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

Introduction

Extremity sarcoma management follows a multidisciplinary approach involving orthopedic oncologists, plastic surgeons, medical oncologists, and radiation oncologists. Surgical resection of lower extremity soft tissue sarcomas often leads to large, complex defects with exposure of underlying neurovascular structures, tendons, and/or bone. Subsequent reconstructive surgery is often required in order to provide adequate soft tissue coverage and allow for functional preservation of the limb. We report our 20-year experience with limb-salvage surgery following lower extremity soft tissue sarcoma resection.

Methods

We performed a retrospective review on all patients 18 years or older at the time of operation that underwent soft tissue reconstructive surgery following resection of lower extremity soft tissue sarcomas between 1996 and 2016 at our institution. Medical records were reviewed for patient demographics, tumor characteristics, details of tumor resection and plastic surgery reconstruction, administration and timing of chemo/radiation therapy, and postoperative outcomes.

Results

136 patients underwent plastic surgery reconstruction following tumor resection. The average age was 55.7 years. The majority of tumors were high grade (47.1%), greater than 5 cm (66.9%), AJCC stage 3 (38.2%) and located in the proximal thigh (41.2%). 93.4% of reconstructive procedures were performed in the same operative setting as the oncologic resection. Approximately 90% of the advanced plastic surgery reconstructions involved a flap for coverage. Local flap reconstruction was most common for proximal thigh wounds (69.6%) and microvascular free flap reconstruction was most common for distal leg wounds (60.9%) (p=0.013). Skin grafts alone were most common for tumors ≤5cm (p=0.043), superficial wounds (p=0.001), and re-excisions (p=0.029) due to incomplete margins or recurrent disease. In conjunction with surgery, seventy-two patients (52.9%) received neoadjuvant radiation and twenty-six patients (19.1%) received neoadjuvant chemotherapy. The utilization of neoadjuvant radiation or neoadjuvant chemotherapy was not associated with the type of reconstruction utilized following tumor resection.

Wound complications occurred within 6-months postoperatively in 52.9% of patients. The most common complication was wound dehiscence (26.4%), followed by infection (18.4%), and seroma (15.4%). Thirty-two patients (23.5%) required a re-operation for wound complications. Average time to healing was 13.0 weeks. Limb survival was 94.9%. There was no significant difference in the incidence of overall wound complications, re-operations, time to heal, or limb survival, between patients receiving local flap, free flap, or skin graft coverage. 16.9% and 36.8% of patients had evidence of local recurrence or metastatic disease through last known follow up, respectively. There was no significant difference in local recurrence or metastatic disease between the different reconstructive techniques.

Conclusions

Patients with extensive lower extremity soft tissue defects often require plastic surgery soft tissue reconstruction after sarcoma resection. Based on our results, in patients that cannot undergo primary closure, local flaps can effectively reconstruct the majority of lower extremity sarcoma defects. However, microvascular free tissue transfer may be warranted for large wounds, areas of previous irradiation damage, or in the distal lower extremity. The post-operative management of sarcoma patients remains challenging due to high rates of wound complications. Local recurrence and metastatic disease confer additional morbidity and mortality in this patient population.