Risk Factors for Lymphedema after Thigh Sarcoma Resection and Reconstruction.

Secondary lymphedema can be a lifelong and debilitating consequence of lower extremity oncologic resection and reconstruction. The goal of this study was to identify risk factors for the development of lymphedema in patients treated for thigh sarcoma. METHODS: A retrospective review analyzed all patients who underwent thigh sarcoma resection and reconstruction by a plastic surgeon at the Mayo Clinic between 1997 and 2014. Patient demographics, tumor characteristics, surgical management, adjunctive therapies, and complications of patients who did and did not develop postoperative lymphedema were compared. RESULTS: A total of 148 patients were identified. Twelve percent of patients developed lymphedema postoperatively during an average follow-up of 26 months. Risk factors for the development of lymphedema included defect location in the medial thigh (P = 0.04), arterial resection (P = 0.001), arterial reconstruction (P = 0.027), and a history of cardiac disease (P = 0.03). Twenty-two percent of patients who developed lymphedema also experienced wound dehiscence compared with 4.6% of patients without lymphedema (P = 0.02). There were no differences in age, body mass index, smoking, history of deep venous thrombosis or venous stasis, wound dimensions, or type of reconstruction performed in patients with and without lymphedema. CONCLUSIONS: Lymphedema is common following major oncologic resection. Preexisting cardiac disease, tumor location in the medial thigh, and arterial resection and reconstruction were associated with a higher risk of postoperative lymphedema. Noninfectious wound dehiscence may be secondary to lymphedema or represent an early indicator of patients who will ultimately develop lymphedema.

Complications after thigh sarcoma resection.

BACKGROUND AND OBJECTIVES: Standard treatment for extremity sarcoma is limb-sparing surgery often with radiation, but complications occur frequently. We sought to determine factors predictive of wound complications after thigh sarcoma resection and reconstruction while analyzing trends over time. METHODS: We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014. Patient demographics, comorbidities, operative characteristics, multi-modality therapies, and complications were analyzed. Wound complications were: infection, dehiscence, seroma, hematoma, or partial/total flap loss. RESULTS: There were 159 thigh reconstructions followed for 30 months on average. Eighty-seven percent of patients underwent radiation and 42% had chemotherapy. Almost half (49.1%) had a complication. The most common wound complication was surgical site infection (23.3%) followed by dehiscence (19.5%), and seroma (10.7%). Less common were partial (2.5%) or total flap loss (0.6%). Reoperation was required in 21 patients (13.2%). Tobacco use, older patient age, cardiac disease, and higher body mass index were independently associated with wound complications. Complications trended towards decreasing over time, but this was not statistically significant. CONCLUSIONS: Tobacco use, cardiac disease, and higher body mass index, but not the timing of reconstruction, appear to increase the risk of wound complications after thigh soft tissue sarcomas resection and plastic surgery reconstruction.

A reconstructive algorithm after thigh soft tissue sarcoma resection including predictors of free flap reconstruction✰.

BACKGROUND: Reconstruction of defects of the thigh after oncologic resection plays a vital role in limb salvage. Our goal was to evaluate our institution's experience on thigh sarcomas to develop evidence-based recommendations to guide the reconstructive surgeon, including factors that would predict the need for free flap reconstruction. METHODS: We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014. Patient demographics, comorbidities, multimodality therapies, and operative characteristics were analyzed. RESULTS: There were 159 thigh reconstructions. Reconstruction was achieved by primary closure (15%), skin graft (13%), local fasciocutaneous flap (8%), local muscle flap (31%), regional muscle flap (28%), or free flap (4%). For the proximal third of the thigh, the most common flaps were pedicled thigh muscle and rectus abdominis flaps; for the middle third of the thigh, it was pedicled thigh muscle flaps; and for the distal third, it was pedicled gastrocnemius muscle flaps. Factors shown to be predictive of requiring a free flap included wide defects (p = 0.03) and location in the middle third of the thigh (p = 0.001). CONCLUSION: There are multiple options for reconstructing defects from thigh STS. When primary closure and skin grafts are not an option, most defects can be closed with pedicled local or regional muscle or fasciocutaneous flaps. Free flap reconstruction is rarely required but can be necessary when defects are wide or located in the middle third of the thigh.

Molecular testing for lipomatous tumors: critical analysis and test recommendations based on the analysis of 405 extremity-based tumors.

Ancillary molecular testing has been advocated for diagnostic accuracy in the differentiation of lipomas from atypical lipomatous tumors/well-differentiated liposarcomas (ALT/WDL); however, the implications and specific indications for use are not well-established in the current literature. Herein, we extend previous findings by quantitatively evaluating the impact of molecular testing of lipomatous neoplasms in our routine clinical practice, how it modifies the historical perspective of their clinical course, and the effect of distinct surgical procedures in modulating the risk of local recurrence for these tumors after molecular classification. On the basis of these analyses, we suggest a specific set of basic recommendations for complementary molecular assessment in the diagnosis of lipomatous tumors. Four hundred and five lipomatous neoplasms located in the trunk and extremities were analyzed histologically and for the presence of 12q13-15 amplification on paraffin-embedded tissues by assessing MDM2/CPM amplification. Survival analyses were calculated with Kaplan-Meier and compared with the log-rank. Multivariate analysis was evaluated by the Cox regression method. The 405 tumors were histologically classified as ordinary lipoma (n=324), intramuscular lipoma (n=29), and ALT/WDL (n=52). The level of agreement between the histologic diagnosis and the molecular diagnosis was high (96%) but pathologists showed a tendency to overestimate cytologic atypia and the diagnosis of ALT/WDL (precision, 79%; accuracy, 88%). Molecular assessment led to a major diagnostic reclassification in 18 tumors (4%). Eleven of the tumors histologically classified as ALT/WDL were reclassified as ordinary lipoma (n=5) and intramuscular lipoma (n=6); none of which recurred. Seven ordinary lipomas were reclassified as ALT/WDL, 6 of which were larger than 15 cm and deeply located; 2 recurred locally. After molecular data, the 5-year local recurrence rates for ordinary lipoma, intramuscular lipoma, and ALT/WDL were 1%, 12%, and 44%, respectively. Multivariate analyses after molecular assessment showed tumor type and type of resection to be associated with the risk of local recurrence. Complementary molecular testing refines the histologic classification of lipomatous tumors and better estimates the impact of surgical procedures on the risk of local recurrence. Pathologists tend to overestimate the degree of cytologic atypia and the indiscriminate use of molecular testing should be avoided, especially for extremity-based tumors. Molecular testing should be considered for "relapsing lipomas," tumors with questionable cytologic atypia (even if widely excised), or for large lipomatous tumors (>15 cm) without diagnostic cytologic atypia.