Limb Sparing Surgical Resection of Groin Sarcoma. Surgical ... - NCI

282A high percentage of patients having groinsarcoma presents to NCI Cairo University withsome sort of improper management in the formof improper long transverse incision for biopsyor trial of resection, incomplete excision withgross residual disease left, usually near thepubic bone, around femoral vessels or a missedintrapelvic component. Some cases may havea recurrent disease after previous surgery withor without radiotherapy and need salvage surgery.Patients may be referred for primary radiotherapyby inexperienced surgeons in nonspecialized centers [5].The aim of this study is to evaluate thefeasibility of limb sparing surgical resectionand reconstructive options in 14 patients havinggroin soft tissue sarcoma; most of them weresubjected to improper management before presentationto NCI, Cairo University. Oncologicoutcome and functional results of those patientsare also reported.MATERIAL AND METHODSThis study was conducted in the NationalCancer Institute, Cairo University during theperiod from January 2001 to December 2006and included 14 patients having soft tissuesarcoma of the groin.Preoperative clinical evaluation included amedical history of previous surgery or radiotherapyand a physical examination with assessmentof distal pulsation of the popliteal andtibial vessels and femoral nerve function. Presenceor absence of distal edema was determinedby visual inspection and by determining indentationof the pretibial skin. The presence ofedema warrants preoperative Doppler ultrasonographyto assess patency of the ileofemoralvein. Preoperative edema was seen in two casesand duplex showed no thrombosis of femoralvein.Preoperative staging studies included plainradiograph to the pelvic bone, CT and MRI withcontrast to assess local extension of the tumorespecially intrapelvic extension, the relation ofthe tumor to the ileofemoral vessels whetherdisplaced or surrounded by the tumor. Duplexassesses the patency of the lumen of vessels.MRA and conventional or CT angiography weredone to assess vascular involvement. Chest CTscan was done routinely to all patients to excludeLimb Sparing Surgical Resection of Groin Sarcomapulmonary metastasis. Vascular involvementwas diagnosed when MRI or CT imaging didnot show a rim of normal tissue in the tumorto-vessel interface (Figs. 1-4).One patient had extensive pulmonary metastasesand was excluded from the study. Anotherpatient had single pulmonary nodule andwas included in the study. He was subjected tolimb sparing surgery and metastatectomy. Radiologicalvascular involvement was seen in 2cases who were subjected to salvage procedure.One patient had extensive recurrent diseasewith extensive involvement of the bony pelvisand iliofemoral vessels that necessitate externalhemipelvectomy and was subjected to externalhemipelvectomy and excluded from the study.Finally the salvage procedure was done in 14cases.According to the Enneking staging system[6], 9 patients had stage II, 4 had stage IIA andone patient had stage III. Six cases had variabledegrees of intraapelvic extension through theobturator foramen.Histopathological study was done throughrevision of previous pathology reports for caseswhich received any type of surgery or biopsybefore referral to us (no. 11 cases). Tru-cutneedle, or core biopsy was done for new cases(4 cases). The histological types encounteredwere synovial sarcoma (2 cases), malignantfibrohistiocytoma (4 cases), fibrosarcoma (6cases), hemangiopericytoma (1 case) and liposarcoma(1 case).The extent of surgical technique, complicationsand functional results of limb-salvagesurgery compared with amputation were discussedwith the patients and consent for operationwas signed in.Tumor resection:Primary tumors without skin involvementand with minimal intrapelvic extension wereapproached through a modified radical groinincision [4]. If groin sarcoma has large extensioninto the pelvis it was preferred to be approachedthrough abdominoinguinal incision that allowsintraabdominal exploration with better exposureof pelvic structures [7]. In patients who havesome sort of previous management or recurrentcases, the incision was modified accordinglyto include the previous scar or the skin over the

Magdy El-Sherbiny 285tivity, emotional acceptance, need to externalsupport, walking ability and gait. A score offive indicates normality and a score of oneindicates significant disability. A middle scoreof three would suggest problems such as theneed for non narcotic analgesics, being unableto play sports, the occasional need for a walkingdistant stick and a modest limp. A percentagescore can be given to each factor.Adjuvant therapy: Thirteen patients out of14 received postoperative adjuvant radiotherapyafter complete healing of the wound. One patienthad preoperative radiotherapy so postoperativeradiotherapy was ignored. One patient havingone pulmonary nodule and 3 patients havinglarge size and high grade were referred forpostoperative chemotherapy.RESULTSPatient details:During the period between 2002 and 2006,we treated and followed 14 patients having softtissue sarcoma of the groin by limb sparingsurgery. The mean age at diagnosis was 39-years (range 28-55 years). Eight patients weremales and 6 were female. The mean follow-uptime was 31 months (range 25-53 months).Ten cases had a primary groin sarcoma;eight of them had long transverse incision eitherfor biopsy or trial of resection, one of thoseeight patients had been treated primarily byradiotherapy and two patients had small transversebiopsy incision. The last four patients hadincomplete resection with gross residual diseaseleft.Approach: The incision was modified accordingto the direction and length of the previousscars. Finally, 11 cases were approachedretroperitoneally through modified inguinalapproach and 3 were approached intraabdominallythrough abdominoinguinal approach.Six cases had variable degrees of intrapelvicextension of their tumors; four of them wereresected completely through retroperitonealmodified inguinal approach.Surgical margins: According to the histopathologicalreports, wide resection in 9 patients,close but negative margins in 4 patients andpositive microscopical lateral margin in onepatient. Histopathologic examination of thespecimens with vascular resection revealed thattwo cases, showed infilteration of the bloodvessels.The spermatic cord was dissected in theinguinal canal in all male patients and no patientrequired resection of the spermatic cord.The femoral nerve was scarified in threepatients. All patients required sacrifiying ofsome branches of the nerve.Bone resection included the superior pubicramus in 7 cases, superior pubic ramus andpubic bone in 5 cases (Fig. 12), superior pubicramus, inferior pubic ramus and pubic bone in2 cases. Part of the roof of acetablum wasremoved in one case having superior pubicramus resection. The part resected was reconstructedby a double layer of dacron graft andproline mesh.Vascular resection and reconstruction: Twocases had femoral vessels involvement and theirtumors were resected en bloc with involvedvessels without amputation. One case requiredprosthetic graft replacement of both femoralvein and artery and one case required prostheticgraft replacement of femoral vein only.Vascular graft function: After a mean followupperiod of 5 months, one case developedocclusion of the femoral artery graft. No revisionwas done despite absence of distal pulsationbecause the capillary circulation was good andthe patient had no complaint. The two venousgrafts showed graft obstruction however nointerference was done due to absence of distaledema.Healing of the modified inguinal incision(1 case) or abdominoinguinal incision (1 case)generally healed well without any complications(Fig. 13).Skin coverage: Ten cases required localmyocutaneous flaps for coverage of associatedskin loss. Defect size ranged from 15 to 25cmin length and 8 to 16cm in width. Local pedicledflaps used included, gracilis myocutaneous flapin two cases, inferiorly based rectus abdominsmyocutaneous flap in 5 cases (three ipsilateraland 2 contralateral), tensor fascia lata flap inone case and anterolateral thigh flap in onecase. Inferiorly based rectus abdomins muscle

286flap without skin was used in 2 cases (Fig. 14).Sartorius muscle flap was used in 8 patients asit was included with the resection in 6 patients(Fig. 10).We had no flap failure or partial necrosis inall the flaps used.Complications:1- Seroma was the most frequent early complications(incidence 100%). The daily drainoutput ranged from 700 to 1900ml/day. Thiswas managed by prolonged drainage for 2weeks.2- Superficial stitch gaping occurred in 3 caseswhich healed completely within 2 weekswith repeated dressing.3- Wound breakdown and deep infection withexposure of the part of the underlying abdominalmesh was seen in one case (7%).This patient had previous radiotherapy andwas treated by removal of the mesh and thewound was left opened to granulate.4- Lymphedema. The most frequent late complication(35%) and was controlled by legelevation, massage and compression. It wasmild to moderate with no interference withwalking or climbing stairs.Limb salvage and limb function results:Over the 5 years study period, the extremitysalvage rate for patients present to us was 87.5%and included 14 patients out of 16 patients.Limb sparing radical resection was consideredLimb Sparing Surgical Resection of Groin Sarcomasuccessful if the patients did not require amputationand have a functioning limb and the tumorwas resected without a residual. Removal ofthe pubic bone does not appear to have any longterm effects in ambulation. According to theMSTS function score, all patients achieved ahigh functional score ranging from 92% to 97%.Tumor control and survival: One patientrequired external hemipelvectomy after 23months postoperatively because of extensivelocal recurrence in the proximal thigh. The 2year local tumor control rate of those patients(minimal follow-up period) was 92.8% for 13/14patients. Two patients died because of extensivepulmonary metastasis after 24 and 26 monthsof surgery. The 2 year survival rate, the minimalfollow-up period, was 85.7% for 12/14 patients.Fig. (1): T1 MRI, showing the proximal extension of groinsoft tissue sarcoma.Fig. (2): T1 MRI, showing the proximalextension of groin soft tissuesarcoma.Fig. (3): T2 MRI, showing intrapelvicextension of groin sarcoma.Fig. (4): Preoperative angiographyshowing involvement of superfacialfemoral artery.

Magdy El-Sherbiny 287Fig. (5): Improper transverse incision with incompleteresection.Fig. (6): Defect after resection of groin sarcoma.Note, femoral vessels, spermatic cordand proline mesh for reconstruction ofabdominal wall defect.Fig. (7): Rectus abdomins myocutaneous flap for coverage of longitudinalgroin and thigh defect after resection of groin softtissue sarcoma.Fig. (8): Rectus abdomins myocutaneous flapfor coverage of transverse defect afterresection of groin soft tissue sarcoma.Fig. (9): Gracilis myocutaneous flap for reconstruction ofgroin defect after resection of groin soft tissuesarcoma.Fig. (10): Gracilis myocutaneous flap for reconstructionof groin defect after resectionof groin sof tissue sarcoma.

288Limb Sparing Surgical Resection of Groin SarcomaFig. (11): Tensor fascia lata flap for reconstruction oflarge transverse groin defect after resection ofgroin soft tissue sarcoma.Fig. (12): Postoperative plain X-ray, showing resectionof pubic bone and superior puboc ramius.Fig. (13): Healing of abdominoinguinal incisionafter resection of groin soft tissuesarcoma with pelvic extension.Fig. (14): Inferior rectus muscle flap without skin for coverageof femoral vascular graft and proline mesh.DISCUSSIONThe rationale of limb sparing surgical resectionfor soft tissue sarcoma includes improvementof survival, achievement of adequate negativesafety margins around the tumor tomaximize local control, adequate soft tissuecoverage of implants and deep structures witha reliable myocutaneous flap [9-13].Limb sparing surgical resection of groinsarcoma is different from that of anterior thighdue to proximity to the pubic bone with possibleintrapelvic extension and close relation to thefemoral vessels. Wound problems may occurwith minimal skin excision or even followingsimple elevation of skin flaps. Safe resectionwith achievement of clear margins entails theneed of wide retroperitoneal or intraabdoimalexploration through modified inguinal or abdominoinguinalincisions, exposure and controlof iliofemoral vessels proximally and distallyand resection of the pubic bone. Also, good

Magdy El-Sherbiny 289orientation with the reconstructive options isneeded [2,3,4].Mismanagement in the form of improperbiopsy incision or incomplete resection or localrecurrence with skin involvement will add tothe difficulty to the proper approach. In thepresent study, the skin incision was modifiedin 85.7% of cases to include previous scars orareas of possibly infiltrated skin and then theapproach was continued as previously describedmodified inguinal or abdominoinguinal approach[4,7]. Through this approach, we wereable to resect the tumor with negative marginsin 12/14 of cases (92.8%). Only one case (7%)had single microscopic positive margin. Thismight be due to previous radiotherapy and theresulting dense fibrosis that may add difficultyto the proper intraaoperative assessment of themargins.Vascular resection and prosthetic reconstructionwas done in two cases. Soft tissue sarcomasinvolving major vascular structures are notconsidered a contraindication of limb sparingsurgery. Patients can undergo vascular resectionwhen the tumor is infiltrating or encasing thevessels [14,15]. Schwarzbach et al. [16], recommendedsynthetic grafts for arterial and venousvascular substitute in the iliofemoral region.The rational of this is to reduce the operativetime and to preserve the great saphenous vein(GSV) and usually there is some degree ofcaliber discrepancy between iliofemoral andGSV.Reconstruction of resected iliofemoral veinis mandatory. This prevents limb edema in theimmediate postoperative period and associatedclinical sequale as complicated wound healing,pain, edema, tension and skin alteration. Femoralvein resection distal to the entry of the ipsilateralGSV can be ligated if GSV was preserved andwas patent, however, some recommended autologousvein graft for fear of infection ofprosthetic grafts [16].When a prosthetic vascular raft has beenused to replace the femoral vessels, an effortshould be made to cover the graft at the end ofthe procedure with rotation of muscle to avoidexposure and infection [16,17,18]. In the 2 caseshaving prothetic vascular graft in the presentstudy, medial transposition of sartoius musclewas not enough for complete coverage, so the2 cases had had rectus muscle and mucocutaneousflap coverage.The reported patency rates for prostheticvenous reconstructions are lower than for arterialones; however, the use of the autologous veinhas not proven to be superior to synthetic graftswith respect to the long-term patency rate afterlimb-salvage surgery [16,19,20]. In the presentstudy, one case had concomitant venous andarterial prosthetic reconstruction and one hadonly venous prothetic reconstruction. All the 3grafts lost patency within 5 months postoperativelydespite anticoagulant therapy. Usuallyrevision is not needed for venous reconstructionas usually by time collaterals develop. Revisionof arterial graft may be considered however, inthe present study revision was ignored as thepatient had no complaint and distal circulationwas very good.Involvement of the femoral nerve in threecases (21%) necessitated nerve sacrifice. Mostof tumors in the present study were medial tothe femoral vessels so the nerve could be sparedin most cases. The residual function of postnerve resection was frequently very good. Thosepatients only need a temporary knee brace [7].Microvascular free flap transfer is rarelyrequired to cover groin defects. This is due toavailability of some reliable local muscle andmusculocutaneous flaps. Local flaps reportedfor groin defect reconstruction included tensorfacia lata flap [21], anterolateral thigh flap [22],inferiorally based rectus abdomins myocutaneousflap [23], gracilis myocutaneous [24], Sartoriusmuscle flap [25] and rectus femoris muscleand musculocutaneous flap [26].A total of number of 10 myocutaneous flapswere used in the present study. We had no flapfailure or partial necrosis. To minimize the riskof failure, the selection between the availableflaps in the present study was finalized aftercompletion of the process of resection and wasbased on many factors such as the site of thedefect (lateral or medial part of the groin), sizeof the defect, orientation of the axis of the defectand which branches of the iliofemoral vesselwere preserved such as the profunda artery andits branches and the inferior epigastric artery.Inferiorly based rectus abdomins myocutaneousflap has a pedicle length ranging from 7-

29012cm which is the inferior epigastric artery.This allows a wide arc of rotation when usedas a pedicled flap [23]. This wide arc of rotationallows easy usage of either the right or leftrectus muscle. Adding to the possibility ofharvesting the skin island in a transverse or avertical direction, over its proximal or its distalpart are the main factors behind selection ofthis flap in most patients in the present studyso as to fit most of the previously unplannedskin defects in our patients. We prefer the ipsilateralone except if the ipsilateral inferiorepigastric artery is ligated. The main disadvantageof this flap is abdominal wall weakness soabdominal wall reconstruction by a prolinemesh was mandatory.Tensor fascia lata flap is a myofasciocutaneousflap based on the transverse branch ofthe lateral circumflex femoral artery [21,27,28].We had one case of tensor facia lata flap. A skinisland of 12cm in width and 23cm in lengthwas elevated. The main disadvantage was creationof dog ear and the need to graft the donorsite. Necrosis of distal part has also been reported[27] however; this has been avoided by leavingat least 8cm above the knee joint. Also it isnot suitable for reconstruction of longitudinalgroin defects parallel to the longitudinal axisof the tensor fascia lata flap that is why we hada limited number of patients having this flapreconstruction.The pedicled anteroalteral thigh flap hasbeen used for reconstruction of groin, perinealand gental defects [22]. It can be raised as afasciocutaneous or myocutaneous flap (a portionof vastus lateralis muscle), it is based on thedescending branch of lateral circumflex femoralvessel. The pedicle is long and allows easilymedial rotation. Skin territory of the flap is verywide and large (25 x 18cm). Primary closureof the donor site is possible when the transverseaxis of the defect is less than 8cm [29,30,31]. Wehad one case in the present study having anterolateralthigh flap.Limb Sparing Surgical Resection of Groin SarcomaGracilis myocutaneous flap is a versatileflap for reconstruction of groin, perineal andgental defects [32]. It is based on descendingbranches of medial circumflex femoral artery[24]. Skin availability is limited, that is why weused it in only 3 cases in the present studybecause they had little skin defect. It has noadverse effect on adductor muscle group functiondonor site can be closed primary leavingan acceptable scar in the medial aspect of thethigh.Rectus femoris muscle and myocutaneousflap has been reported in reconstruction of groindefect [26]. It is based on branches from descendingbranch of lateral circumflex femoral.However, it is not widely used because it hassignificant knee weakness and there are otherreliable flap, that is why we did not try to useit in the present study.Sartorius muscle has a segmental bloodsupply (Type IV) [25]. It has a thin muscle belly,which is not suitable to cover large defects afterresection of groin sarcoma [33]. However, weroutinely used it even in the presence of othermuscle flaps to cover femoral vessels unless itis included in the resection. It has been used in57% of our cases.Modified inguinal or abdominoinguinal incisionin the 2 cases shown in the present study,generally healed well without any complicationsand without ischemia to the skin edges. Thishas also been also reported by Karakousis [7].This raises the issue that, appropriate biopsymay avoid the need to remove part of the skinunless involved by the tumor. In such cases,muscle transfer without skin may be enough tocover vascular prosthesis, mesh or exposedvessels. The only situation where ischemia wasexpected to occur with abdominoinguinal incisionwas in a patient who have already had inthe past a transverse incision in the ipsilaterallower abdominal quadrant and therefore thismay result is a narrow strip of skin between theprevious transverse incision and the transverseportion of the abdominoinguinal incision whichmay have deficient blood supply. In order toavoid this complication, the transverse portionof incision was included passing through theprevious transverse incision and then extendsvertically into the groin area.Seroma formation after groin node dissectionis reported to be high. The drain output fromgroin can be as high as 4000ml per 24h in theearly postoperative days and frequently takes2-3 weeks to decrease [3,34]. The daily amountof seroma is markedly lower in the presentseries in comparison with that reported withgroin node dissection and took less time todecrease. The explanation of this finding may

Magdy El-Sherbiny 291be related to the retroperitoneal exposure thatmay enhance absorption of the resulting seroma.This encouraged us to remove the drains asearly as possible to minimize the incidence ofdeep infection. The drains were removed beforethe end of 2 weeks postoperatively in all caseswith no resulting lymphatic fistula or collection.The rate of perioperative morbidity must beevaluated in the light of the goals of limb salvagefor soft tissue sarcoma. Hematoma, deep woundinfection, skin necrosis, local flap sloughingand lymphatic fistulas are the major causes ofa complicated postoperative course. The use ofprosthetic material as proline mesh or prostheticvascular graft is considered a possible risk factorfor the development of deep wound infection[5,35]. Wound morbidity rate of 34.7% has beenreported. Deep wound infection and exposureof the proline mesh near the lower part of theabdominal wall was seen in one case in thepresent series (7%). This patient received preoperativeradiotherapy which is considered arisk factor. Cautious interpretation, however, ismandatory to minimize the risk of wound complications.Aseptic procedural standards, thecorrect placement of suction drains, prophylacticadministration of antibiotics, Careful hemostasisand use of suitable local muscle or musculocutaneousflaps to completely cover deep structuresare behind the low rate of complications in thepresent study.Chronic lymphedema is most likely causedby extensive resection of lymphatic tissue andextensive fibrosis due to postoperative radiotherapy[3]. Lymphedema may have a vascularcomponent due to loss of venous patency aftervenous replacement. On long term follow-up,only 35% of our cases developed chroniclymphedema. It is low in comparison with otherauthors [2,16]. This may be explained by developmentof collaterals across myocutaneous flapsused in 71.4% of patients. For most patients,the edema occasionally decreases with physiotherapy.Removal of the pubic bone and its rami doesnot appear to have any long term effects inambulation [36] however, reconstruction of theresulting defect is mandatory to prevent thedevelopment of inguinal heria. In one case inaddition of resection pubic bone, part of theacetabulum was included with the resection.This was reconstructed by a double layer ofdacron graft and proline mesh. This has notbeen reported however, this may be consideredas, on follow-up, this patient did not have anyhip pain, stiffness or migration of the head offemur. According to the MSTS function score,all our patients have achieved a high functionalscore ranging from 92% to 97%.The use of adjuvant radiation therapy inpatients with limb sparing surgery for extremitySTS has been widely accepted [37,38,39]. Weapply postoperative radiotherapy for extremitysoft tissue sarcoma in our institute. Intraoperativeradiotherapy improves local tumor control[40]. However; this type of therapy is not availablein our institute. We had no delay in startingradiotherapy in the present study as we had nowound problems in nearly all cases. The onlyone case who had wound breakdown had receivedradiation therapy before salvage surgery.Concerning patient survival and local tumorcontrol, this study had shown that a stagedependentlong-term survival and local tumorcontrol could be achieved. The 2 year survivalrate and local tumor control in those selectivehigh-risk group of STS patients, the minimalfollow-up period, was 92.8% and 85.7% respectively.We cannot compare our results with otherreported series [2,41,42] because we need a largernumber of patients and a longer follow-up period.Conclusion: Patients having groin sarcomawith some sort of improper management maystill have a chance of successful limb sparingsurgical resection with a curative intent. Properpreoperative reevaluation of extension of thetumor and vascular involvement, wide retroperitonealexposure to maximize tumor resectionwith negative margins, vascular replacement ifiliofemoral vessels are involved and availabilityof local myocutaneous flaps minimizes theproblems of wound healing and subsequentinfection. All those factors enable a safe limbsparingresection with stage-dependent oncologiclong-term outcome and good limb functionalresults.Acknowledgment: I would like to thank DrKarim salam for his support during vascularreconstruction in this series. Also, I would liketo thank Dr. Mohamed Rifat and Dr. Wael Samywho allowed us to include one case done bythem in this series.

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