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