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

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