, when delaying a reconstruction, the resection site can be managed with a NWPT dressing that is left in place until the time of reconstruction. When structures such as bone or nerves are exposed, we typically utilize a minimally adherent NPWT sponge (e.g., V.A.C.1 WhiteFoam) and set the device to low continuous suction (50– 75 mmHg). However, in some cases, particularly those where prostheses or vascular grafts are exposed, immediate soft tissue reconstruction is necessary.
Prior Treatments Prior surgical resections or adjuvant therapies, particularly radiation, may impact decision‐making about soft tissue reconstruction. In patients who have undergone prior resections, operative reports should be reviewed to establish whether the vascular supply to potential flaps has been affected, although the final determination should be made intraoperatively prior to committal to a reconstructive technique. In patients who have previously received radiation therapy, either in the distant past or in the neoadjuvant setting, preference should generally be given toward flap reconstruction over primary closure or skin grafting, due to the effects of radiation on local tissues [21]. If a free flap reconstruction is planned in an irradiated field, microvascular anastomoses should be performed outside of the zone of radiation whenever possible.
innervation of the LDF is the thoracodorsal nerve, and functional transfers have been reported for elbow flexion, elbow extension, and shoulder abduction [22]. For defects of the forearm, the pedicled radial forearm flap (RFF) serves as one of the most reliable options for soft tissue reconstruction [24]. An Allen’s test should be performed preoperatively to ensure an intact palmar arch and perfusion to the hand following flap harvest. The RFF may be performed as a standard flap with antegrade vascular flow from the brachial artery into the radial artery, or as a reverse flap based on retrograde flow through the palmar arch into the radial artery. The antegrade flap is better suited for rotation into proximal forearm defects (Fig. 2), while the reverse flap is more useful for rotation into distal forearm defects. For defects of the elbow, both the LDF and RFF are effective options [25]. Soft tissue reconstruction of the hand should aim to provide thin supple coverage, and consideration given to whether future elevation of a flap may be necessary such as for tendon reconstruction, which favors
Upper Extremity In the shoulder and arm, the pedicled latissimus dorsi flap (LDF) represents one of the most reliable and effective methods of soft tissue reconstruction, and is usually performed as a myocutaneous flap [22]. Its blood supply (thoracodorsal artery) is typically spared in the resection of upper extremity sarcomas. The arc of rotation of the LDF includes the shoulder and arm, and can extend as far as the elbow (Fig. 1). Relatively recent, variations of the traditional LDF have been described, including the muscle‐sparing LDF and the thoracdorsal artery perforator (TAP) flap, where little or no LD muscle is transferred with the flap, respectively, to minimize donor site morbidity [23]. The motor Journal of Surgical Oncology
Fig. 2. A: A 7 cm circular defect of the antecubital fossa with exposed brachial vessels. B: Reconstruction of antecubital defect with a pedicled radial forearm flap and split‐thickness skin grafting of the flap donor site.
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fasciocutaneous flaps over muscle flaps. The hand has relatively limited locoregional options for soft tissue reconstruction. The reverse RFF can reach proximal hand defects. In some cases, a finger fillet flap and ray amputation, or free flap, may be necessary [26].
Lower Extremity Many defects of the thigh may be closed primarily or skin grafted, due to the relative availability of adjacent local tissues and thigh musculature. When flap reconstruction is necessary, many options are available, including anterolateral thigh, gracilis, rectus femoris, tensor fascia lata, vastus lateralis, and vertical rectus abdominis myocutaneous flaps [27]. Free flap reconstruction of the thigh is most often necessary for posterior defects where pedicled flap options are more limited. In the leg, primary closure is often not possible following sarcoma resections. Skin grafting is an option in some cases, but can be somewhat limited especially for anterior defects where the tibia is relatively superficial. From a reconstructive standpoint, anterior leg defects are traditionally divided into thirds [28]. Defects involving the knee and proximal third of the leg can generally be reconstructed with pedicled gastrocnemius muscle flaps, of which the medial head confers greater tissue volume and a greater arc of rotation. Middle third defects can typically be reconstructed with pedicled soleus muscle flaps, and defects involving the distal third of the leg ordinarily require free flap reconstruction (Fig. 3). Another option for the distal third is the reverse sural fasciocutaneous flap which is based on reverse flow through the peroneal artery, which can also reach the ankle and proximal foot [29]. Soft tissue reconstruction of foot defects is based largely on whether the defect is located on a weight‐bearing or non‐weight‐bearing surface. The entire plantar aspect of the foot other than the instep is weight‐ bearing, and therefore typically requires a durable reconstruction with either a medial plantar artery flap or free flap. All other areas of the foot are non‐weight‐bearing and can be reconstructed with skin grafts provided that no structures are exposed. When this is not possible, then a reverse sural fasciocutaneous, dorsalis pedis, or free flap is likely to be necessary [28].
Fig. 3. A: A 13 cm 9 cm anterior defect involving the middle and distal thirds of the leg with exposed tibia in a patient in whom adjuvant radiation therapy is anticipated. B: Reconstruction of the lower extremity defect with a free anterolateral thigh perforator flap. Journal of Surgical Oncology
In conclusion, wide surgical resection remains the mainstay of treatment for soft tissue sarcomas. Adjuvant treatments with chemo‐ and/or radiotherapy may improve local control with marginal effects seen on overall survival. Multidisciplinary care with the plastic surgery and other teams may allow a higher rate of limb salvage due to advanced reconstruction options.
REFERENCES 1. White LM, Wunder JS, Bell RS, et al.: Histologic assessment of peritumoral edema in soft tissue sarcoma. Int J Radiat Oncol Biol Phys 2005;61:1439–1445. 2. Stoeckle E, Coindre JM, Kind M, et al.: Evaluating surgery quality in soft tissue sarcoma. Recent Results Cancer Res 2009;179: 229–242. 3. Brennan MF: Lessons learned from the study of soft tissue sarcoma. Int J Surg 2013;11:S8–S10. 4. Kandel R, Coakley N, Werier J, et al.: Surgical margins and handling of soft‐tissue sarcoma in extremities: A clinical practice guideline. Curr Oncol 2013;20:e247–e254. 5. O’Donnell PW, Griffin AM, Eward WC, et al.: The effect of the setting of a positive surgical margin in soft tissue sarcoma. Cancer 2014;120:2866–2875. 6. Gilbert NF, Cannon CP, Lin PP, et al.: Soft‐tissue sarcoma. J Am Acad Orthop Surg 2009;17:40–47. 7. Malek F, Somerson JS, Mitchel S, et al.: Does limb‐ salvage surgery offer patients better quality of life and functional capacity than amputation? Clin Orthop Relat Res 2012;470: 2000–2006. 8. Sheldon DG, James TA, Kraybill WG: Palliative surgery of soft tissue sarcoma. Surg Oncol Clin N Am 2004;13:531– 541, ix. 9. Miner TJ, Jaques DP, Tavaf‐Motamen H, et al.: Decision making on surgical palliation based on patient outcome data. Am J Surg 1999; 177:150–154. 10. Canter RJ, Smith CA, Martinez SR, et al.: Extremity soft tissue tumor surgery by surgical specialty: A comparison of case volume among oncology and non‐oncology‐designated surgeons. J Surg Oncol 2013;108:142–147. 11. Arai E, Nishida Y, Tsukushi S, et al.: Clinical and treatment outcomes of planned and unplanned excisions of soft tissue sarcomas. Clin Orthop Relat Res 2010;468:3028– 3034. 12. Alamanda VK, Delisca GO, Mathis SL, et al.: The financial burden of reexcising incompletely excised soft tissue sarcomas: A cost analysis. Ann Surg Oncol 2013;20:2808–2814. 13. Jones DA, Shideman C, Yuan J, et al.: Management of unplanned excision for soft‐tissue sarcoma with preoperative radiotherapy followed by definitive resection. Am J Clin Oncol 2014. Epub ahead of print. 14. Bui DT, Chunilal A, Mehrara BJ, et al.: Outcome of split‐thickness skin grafts after external beam radiotherapy. Ann Plast Surg 2004;52:551–556;discussion 7. 15. O’Sullivan B, Davis AM, Turcotte R, et al.: Preoperative versus postoperative radiotherapy in soft‐tissue sarcoma of the limbs: A randomised trial. Lancet 2002;359:2235–2241. 16. Kurul S, Dincer M, Kizir A, et al.: Plastic surgery in irradiated areas: Analysis of 200 consecutive cases. Eur J Surg Oncol 1997;23: 48–53. 17. Rudolph R: Complications of surgery for radiotherapy skin damage. Plast Reconstr Surg 1982;70:179–185. 18. Senchenkov A, Petty PM, Knoetgen J III, et al.: Outcomes of skin graft reconstructions with the use of Vacuum Assisted Closure (VAC(R)) dressing for irradiated extremity sarcoma defects. World J Surg Oncol 2007;5:138. 19. Sauerbier M, Unglaub F: Perforator flaps in the upper extremity. Clin Plast Surg 2010;37:667–676,vii. 20. Samant M, Chang EI, Petrungaro J, et al.: Reconstruction of massive oncologic defects following extremity amputation: A 10‐year experience. Ann Plast Surg 2012;68:467–471.
Surgical Management of Soft Tissue Sarcomas 21. Chao AH, Chang DW, Shuaib SW, et al.: The effect of neoadjuvant versus adjuvant irradiation on microvascular free flap reconstruction in sarcoma patients. Plast Reconstr Surg 2012;129:675–682. 22. Pierce TD, Tomaino MM: Use of the pedicled latissimus muscle flap for upper‐extremity reconstruction. J Am Acad Orthop Surg 2000;8:324–331. 23. Hamdi M, Van Landuyt K, Hijjawi JB, et al.: Surgical technique in pedicled thoracodorsal artery perforator flaps: A clinical experience with 99 patients. Plast Reconstr Surg 2008;121:1632– 1641. 24. Jones NF, Jarrahy R, Kaufman MR: Pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand. Plast Reconstr Surg 2008;121:887–898.
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25. Choudry UH, Moran SL, Li S, et al.: Soft‐tissue coverage of the elbow: An outcome analysis and reconstructive algorithm. Plast Reconstr Surg 2007;119:1852–1857. 26. Talbot SG, Mehrara BJ, Disa JJ, et al.: Soft‐tissue coverage of the hand following sarcoma resection. Plast Reconstr Surg 2008;121: 534–543. 27. Hollenbeck ST, Toranto JD, Taylor BJ, et al.: Perineal and lower extremity reconstruction. Plast Reconstr Surg 2011;128:551e– 563e. 28. Reddy V, Stevenson TR: MOC‐PS(SM) CME article: Lower extremity reconstruction. Plast Reconstr Surg 2008;121:1–7. 29. Almeida MF, da Costa PR, Okawa RY: Reverse‐flow island sural flap. Plast Reconstr Surg 2002;109:583–591.
Surgical Management of Soft Tissue Sarcomas: Extremity Sarcomas ALBERT H. CHAO,
MD,
1
JOEL L. MAYERSON, MD,2 RAJIV CHANDAWARKAR, THOMAS J. SCHARSCHMIDT, MD2
1 MD,
AND 1
Department of Plastic Surgery, The Ohio State University, Columbus, Ohio Department of Orthopaedics, The Ohio State University, Columbus, Ohio
2
Wide surgical resection is the recommended treatment for extremity soft tissue sarcomas. Chemotherapy and/or radiotherapy may improve local control, but with marginal effect on overall survival. Advanced reconstructive techniques and multidisciplinary care, including plastic surgery, may allow a higher rate of limb salvage. This report focuses on surgical and reconstructive aspects in the multimodality care of extremity sarcomas.
J. Surg. Oncol. 2015;111:540–545. ß 2014 Wiley Periodicals, Inc.
KEY WORDS: extremity sarcoma; reconstruction; limb preservation
INTRODUCTION Surgical resection is the mainstay and cornerstone of treatment for extremity soft tissue sarcomas. Although radiation and/or chemotherapy often play a role in the multimodality treatment of these malignancies, they are almost always used in conjunction with surgical resection of the mass. This report will focus on surgical and reconstructive aspects in the multimodality care of extremity sarcomas.
SURGICAL INDICATIONS Surgery in indicated in the treatment algorithm of nearly all soft tissue sarcomas. The only exception to this is in the diffusely metastatic setting, where systemic options may be explored first. The optimal surgical procedure is a wide surgical resection. This terminology and classification of oncologic procedures was originally described by Enneking and is as follows: intralesional, marginal, wide, and radical. Intralesional excisions are those typically performed by entering the substance of the tumor and removing it in a piece‐meal fashion. Intralesional excisions are reserved for benign conditions such as evacuation of a hematoma. Marginal excisions refer to en bloc excision through what is called the reactive zone. The reactive zone is equivalent to the thin capsule around a lipoma or the signal changes seen surrounding a mass on MRI. Marginal excisions are usually reserved for benign tumors such as neurofibromas, lipomas, and giant cell tumors of tendon sheath. Marginal excisions are not indicated for most malignancies as there can be tumor cells within the reactive zone [1]. A marginal resection may also be considered for a low‐grade malignant tumor if it abuts a vital structure and sacrifice of the structure leads to unacceptable or unwanted morbidity. The biologic aggressiveness of the tumor should be considered in this instance. Wide excisions are most commonly performed for primary malignant masses. In a wide excision, a cuff of normal tissue as taken as the margin as to ensure complete removal of the tumor is accomplished. More than 90% of extremity sarcomas can be widely excised preserving the limb. In an attempt to formalize the surgical intent and subsequent resection specimen, a new terminology has gained acceptance. The International Union Against Cancer (UICC) definitions of residual disease quantify the quality of the surgical resection. This contemporary classification of surgical margins includes: R0, R1, and R2. R0 refers to negative margins (no tumor at the inked surface upon histologic analysis), R1 is used to define microscopic tumor at the inked margin, and R2 is gross tumor at the inked margin. The goal of surgery in sarcomas is achievement of negative surgical
ß 2014 Wiley Periodicals, Inc.
margins (R0). Positive margins are a risk factor for local recurrence, but the overall effect on survival is controversial and unproven [2,3]. What constitutes an adequate anatomic margin deserves discussion and is controversial. For intra‐muscular locations, 1 cm of muscle is generally considered an appropriate wide margin [4]. When the tumor extends outside of the muscle or lies in inter‐fascial planes, the adequacy of the margin is more difficult to define. Other non‐muscular margins that may be pertinent depending on the location of the tumor that are considered to be adequate (i.e., tumor rarely invades) include fascia, peri‐neurium, periosteum, and vascular adventitia. A 1 mm margin where one of these structures represents the inked portion on histologic analysis is usually considered a R0 equivalent resection. The caveat to the preservation of the underlying structures (nerve, vessel, or bone) is that there is no microscopic violation on histologic analysis. In general, because positive margins and local recurrence have not been convincingly correlated with overall survival or the development of metastatic disease, an attempt to salvage vital structures with close margins is favored [5]. However, if there is gross invasion or encasement of the tissue, then re‐resection including the involved structure (nerve, bone, vessel) is generally recommended. Again, the biologic aggressiveness of the tumor should also be taken into consideration in these cases. In general, it is reasonable to accept closer margins in low‐grade tumors than it is in high‐grade lesions. A majority of sarcomas (>90%) can be treated with a limb salvage resection [6]. The considerations for whether to attempt limb salvage or to consider amputation is that the limb salvage result should: (1) achieve R0 resection, (2) have acceptable functional results, and (3) be associated with acceptable and manageable complications. If these goals cannot be accomplished then amputation should be considered [7]. The indications for amputation vary. Amputation should be considered when an R0 resection would leave the patient with a poorly functional limb, or not achieve the goals as described above. It should be noted that what is considered a functional limb will vary
*Correspondence to: Albert H. Chao, MD, Department of Plastic Surgery, The Ohio State University, Columbus, OH. Fax: (614) 293‐3381. E‐mail: [email protected] Received 10 June 2014; Accepted 8 July 2014 DOI 10.1002/jso.23810 Published online 21 October 2014 in Wiley Online Library (wileyonlinelibrary.com).
Surgical Management of Soft Tissue Sarcomas greatly depending on the person and requires individual conversation with discussion of the predicted functional result. In general, the main factor leading to amputation is direct invasion or encasement of a major nerve that will result in a functional deficit that is not acceptable to the patient. Other potential indications in which to consider an ablative procedure include infiltrative tumors of the hand or foot and sarcomas with ipsilateral skip or regional metastasis. In the authors’ opinion, although the involvement of vascular structures or bone may also be problematic, these can often be reconstructed after resection. The same is not true for nerve, and sacrifice often leads to profound functional deficit. The decision to undergo limb salvage versus ablative procedure must be discussed on an individual basis with the patient and family. The other role for surgery in sarcomas, and one that is often not discussed nor well defined is in the palliative setting. Palliative surgery is defined as resection without curative intent. This is generally considered if R0 resection cannot be accomplished due to anatomic constraints or in the setting of metastatic disease. It is controversial, and each case should be considered independently with the patient’s goals in mind. Because of their painless growth, aggressive nature, presentation at an advanced stage, varied anatomic location, and relatively young mean patient age (56 years old), cure is often not an achievable goal in soft tissue sarcomas. In approximately 20% of high‐grade tumors, the patient will have distant metastatic disease discovered at the time of their initial presentation. In those patients a palliative approach must be undertaken or considered early in the treatment course. It should be stressed that palliative surgery without curative intent is distinctly different from a non‐curative procedure performed in an asymptomatic patient that results in residual disease [8]. The success of palliation is almost entirely dependent upon appropriate selection of patients. In contrast to curative therapy where the goal is prolongation of life, palliation focuses on quality of the remainder of life, and measures of success should focus on this. Therefore, consequences of treatment such as toxicity, discomfort, and mortality need to be carefully considered in patients for whom no additional survival benefit exists [9]. Open discussions with the patient and family outlining all treatment options and what to expect from each palliative intervention is paramount. The surgeon should attempt to provide an estimation of prolonged survival as a result of the proposed surgical procedure. In this context, it should be realized that prolonged survival and palliative interventions are not mutually exclusive; a palliative resection may indeed prolong the patient’s survival but this is not the primary goal of the procedure. In a report from the Roswell Park Cancer Institute, selection of patients for palliative procedures was based on four distinct criteria: (1) The patient’s debilitating symptoms can be relieved by surgical intervention; (2) The patient is assessed to determine whether the procedure will give him a better quality of life, after thoughtful consideration of risk‐to‐benefit ratio; (3) The estimation of the patient’s post treatment survival and whether a surgical intervention would justify the risk and morbidity of the procedure; and (4) If the patient can undergo an operation, that surgery is the most effective treatment for their specific problem [8]. These again are difficult principles to define, but the impact on a patient’s quality of life is great. In summary, the palliative approach should be considered after careful consideration with the family and multidisciplinary review of the individual case. Surgical management of an incompletely excised or unplanned excision with subsequent positive postoperative margins deserves mention. Benign soft tissue masses are much more common than malignant soft tissue sarcomas and therefore 50% of soft tissue sarcomas are excised non‐surgical oncologists. Many of these masses are presumed benign and only recognized as sarcoma at definitive pathology. These “whoops” procedures do not necessarily confer inferior survival, but mandate referral to a tertiary sarcoma cancer center Journal of Surgical Oncology
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given the need for radical re‐excisions, radiation and soft tissue reconstructions [10]. The mainstay of treatment remains the same: achievement of negative (R0) surgical margins. In the setting of a re‐ resection, this often requires a larger resection and more complex reconstruction, including all tissues that were manipulated and any resulting hematoma. Any tissue involved during the index procedure is considered contaminated [11]. However, in the absence of metastatic disease and the ultimate achievement of negative margins at the time of re‐resection, overall survival is not impacted by the initial unplanned procedure. All series agree that the re‐excisions are associated with increased cost and morbidity from complex soft tissue coverage [12,13]. The preference of the authors is to perform re‐resections that will require skin graft or flap reconstruction in a staged fashion with the plastic surgery team. The resection is performed, temporized with a wound vacuum, and the reconstruction is undertaken after the margin status is confirmed to be R0. Postoperative radiation is performed, as we have found is it often easier to define the contaminated tissues before radiation. Other large centers however, advocate for preoperative radiotherapy in this scenario [13]. Modern techniques of reconstruction have made limb salvage a more realistic and functional option for many patients. Multi‐disciplinary care and advances with our plastic surgery colleagues has fostered this collaboration. Plastic surgery is an essential part of the multidisciplinary care of patients with extremity sarcomas. In the extremities, the relative paucity of local tissues and the high concentration of structures (tendons, bone, vessels, nerves), result in a frequent need for soft tissue reconstruction following tumor resections. Soft tissue reconstruction may be necessary to attain wound closure, cover critical structures, salvage a limb, and restore function. This can have greater implications in patients who will receive multimodality treatment, where reconstructive surgery may facilitate wound healing and reduce surgical complications.
PLASTIC AND RECONSTRUCTIVE SURGERY Method of Reconstruction The reconstructive ladder is a familiar concept in plastic surgery, where simpler techniques (primary closure, skin grafts) are considered prior to escalating to more complex methods (pedicled flaps, free flaps). In patients with extremity sarcomas, flap reconstructions may be necessary in many cases due to the margins that are required, limited local tissues and high concentration of structures, especially in the distal extremities. The most commonly utilized pedicled flap options for reconstruction following resection of extremity sarcomas are presented in Table I. Primary closure is sometimes possible, particularly for small tumors in proximal locations. Split‐thickness skin grafts (STSG) may be performed for defects with a vascularized wound bed when no vital structures are exposed, but should be avoided over joints due to secondary contraction, or in patients who have received or will be receiving radiation therapy [14,15]. In previously irradiated wounds, skin grafting has traditionally been associated with a high rate of complications [16,17]. Although there is some recent evidence suggesting that skin grafts can be successful in this setting [18], this remains controversial, and therefore a backup plan should be in place in case of graft failure. In our experience, negative pressure wound therapy (NPWT) dressings, such as the V.A.C.1 (Kinetic Concepts, Inc., San Antonio, TX), function as effective bolster dressings for STSGs. In these cases, we place a non‐adherent gauze between the STSG and the dressing sponge, and then apply a splint to immobilize the recipient site. We typically remove the bolster on postoperative days 4–5, after which splint immobilization is performed for an additional 1 week during which twice daily dressing changes with a non‐adherent gauze are performed.
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TABLE I. Commonly Used Pedicled Flap Options for Reconstruction Following Extremity Sarcoma Resection Flap Upper Extremity
Latissimus dorsi flap
Blood supply
Indications
Thoracodorsal artery
Shoulder
Arm
Radial forearm flap
Elbow Elbow
Radial artery
Forearm
Hand
Lower Extremity
Rectus abdominis flap
Deep inferior epigastric artery
Anterolateral thigh flap
Descending branch of lateral circumflex femoral artery
Gastrocnemius flap
Sural artery
Groin
Thigh (proximal) Groin
Thigh Knee
Leg (proximal third)
Soleus flap Reverse sural flap
Popliteal, posterior tibial, and peroneal arteries Sural artery perforator
Leg (middle third) Leg (distal third)
Ankle
Medial plantar artery flap
Medial plantar artery
Myocutaneous, fasciocutaneous, and muscle flaps that are skin grafted can all be effective in reconstructing defects following extremity sarcoma resections, both as pedicled and free flaps. While there are many options for pedicled flaps (as discussed below), free flaps may become necessary especially for large defects, recurrent disease that has been Journal of Surgical Oncology
Foot Foot (plantar)
Pearls/pitfalls Typically performed as a myocutaneous flap; however, for larger defects the muscle may be skin grafted Division of the humeral muscle insertion can increase arc of rotation The antegrade flap is utilized for proximal defects, and the reverse flap for distal defects A preoperative Allen’s test should be performed to confirm an intact palmar arch; if not intact, vein grafting of the radial artery may be necessary The paratenon of the brachioradialis and flexor carpi radialis tendons should be preserved to ensure successful skin grafting of the donor site Usually performed as a myocutaneous flap with a vertical skin paddle Effective as both a perforator skin flap, or as a myocutaneous flap that includes vastus lateralis muscle for dead space obliteration The medial and lateral heads have separate vascular pedicles and can be transferred independently The medial gastrocnemius tends to confer more tissue and have a wider arc of rotation Typically performed as a muscle flap that is skin grafted Typically performed as a muscle flap that is skin grafted The flap blood supply is based on reverse flow through perforator vessels from the peroneal artery located within 7 cm of the lateral malleolus Venous congestion can be a problem with this flap and should be used with caution in patients with peripheral vascular disease and smokers Preoperatively the posterior tibial artery circulation should be assessed The flap should be harvested only within the confines of the non‐weight‐bearing portion of the foot, which is skin grafted following flap transfer
previously resected/reconstructed, or in irradiated fields. When thin supple soft tissues are desired for reconstruction, such as in the distal extremities, preference should be given to thinner flaps, such as perforator flaps, that confer skin without muscle bulk and have no need for skin grafting [19]. In patients undergoing amputation, distal tissue
Surgical Management of Soft Tissue Sarcomas should be considered for possible use as a fillet flap for reconstruction [20]. Structured postoperative protocols are essential to ensure successful wound healing following flap reconstructions. In general, patients who undergo pedicled flap reconstructions may bear weight without immobilization immediately postoperatively. Exceptions to this are cases involving flaps located on the weight‐ bearing surface of the foot, where we typically wait at least 6 weeks prior to full weight‐bearing, or muscle flaps with STSGs where we will splint immobilize the site for 2 weeks to prevent shearing of the STSG. When free flap reconstructions are performed, we typically employ a more conservative postoperative protocol due the presence of microvascular anastomoses. Patients are instructed to strictly elevate the involved extremity for 1 week, after which we implement a dangling protocol. During this period, patients are permitted to dangle the extremity in a dependent position for 5 min every 2 hr, and increase the duration by 5 min every 2 days. Once patients are able to do this for 30 min without any evidence of an abnormality of the flap (e.g., discoloration or excessive edema), they are released from the dangling protocol and may also bear weight as tolerated.
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Fig. 1. A: An 18 cm 12 cm posterior arm defect. B: Reconstruction of the posterior arm defect with a pedicled latissimus dorsi myocutaneous flap.
Timing of Reconstruction Soft tissue reconstruction may be performed either immediately following sarcoma resection, or in delayed fashion once final pathologic margin status is known. Although delayed reconstruction obligates a patient to a second operation, it may be beneficial in cases where there is uncertainty about margin status, especially when a flap reconstruction is planned. In most cases, when delaying a reconstruction, the resection site can be managed with a NWPT dressing that is left in place until the time of reconstruction. When structures such as bone or nerves are exposed, we typically utilize a minimally adherent NPWT sponge (e.g., V.A.C.1 WhiteFoam) and set the device to low continuous suction (50– 75 mmHg). However, in some cases, particularly those where prostheses or vascular grafts are exposed, immediate soft tissue reconstruction is necessary.
Prior Treatments Prior surgical resections or adjuvant therapies, particularly radiation, may impact decision‐making about soft tissue reconstruction. In patients who have undergone prior resections, operative reports should be reviewed to establish whether the vascular supply to potential flaps has been affected, although the final determination should be made intraoperatively prior to committal to a reconstructive technique. In patients who have previously received radiation therapy, either in the distant past or in the neoadjuvant setting, preference should generally be given toward flap reconstruction over primary closure or skin grafting, due to the effects of radiation on local tissues [21]. If a free flap reconstruction is planned in an irradiated field, microvascular anastomoses should be performed outside of the zone of radiation whenever possible.
innervation of the LDF is the thoracodorsal nerve, and functional transfers have been reported for elbow flexion, elbow extension, and shoulder abduction [22]. For defects of the forearm, the pedicled radial forearm flap (RFF) serves as one of the most reliable options for soft tissue reconstruction [24]. An Allen’s test should be performed preoperatively to ensure an intact palmar arch and perfusion to the hand following flap harvest. The RFF may be performed as a standard flap with antegrade vascular flow from the brachial artery into the radial artery, or as a reverse flap based on retrograde flow through the palmar arch into the radial artery. The antegrade flap is better suited for rotation into proximal forearm defects (Fig. 2), while the reverse flap is more useful for rotation into distal forearm defects. For defects of the elbow, both the LDF and RFF are effective options [25]. Soft tissue reconstruction of the hand should aim to provide thin supple coverage, and consideration given to whether future elevation of a flap may be necessary such as for tendon reconstruction, which favors
Upper Extremity In the shoulder and arm, the pedicled latissimus dorsi flap (LDF) represents one of the most reliable and effective methods of soft tissue reconstruction, and is usually performed as a myocutaneous flap [22]. Its blood supply (thoracodorsal artery) is typically spared in the resection of upper extremity sarcomas. The arc of rotation of the LDF includes the shoulder and arm, and can extend as far as the elbow (Fig. 1). Relatively recent, variations of the traditional LDF have been described, including the muscle‐sparing LDF and the thoracdorsal artery perforator (TAP) flap, where little or no LD muscle is transferred with the flap, respectively, to minimize donor site morbidity [23]. The motor Journal of Surgical Oncology
Fig. 2. A: A 7 cm circular defect of the antecubital fossa with exposed brachial vessels. B: Reconstruction of antecubital defect with a pedicled radial forearm flap and split‐thickness skin grafting of the flap donor site.
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fasciocutaneous flaps over muscle flaps. The hand has relatively limited locoregional options for soft tissue reconstruction. The reverse RFF can reach proximal hand defects. In some cases, a finger fillet flap and ray amputation, or free flap, may be necessary [26].
Lower Extremity Many defects of the thigh may be closed primarily or skin grafted, due to the relative availability of adjacent local tissues and thigh musculature. When flap reconstruction is necessary, many options are available, including anterolateral thigh, gracilis, rectus femoris, tensor fascia lata, vastus lateralis, and vertical rectus abdominis myocutaneous flaps [27]. Free flap reconstruction of the thigh is most often necessary for posterior defects where pedicled flap options are more limited. In the leg, primary closure is often not possible following sarcoma resections. Skin grafting is an option in some cases, but can be somewhat limited especially for anterior defects where the tibia is relatively superficial. From a reconstructive standpoint, anterior leg defects are traditionally divided into thirds [28]. Defects involving the knee and proximal third of the leg can generally be reconstructed with pedicled gastrocnemius muscle flaps, of which the medial head confers greater tissue volume and a greater arc of rotation. Middle third defects can typically be reconstructed with pedicled soleus muscle flaps, and defects involving the distal third of the leg ordinarily require free flap reconstruction (Fig. 3). Another option for the distal third is the reverse sural fasciocutaneous flap which is based on reverse flow through the peroneal artery, which can also reach the ankle and proximal foot [29]. Soft tissue reconstruction of foot defects is based largely on whether the defect is located on a weight‐bearing or non‐weight‐bearing surface. The entire plantar aspect of the foot other than the instep is weight‐ bearing, and therefore typically requires a durable reconstruction with either a medial plantar artery flap or free flap. All other areas of the foot are non‐weight‐bearing and can be reconstructed with skin grafts provided that no structures are exposed. When this is not possible, then a reverse sural fasciocutaneous, dorsalis pedis, or free flap is likely to be necessary [28].
Fig. 3. A: A 13 cm 9 cm anterior defect involving the middle and distal thirds of the leg with exposed tibia in a patient in whom adjuvant radiation therapy is anticipated. B: Reconstruction of the lower extremity defect with a free anterolateral thigh perforator flap. Journal of Surgical Oncology
In conclusion, wide surgical resection remains the mainstay of treatment for soft tissue sarcomas. Adjuvant treatments with chemo‐ and/or radiotherapy may improve local control with marginal effects seen on overall survival. Multidisciplinary care with the plastic surgery and other teams may allow a higher rate of limb salvage due to advanced reconstruction options.
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25. Choudry UH, Moran SL, Li S, et al.: Soft‐tissue coverage of the elbow: An outcome analysis and reconstructive algorithm. Plast Reconstr Surg 2007;119:1852–1857. 26. Talbot SG, Mehrara BJ, Disa JJ, et al.: Soft‐tissue coverage of the hand following sarcoma resection. Plast Reconstr Surg 2008;121: 534–543. 27. Hollenbeck ST, Toranto JD, Taylor BJ, et al.: Perineal and lower extremity reconstruction. Plast Reconstr Surg 2011;128:551e– 563e. 28. Reddy V, Stevenson TR: MOC‐PS(SM) CME article: Lower extremity reconstruction. Plast Reconstr Surg 2008;121:1–7. 29. Almeida MF, da Costa PR, Okawa RY: Reverse‐flow island sural flap. Plast Reconstr Surg 2002;109:583–591.
