TURGUT AKGÜL, İSMAİL CEM SORMAZ, Murat AKSOY, Adem UÇAR, Harzem ÖZGER, Levent ERALP

Results and functional outcomes of en-bloc resection and vascular reconstruction in extremity musculoskeletal tumors

Objectives: This paper aims to evaluate the extremity function and vascular outcome after limb-sparing surgery for extremity musculoskeletal tumors invading vascular structure required reconstruction. Methods: Of the 507 patients with musculoskeletal tumors, who underwent surgery between 2004 and 2007, 17 (3,3%) patients with major vessel involvement were included in the study. The mean age was 37.8 ± 14.5, with a female/male ratio of 8/9. Thirteen (76.4%) patients had Stage IIb disease, and 2 (11,7%) patients had Stage III disease. In 2 (11,7%) patients have locally aggressive tumor that had Stage 3. Fifteen (88.2%) of the cases involved lower extremity, whilst 2 (11.8%) of them involved upper extremity. An arterial reconstruction was carried out in all patients. Wide tumor resection and endoprosthetic reconstruction were performed in 6 (35.2%) patients. Other 11 (65.8%) patients were treated with wide resection and soft tissue reconstruction. Postoperative data included; perioperative morbidities such as bleeding, infection, graft thrombosis, rupture, metastatic local recurrence and mortality. Ankle brachial index (ABI) and color-flow-duplex-scan (CFDS) were done at the final follow-up of the study, in order to prove the efficacy of reconstruction. Functional outcome was evaluated with International Society of Limb Salvage (ISOLS) criteria. Results: The mean follow-up was of 39 months (range 3e120). Perioperative complications were arterial graft thrombosis occurred in 3 (17.6%) patients treated acutely with thrombectomy, uncontrolled deep wound infection occurred in 2 patients whom extremities were amputated. The most frequent complication after surgery was limb edema according to possibly venous and lymphatic obstruction, staged as C1, C2 and C3 disease was established in 6 patients (two patients in each group), and 1 patient was classified as C6 disease. Three (17.6%) patients had local recurrence (1/3 patient died and 2/3 (11.7%) patients underwent transfemoral amputation). At the last follow-up, 9 (52.9%) patients were alive without evidence of disease, 8 (47.1%) patients were died due to primary disease. There were 8 (47.1%) patients alive with an intact limb. Although functional outcome scores were satisfactory, emotional acceptance scores were low. The limb salvage probability was 74.0%. Conclusion: Limb-sparing oncological surgery in musculoskeletal tumors with vascular invasion provides a satisfactory limb function, which may lead to an improved life quality. Arterial reconstruction has a high rate of patency in the long term. The surgeon should be aware of early perioperative complication related to vascular reconstruction and infection that effect on the rate of extremity survival.

___

Fortner JG, Kim DK, Shiu MH. Limb-preserving vascular surgery for malignant tumours of the lower extremity. Arch Surg. 1977;112(4):391e394.

Ghert MA, Davis AM, Griffin AM, Alyami AA, White L. The surgical and functional outcome of limb salvage surgery with vascular reconstruction for soft tissue sarcomas of extremity. Ann Surg Oncol. 2005;12(12):1102e1110.

Ghert MA, Abudu A, Driver N, et al. The indications for and the prognostic significance of amputation as the primary surgical procedure for localized soft tissue sarcoma of the extremity. Ann Surg Oncol. 2005;12(1):10e17.

Koperna T, Teleky B, Vogl S, Windhager R, Kainberg F. Vascular reconstruction for limb salvage in sarcoma of the lower extremity. Arch Surg. 1999;131(10): 1103e1107.

Teleky B, Ritschl P, Kotz R, Polterauer P. Gefasschrurgische rekonstruktionen bei orthopadischen Tumoroperationen. Chirurg. 1988;59(3):159e164.

Karakousis CP, Emrich LJ, Vesper DS. Soft tissue sarcomas of the proximal lower extremity. Arch Surg. 1989;124(11):1297e1300.

Nambisan RN, Karakousis CP. Vascular reconstruction for limb salvage in soft tissue sarcomas. Surgery. 1987;101(6):668e677.

Puri A. Limb salvage: when, where and how? Indian J Orthop. 2015;49(1): 46e55.

Hohenberger P, Allenberg JR, Schlag PM, Reichardt P. Results of surgery and multimodal therapy for patients with soft tissue sarcoma invading to vascular structures. Cancer. 1999;85(2):396e408.

Gooding GAW, Perez S, Rapp JH, Krupski WC. Lower- extremity vascular grafts placed for peripheral vascular disease: prospective evaluation with duplex Doppler sonography. Radiology. 1991;180(2):379e386.

Tsubuyama T, Windhager R, Dock W, Bochdansky T, Yamamuro T, Kotz R. Knee function after operation for malignancy of the distal femur. Acta Orthop Scand. 1993;64(6):673e677.

Tsubuyama T, Windhager R, Bochdansky T, Yamamuro T, Kotz R. Gait after knee arthroplasty for femoral tumor. Acta Orthop Scand. 1994;65(1):51e54.

Enneking WF, Spanier SS, Goodman MA. Current concepts review. The surgical staging of musculoskeletal sarcoma. J Bone Joint Surg Am. 1980;62(6): 1027e1030.

Kato D, Maezawa K, Yonezawa I, et al. Randomized prospective study on prophylactic antibiotics in clean orthopedic surgery in oneward for 1 year. J Orthop Sci. 2006 Jan;11(1):20e27.

Clagett GP, Sobel M, Jackson MR, Lip GY, Tangelder M, Verhaeghe R. Antithrombotic therapy in peripheral arterial occlusive disease: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126(3): 609e626.

Agnelli G, Gitt AK, Bauersachs R, et al, PREFER in VTE investigators. The management of acute venous thromboembolism in clinical practice e study rationale and protocol of the European PREFER in VTE Registry. Thromb J. 2015;21(13):13e41.

Padberg Jr FT. CEAP classification for chronic venous disease. Dis Mon. 2005;51(2e3):176e182.

Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993;286: 241e246.

Spiro IJ, Rosenboerg AE, Springfield D, Suıt H. Combined surgery and radiation therapy for limb preservation in soft tissue sarcoma of the extremity. Cancer Invest. 1995;13(1):137e138.

Malawer MM, Link MP, Donaldson SS. Sarcomas of bone. In: De Vita VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 4th ed. Philadelphia Pa: JB Lippincott; 1993:1509e1566.

Leggon RE, Huber TS, Scarborough MT. Limb salvage surgery with vascular reconstruction. Clin Orthop Relat Res. 2001;387(387):207e216.

Diperna CA, Bowdish ME, Weaver FA, et al. Concominant vascular procedures for malignancies with vascular invasion. Arc Surg. 2002;137(8):901e907.

Fadel E, Chalepier A, Bacha E, et al. Subclavian artery resection and reconstruction for thoracic inlet cancers. J Vasc Surg. 1999;29(4):581e588.

Xin Li MD, Vincent M, Moretti MD, et al. Perioperative infection rate in patients with osteosarcomas treated with resection and prosthetic reconstruction. Clin Orthop Relat Res. 2011;469(10):2889e2894.

Myers GJC, Abudu AT, Carter SR, Tillman RM, Grimer RJ. The long-term results of endoprosthetic replacement of the proximal tibia for bone tumours. J Bone Joint Surg Br. 2007;89(12):1632e1637.

Muramatsu K, Ihara K, Miyoshi T, Yoshida K, Taguchi T. Clinical outcome of limb-salvage surgery after wide resection of sarcoma and femoral vessels reconstruction. Ann Vasc Surg. 2011;25(8):1070e1077.

Emori M, Hamada K, Omori S, et al. Surgery with vascular reconstruction for soft tissue sarcomas in the inguinal region: oncological and functional outcomes. Ann Vasc Surg. 2012;26(5):693e699.

Kurtoglu M, Yanar H, Taviloglu K, Sivrikoz E, Plevin R, Aksoy M. Serious lower extremity venous injury management with ligation: prospective overview of 63 patients. Am Surg. 2007;73(10):1039e1043.

Oktar GL. Iatrogenic major venous injuries incurred during cancer surgery. Surg Today. 2007;37(5):366e369.

Adelani AM, Holt G, Dittus R, Passman M, Schwartz H. Revascularization after segmental resection of lower extremity soft tissue sarcomas. J Surg Oncol. 2007;95(6):455e460.

Satoshi T, Yoshihiro N, Hideshi S, Hitoatsu N, Naoki I. Results of Limb-Salvage surgery with vascular reconstruction for soft tissue sarcoma in the lower extremity: comparison between only arterial and arterovenous reconstruction. J Surg Oncol. 2008;97(3):216e220.

Nishinari K, Wolosker N, Yazbek G, Zerati AE, Nishimoto IN. Venous reconstruction in lower limbs associated with resection of malignancies. J Vasc Surg. 2006;44(5):1046e1050.

Ayerza MA, Farfalli GL, Aponte-Tinao L, Muscolo DL. Does increased rate of limb-sparing surgery affect survival in osteosarcoma? Clin Orthop Relat Res. 2010;468(11):2854e2859.