Management of Vascular Involvement in Extremity Soft Tissue Sarcoma
Advances in adjuvant treatment protocols and improvements in imaging techniques have helped improve the limb-salvage rate for extremity soft tissue sarcomas to approximately 95%. Moreover, improvements in operative techniques have enabled successful limb-
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Ashish Mahendra, Yair Gortzak, Peter C. Ferguson, Benjamin M. Deheshi, Thomas F. Lindsay, and Jay S. Wunder
Abstract Advances in adjuvant treatment protocols and improvements in imaging techniques have helped improve the limb-salvage rate for extremity soft tissue sarcomas to approximately 95%. Moreover, improvements in operative techniques have enabled successful limb-salvage surgery to be performed even in the face of vascular invasion or encasement by tumor. En bloc resection of major vascular structures with the tumor and reconstruction with reversed saphenous vein grafts, femoral venous grafts, or synthetic grafts has proved to be a feasible option in limb-salvage surgery. However, the surgical oncologist and patient should be aware that although overall function is only slightly worse after these procedures, individual functional results are less predictable. In addition, procedures requiring vascular resection and reconstruction are associated with an increased risk of complications, including amputation.
Jay S. Wunder () University Musculoskeletal Oncology Unit Mount Sinai Hospital 476-600 University Avenue Toronto, ON M5G 1X5, Canada E-mail: [email protected]
18.1 Introduction Limb-salvage surgery has become the standard of care in the surgical management of most patients with extremity soft tissue sarcomas. With the use of adjuvant chemotherapy, radiation protocols, or both, as well as advanced imaging techniques, adequate margins can be obtained in most cases without the need for radical resection or amputation. The current concept for local management of soft tissue sarcomas of the extremities consists of either a wide excision of the tumor with an adequate surgical margin alone, or a less-thanwide or more marginal excision together with adjuvant treatment. It has been demonstrated that when a less-than-wide yet adequate surgical margin is combined with adjuvant radiation therapy, there is no difference in local disease-free status or the survival rate between limb-salvage procedures and amputations. One of the theoretical roadblocks to limbsalvage surgery is neurovascular involvement by the tumor. Soft tissue sarcomas can be safely resected when adjacent to major blood vessels by longitudinally splitting the adventitia opposite the tumor, thereby preserving a rim of “normal”
Per-Ulf Tunn (Ed.), Treatment of Bone and Soft Tissue Sarcomas. Recent Results in Cancer Research 179, DOI: 10.1007/978-3-540-77960-5, © Springer-Verlag Berlin Heidelberg 2009
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tissue in the vessel–tumor interface. Prior experience from our multidisciplinary sarcoma group has shown that even a planned microscopically positive margin against one or more critical structures (e.g., major vessel, nerve, or bone) following resection of a soft issue sarcoma in combination with (neo-) adjuvant radiotherapy is associated with a low risk of local recurrence (Gerrand et al. 2001; Clarkson et al. 2005). If a soft tissue sarcoma arises directly from the vessel wall, then vascular resection is inevitable. Furthermore
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