Staged Soft Tissue Reconstruction Following
Sarcoma Resection with Anticipated Large
Cutaneous Defects:
An Oncologically Safe Alternative
Geoffrey W. Siegel, M.D.,1 William Kuzon, M.D.,2 Jill
Hasen, P.A.-C.,3
and J. Sybil Biermann, M.D.3
1Wayne
State University Department of Orthopaedics, Detroit, MI
of Michigan Department of Plastic and Reconstructive Surgery, Ann Arbor, MI
3University of Michigan Department of Orthopaedics, Ann Arbor, MI
2University
Disclosures
• No relevant financial disclosures
Soft Tissue Sarcoma Background
• Negative margin surgery difficult to obtain
• Subcutaneous infiltrative type
• Previous Unplanned Resections
• Inconclusive imaging
• Surgeon must plan for resultant large skin and soft
tissue defect
Case in point
• 68 year old woman
• Unplanned resection
• Outside hospital
• High grade
myxofibrosarcoma
• Multiple positive
margins
• Specimen not oriented
as it was removed in
multiple fragments
MRI obtained following referral to
sarcoma center shows hematoma
overlying latissimus dorsi muscle
Case Continued
• Wide re-resection was
planned
• Challenge of coverage
Case Continued
• Split thickness skin
grafting may heal
• Grafts often indurated
• Adherent to underlying
tissue
• Donor site issues
Plastic Surgery Advances
Keystone Island Flap
Final result
• Where are the original
margins of the resected
tumor bed for radiation
planning?
• If there was a positive
margin
• Can it be re-resected?
• Is this entire wound at
risk for seeding and
local recurrence?
Hypothesis
• Selected patients with anticipated skin and soft
tissue deficits
• Could be treated with a two staged surgical procedure to
allow some flexibility in re-resection and coverage options
• Result in an acceptable local recurrence rate or wound
complication rate
Methods
• IRB approved retrospective chart review June 2001-2011
• Selected patients underwent
• Resection with temporary coverage
• Wound Vac initially
• Skin substitute grafting later in treatment protocol
• Staged soft tissue coverage procedure
• Following pathologic analysis of the specimen.
• All patients were treated by
• One senior orthopaedic oncologist
• Selected patients based on clinical experience
• One senior plastic surgeon
• Re-resection of unplanned positive margins was undertaken
prior to definitive soft tissue coverage
• Minimum two year follow-up
Results
• A total of 425 soft tissue sarcoma resections were
performed.
• 107 with anticipated skin defects underwent a 2-stage
surgical approach.
• Of these, 73 had a minimum 2 year follow-up.
• 9 were lost
• 26 deferred followup to local physicians
• Due to distance travelled
• 1 was incarcerated.
Demographics
Male
42 (58%)
Female
31 (42%)
Age
Years
52.0 (17.7-86.3)
BMI
Kg/m²
30.2 (19.4-45.2)
Average Follow Up
Months
57.1 (24.5-125.9)
Gender
Results
Tumor Grade
High
Low
DFSP
Ungraded
50 (68%)
14 (19%)
5 (7%)
4 (5%)
Prior surgical procedure
Unplanned positive margin excisional biopsy
Biopsy only
51 (70%)
22 (30%)
Defect size
Mean cm² (Range)
123 (14-528)
Chemotherapy
None
Preop
Postop
55 (76%)
14 (19%)
4 (5%)
Radiation
None
Preop
Postop
20 (27%)
0 (0%)
53 (73%)
Interim Coverage
Homograft
Wound Vac
57 (78%)
16 (22%)
Results
Margins
Wound Complications
Initial Negative
61 (84%)
Initial Positive
12 (16%)
Infections
7 (10%)
Other Wound Complications
8 (11%)
Additional Surgical Procedures to Facilitate Wound Healing
23 Surgeries in 12 Patients
Oncologic
Locally Disease Free at Latest
Followup
65 (89%)
Local Recurrence
8 (11%)
Dead of Disease
5 (10%)
Final Wound Coverage
Local Advancement + STSG
Local Rearrangement no STSG
Primary Closure
STSG Alone
Local Muscle Flap with STSG
1 (1.4%)
2 (2.7%)
3 (4.1%)
16 (21.9%)
14 (19.2%)
Keystone with V-Y Advancement No STSG
4 (5.5%)
Keystone with V-Y Advancement + STSG
Keystone with Primary Closure
Keystone + STSG
Free Flap No STSG
Free Flap + STSG
1 (1.4%)
19 (26%)
6 (8.2%)
4 (5.5%)
3 (4.1%)
Comparison to the Literature
Two-stage approach
One-stage approach
Literature*
Local Recurrence
11%
Planned: 6-25%
Unplanned: 20-34%
Wound Complications
21%
Planned: 22%
Unplanned: 14-37%
Local Recurrence Free Survival
89%
Planned: 85-91%
Unplanned: 64-92%
* Arai et al. 2010, Morii et al. 2008, Potter et al. 2008, Sanniec et al. 2013
Limitations
• Retrospective
• Single-armed study
• Selection bias
• Low numbers
Conclusion
• Staged soft tissue coverage allowed for
• Ease of re-resection to negative margins
• A local recurrence rate comparable to published
literature for single stage resection and wound coverage
• Wound complication rates no worse than published
norms
• Reoperations were frequent due to the high risk of
wound complications in this challenging clinical
situation
• This is a useful option for the armamentarium of
the oncologic surgeon
Thank You