Reconstructive surgery of the lower urinary tract following exenterative resection of gynecological tumors

Summary In locally advanced or recurrent tumors of the female genital tract anterior or total exenteration may be mandatory in case of tumor invasion into the lower urinary tract or if a second course of radiation therapy is not feasible. The management of resection and reconstruction of the affected lower urinary tract has to be well integrated into the gynecological therapeutic concept. In 11/32 patients the reconstruction of the partially resected lower urinary tract was feasible with preservation of a functionally intact urinary bladder. Urinary diversion following pelvic exenteration was achieved in 13/17 patients with a continent urinary reservoir and in 4/17 patients with an ileal conduit. Operative reinterventions were needed only in patients with continent urinary diversion in 5 cases. All these patients had a past history of primary radiation therapy of their gynecological tumor. In the remaining other 11 patients with a history of primary radiation therapy no complications occurred. 9 of 32 patients survived the operative procedure 40,8 (25–57) month with no evidence of recurrent tumor. Continent urinary diversion represents an excellent therapeutic option for replacement of function lost due to exenterative pelvic surgery. Stringent selection of patients is mandatory to consider the presented therapeutic concept a reasonable tool in the management of the described clinical situations.      

Reconstructive surgery of the lower urinary tract following exenterative resection of gynecological tumors

In locally advanced or recurrent tumors of the female genital tract anterior or total exenteration may be mandatory in case of tumor invasion into the lower urinary tract or if a second course of radiation therapy is not feasible. The management of resection and reconstruction of the affected lower urinary tract has to be well integrated into the gynecological therapeutic concept. In 11/32 patients the reconstruction of the partially resected lower urinary tract was feasible with preservation of a functionally intact urinary bladder. Urinary diversion following pelvic exenteration was achieved in 13/17 patients with a continent urinary reservoir and in 4/17 patients with an ileal conduit. Operative reinterventions were needed only in patients with continent urinary diversion in 5 cases. All these patients had a past history of primary radiation therapy of their gynecological tumor. In the remaining other 11 patients with a history of primary radiation therapy no complications occurred. 9 of 32 patients survived the operative procedure 40,8 (25–57) month with no evidence of recurrent tumor.     

Assessing prognosis for high-grade soft-tissue sarcomas: Search for a marker

Background: Although improved staging technology, limb-sparing surgery, and adjunctive radiation and chemotherapy have improved the outlook for patients with malignant soft-tissue tumors of the trunk and extremities, it is evident that we cannot predict which patients will develop distant metastases. Although local control is now frequently achieved, most series of high-grade soft-tissue sarcomas carry a mortality rate of >50%. Methods: In a retrospective study of 93 patients with high-grade sarcomas treated between 1986 and 1992 for whom complete studies including size and volume measurements and DNA ploidy determinations as assessed by flow cytometry were available, a search for a marker for increased risk of metastasis or death was performed. Results: Grade of the lesion, sex, diagnosis, anatomical site, ploidic data (including mean DNA index and presence of an aneuploid peak), and treatment factors (including type of surgery, local recurrence, or radiation protocol) did not correlate with outcome. Age (younger patients did better), size (greatest diameter) and volume, and positive margins at surgery correlated with total survival. Conclusions: The results of the study, although negative, point out that using anatomical site, diagnosis, or ploidic analysis offers little toward anticipating outcome, whereas the size of the tumor is important.     

Survival after surgical resection for high-grade chest wall sarcomas

Indications for chest wall resection of metastatic or locally recurrent sarcoma and for subsequent bony reconstruction are controversial. Twenty-eight patients had chest wall resection for high-grade primary, metastatic, or recurrent sarcoma. In all patients, resection with selective reconstruction of the bony thorax was performed without operative mortality. Since 1980, only patients with four or more ribs resected have had selective bony reconstruction. Follow-up ranged from 8 to 132 months (median follow-up, 42 months). All deaths were related to sarcoma recurrence. The overall actuarial survival rate was 85% at 1 year, 65% at 3 years, and 59% at more than 5 years. The overall actuarial proportion without disease recurrence was 64% at 1 year, 52% at 3 years, and 40% at more than 5 years. There was no significant difference in overall or disease-free survival for patients with primary, metastatic, or recurrent tumors. The most important prognostic factors were positive margins and concomitant pulmonary resection for synchronous lung metastases. These data support aggressive resection to obtain pathologically tumor-free margins for chest wall sarcomas, whether primary, metastatic or recurrent. Reconstruction can be individualized based on the extent of resection.     

An evaluation of two methods of limb salvage in extremity soft-tissue sarcomas.

Between 1983 and 1990, 38 sequential patients with stage II to III soft-tissue sarcoma of the extremities, as defined by the American Joint Committee on Cancer, were treated. Eighteen patients were treated with intra-arterial doxorubicin hydrochloride, limb salvage surgery, and radiation (group A). Twenty patients in group B were treated with cisplatin, isolated limb perfusion, limb salvage surgery, and radiation. The study was not randomized, but all patients were treated prospectively using one of the two protocols. The two groups were similar demographically and had similar lengths of survival without disease. There was only one local recurrence in the series, and this occurred in a group B patient who underwent perfusion with the lowest dose of cisplatin. Regional perfusion with either intra-arterial doxorubicin hydrochloride or cisplatin combined with limb salvage surgery and postoperative radiation are highly effective in preventing local recurrences and preserving functional extremities in patients with soft-tissue sarcoma. There was no difference in results between these two methods.     

84例原发性腹膜后肉瘤患者外科处理分析

目的　探讨原发性腹膜后肉瘤的临床处理 ,分析影响其预后因素。方法　收集 84例原发性腹膜后肉瘤患者的临床资料 ,回顾性分析其预后情况。用Kaplan -Meier法估计生存曲线 ,对可能影响患者长期存活的临床 ,病理 ,治疗方法各因素行单因素分析。结果　分级对 5年生存率有显著性影响 (P <0 .0 1)。完全切除率为 5 9.6%,完全切除后 5年生存率和 5年无瘤生存率分别是 48.1%和 3 8.8%,部分切除或活检患者 5年生存率和 5年无瘤生存率均为 0 ,两者存在高度显著性差异 (P <0 .0 0 1)。结论　肿瘤分级和手术切除是否完全是影响腹膜后软组织肉瘤预后的重要因素。对复发病例仍应积极手术治疗。限制肿瘤的假囊不应认为是安全边缘。     

Wound complications after resection and immediate postoperative brachytherapy in the management of soft-tissue sarcomas

Background: When used as the sole source of postoperative radiotherapy, brachyradiation therapy (BRT) (4,500–6,000 cGy) should be delayed beyond the fourth postoperative day to minimize wound complications. However, when 1,000–2,000 cGy BRT are given as a “boost” to the tumor bed, it is unclear if a similar treatment delay is necessary. The purpose of this review was to determine the incidence of wound complications when BRT (1,000–2,000 cGy) is administered ⩽48 h after soft-tissue sarcoma resection. Methods: The results of treatment in 21 patients with soft-tissue sarcomas of the extremity and superficial trunk treated with resection, immediate postoperative brachytherapy, and external beam radiation were reviewed. All patients were followed through the completion of radiation (median follow-up 30 months). A median of seven (range 3–24) after-loading catheters were placed at the time of resection and were loaded with iridium-192 a median of 2 days postoperatively to deliver 1,000–2,000 cGy radiation. Results: Eight patients (38%) experienced minor wound complications (seromas, wound separation, and flap edge necrosis) within 30 days of operation. There were no early complications that required reoperation or delayed further therapy. Conclusions: Brachytherapy (1,000–2,000 cGy) can be administered ⩽48 h postoperatively with a low risk of major wound complications. Minor wound complications are common but do not delay further treatment.     

An open type-IIIB segmental fracture of the lower limb with soft-tissue lesions

Open fractures are a challenge to the orthopaedic surgeon. The bigger the wound the higher the risk of contamination. The prognostic depends also upon the degree of comminution, the time of admittance, the antibiotherapy as well as the treatment options. The latter vary according to the surgeon's preference, the site of the fracture and the existing implants in a unit. We therefore present a case of a young male patient with a type-IIIB fracture of the lower limb, with an excellent result at 11 weeks postoperatively.     

Fractures following radiotherapy and limb-salvage surgery for lower extremity soft-tissue sarcomas. A comparison of high-dose and low-dose radiotherapy

BACKGROUND: The purpose of the present retrospective study was to determine the correlation between radiation therapy and the risk of postradiation fracture following combined therapy for the treatment of soft-tissue sarcomas of the lower extremity. METHODS: Three hundred and sixty-four patients with lower extremity sarcomas that had been treated with combined external beam radiation therapy and limb-salvage surgery were evaluated on the basis of a combined chart and data-base review. For the purposes of analysis, high-dose radiation was defined as 60 or 66 Gy and low-dose radiation was defined as 50 Gy. The timing of irradiation was defined as preoperative, postoperative, or preoperative followed by a postoperative boost. Univariate and multivariate analyses were used to determine which factors were associated with fracture risk. RESULTS: Twenty-seven fractures occurred in twenty-three patients. Twenty-four fractures occurred in twenty patients who had been managed with high-dose radiation. Seventeen of these patients had received postoperative radiation (with fifteen patients receiving 66 Gy and two receiving 60 Gy), and three had received preoperative radiation with a postoperative boost (total dose, 66 Gy). Three fractures occurred in three patients who had received preoperative, low-dose radiation (50 Gy). Of the twenty-three patients who sustained a pathologic fracture, eighteen were female and five were male. The crude median time to fracture was forty-three months. Most fractures occurred in the femoral shaft (thirteen) or the femoral neck (eight). High-dose radiation was associated with a greater risk of fracture when compared with low-dose radiation (p = 0.007). CONCLUSIONS: Women more than fifty-five years of age who are managed with removal of a thigh sarcoma combined with radiation therapy have a higher risk of pathologic fracture. The frequency of pathologic fractures associated with higher doses (60 or 66 Gy) of radiation is significantly higher than that associated with lower doses (50 Gy).     

The staging of soft-tissue sarcomas

Summary We have assessed the ability of the American Joint Committee System, the Hajdu and the Surgical Staging System to separate different prognostic groups of patients with soft-tissue sarcoma. There were 122 patients with nonmetastatic tumours of the locomotor system. All were operated on with a wide, or radical, surgical margin. None of the staging systems could identify more than two groups with significantly different overall survival. A plea is made for the use of statistical multivariate analysis of prognostic factors when constructing staging systems for soft-tissue sarcoma.

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Résumé Les auteurs ont cherché à déterminer la valeur pronostique des trois systèmes de classification des sarcomes des tissus mous, à savoir le système de l'American Joint Committee, celui de Hajdu et celui du Surgical Staging. Cent vingt-deux patients porteurs de tels sarcomes, mais sans métatastases, ont été analysés. Tous ont été traités par exérèse large, passant en tissus sains. Aucun système n'a permis d'identifier plus de deux groupes de malades ayant des taux de survie différents. On recommande de pratiquer une analyse statistique multivariée des facteurs pronostiques avant de construire un système de classification des sarcomes des tissus mous.

     

Massive allograft implantation following radical resection of high-grade tumors requiring adjuvant chemotherapy treatment

Since 1976, the authors have performed a total of 36 resections of malignant tumors of the limbs with reconstruction of these by implantation of allografts. All allografts have been supplied by the University of Miami Tissue Bank. Following resection of the long-bone tumor and obtaining acceptable margins, the allograft was inserted to the limb defect with three different techniques: (1) in addition to a custom prosthesis as a hemi-joint reconstruction, i.e., a custom Neer prosthesis and proximal humerus allograft; (2) an osteoarticular graft to replace an articular surface resected with the metaphyseal-diaphyseal portion of the tumor; and (3) an intercalary diaphyseal-metaphyseal graft replacing the resected tumor but preserving the recipient articular surface. Of the 36 tumors, one was in Stage III disease. The remainder were Stage II A or B by the System of Enneking. All of these patients had adjuvant chemotherapy. The follow-up time was 24 months to 96 months. The resection of tumors in 36 patients and treatment with postoperative chemotherapy resulted in a mortality of eight out of 36 and one amputation due to recurrence. Satisfactory results were obtained in 19 of 36 patients. If the tumor failures (eight deaths) and the amputation are subtracted from this number, the success rate is 70% (19/27). Intercalary grafts were more successful than osteoarticular grafts. Chemotherapy was started one to two weeks postoperation for all but four patients to whom it was also given preoperation. These patients were in a Children's Cancer Study Group (CCSG) protocol for prospective study of the effects of preoperative chemotherapy. There was no apparent difference in the allograft success in these patients as compared to patients receiving only postoperative chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty

Heterotopic ossification following joint replacement in the lower limb occurs in 3% to 90% of cases. Higher grades of heterotopic ossification can result in significant limitation of function and can negate the benefits of joint replacement. The understanding of the pathophysiology of this condition has improved in recent years. It would appear to be related to a combination of systemic and local factors, including over-expression of bone morphogenetic protein-4. There is currently little evidence to support the routine use of prophylaxis for heterotopic ossification in arthroplasty patients, but prophylaxis is recommended by some for high-risk patients. Radiotherapy given as one dose of 7 Gy to 8 Gy, either pre-operatively (< four hours before) or post-operatively (within 72 hours of surgery), appears to be more effective than indometacin therapy (75 mg daily for six weeks). In cases of prophylaxis against recurrent heterotopic ossification following excision, recent work has suggested that a combination of radiotherapy and indometacin is effective. Advances in our understanding of this condition may permit the development of newer, safer treatment modalities.     

Microsurgical reconstruction of lower limb bone defects following tumor resection using vascularized fibula osteoseptocutaneous flap

This study included 25 patients with lower limb tumors who had wide local resection and reconstruction by vascularized fibula osteoseptocutaneous flap, and who had their surgery performed at least 24 months before the end of the study. The average age at operation was 23.5 years. Twenty-three tumors were malignant;16 were staged as high-grade sarcomas (stage IIA, stage IIB, and Ewing's sarcoma). Tumor volume averaged 293.2 cc (range, 41.4-860). The resulting defect after tumor resection averaged 16 cm (range, 9-20 cm). The fibula was inserted as a single strut in 21 patients, and as a double-barrel construct in 4 patients. Fixation was augmented by interlocking nail in 11 cases, bridge plate in 9 cases, and external fixator in 5 cases. Twenty-four (96%) flaps survived. All grafts united in an average period of 4.5 months (range, 3-8 months) after transfer. Two secondary procedures were necessary to achieve graft union. Full weight bearing was possible after an average period of 7.5 months (range, 5-14 months). Significant hypertrophy (> or =30% of original fibular diameter) occurred in 85% of patients after an average period of 10 months from the index operation. In the latest follow-up radiographs (mean, 32 months), the degree of hypertrophy averaged 90% (range, 30-200%). Graft fracture occurred in three patients, and all healed conservatively. The Musculoskeletal Tumor Society rating score (MTSRS) averaged 21.2 points at the end of the first postoperative year, and 23.6 at the end of the study.     

Prognostic features of pediatric soft-tissue sarcomas

Eight hundred ninety-two patients under 20 years of age with soft-tissue sarcomas histologically diagnosed between 1955 and 1971 (before the era of combined modality therapy) were reviewed to delineate important prognostic variables. Differing histologic findings, extent of disease at initial presentation, and site of the primary tumor correlated with prognosis; age, sex, and race did not affect survival significantly. Patients with fibrosarcomas, liposarcomas, and leiomyosarcomas had improved survival rates when compared with adults with the same histologic findings; patients with localized tumors and extremity primary sites had the best prognosis. Patients with rhabdomyosarcomas, disseminated disease, or retroperitoneal primary sites had the worst prognosis. These data suggest that some childhood sarcomas are not as aggressive as adult sarcomas or childhood rhabdomyosarcomas. Therefore they may not require the adjuvant therapy shown to be beneficial in childhood rhabdomyosarcomas.     

Upper and lower limb disarticulation in soft tissue and bone sarcomas

The authors have reviewed 23 patients with proximal disarticulations with the aim of assessing the therapeutic value in sarcoma, taking into account previous radio- and chemotherapy. The following criteria were especially examined: recurrences, survival, and quality of life. There were 14 soft tissue sarcomas, and 9 bone sarcomas. In 11 cases, the tumor was primary and treated for the first time while, in 12 cases, it was recurrent. Eighteen patients had been previously treated by nonradical surgery, 11 by radiotherapy, and 10 by chemotherapy. For upper limb tumors, 6 patients underwent an interscapulothoracic disarticulation, and 3 an interscapulothoracic resection according to Tikhoff-Linberg. For lower limb tumors, 8 patients were submitted to interilioabdominal disarticulation, 3 to coxofemoral disarticulation, and 1 to internal hemipelvectomy according to Eilber. The mean disease-free interval has been 34 months, and the mean survival, 38.5 months. Three (15%) of 20 evaluable patients recurred locally, although most of them benefited from second surgery. Quality of life has been excellent, in general, despite the fact that only 8 patients accepted to wear a prosthesis. The Karnofsky index ranged from 60 to 100%. No significant difference was seen, whether or not previous radio- and/or chemotherapy had been administered.

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Resumen Los autores han revisado 23 pacientes con desarticulaciónes proximales con el propósito de determinar el valor terapéutico en el sarcoma, habida consideración a radioterapia y quimioterapia previas. Los siguientes criterios fueron específicamente analizados: recurrencia, supervivencia, y calidad de la vida. La serie incluyó 14 sarcomas de tejidos blandos, y 9 sarcomas óseos. En 11 casos el tumor era primario y aparecía tratado por primera vez, y en 12 casos el tumor era recurrente. Diez y ocho pacientes habían sido previamente tratados con cirugía no radical, 11 con radioterapia, y 10 con quimioterapia. En cuanto a los tumores del miembro superior, 6 pacientes fueron sometidos a desarticulación interescápulotorácica, y 3 a resección interescapulotorácica según Tikhoff-Linberg. En cuanto a los tumores del miembro inferior, 8 pacientes fueron sometidos a desarticulación interilioabdominal, 3 a desarticulación coxofemoral, y 1 a hemipelvectomía interna según Eilber. El promedio de estado libre de enfermedad ha sido 34 meses, y el promedio de supervivencia, 38.5 meses. Tres (15%) de 20 pacientes valorables presentaron recurrencia aunque la mayoría de ellos se benefició con una segunda operación. En general, la calidad de la vida ha sido excelente a pesar de que solamente 8 pacientes aceptaron usar prótesis. El índice de Karnofsky osciló entre 60 y 100%. No se observó diferencia entre los pacientes que habían recibido radioterapia y/o quimioterapia y los que no la recibieron.

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Résumé Les auteurs ont étudié 23 cas de désarticulations proximales pour sarcome en ayant pour but d'apprécier la valeur de l'intervention, la désarticulation étant précédée de radiothérapie et de chimiothérapie. Les critères retenus furent: l'existence de récidives, la survie et la qualité de la vie. La série a concerné 14 sarcomes des parties molles, 9 sarcomes des os. Dans 11 cas il s'agissait d'une tumeur primitive, dans 13 cas de récidives tumorales. Sur ce groupe de malades, 18 avaient été traités par une intervention limitée, 11 par radiothérapie, et 10 par chimiothérapie. En ce qui concerne le membre supérieur, 6 ont été traités par désarticulations inter-scapulo-thoraciques, et 3 par une résection inter-scapulo-thoracique selon la technique de Tikhoff-Linberg. En ce qui concerne le membre inférieur, 8 malades ont été soumis à une désarticulation interilio-abdominale, 3 à une désarticulation ilio-coxo-fémorale, et 1 à une hémipelvectomie interne selon la technique de Eilber. La moyenne de durée de vie normale a été de 34 mois et la moyenne de la durée de la survie de 38.5 mois. Trois (15%) des 20 malades qui ont été revus ont présenté une récidive locale mais la majorité d'entre eux ont pu bénéficier d'une réintervention. La qualité de la vie a été excellente en général bien que 8 opérés seulement aient accepté le port d'une prothèse. L'index de Karnofsky a varié de 60 à 100%. Aucune différence significative n'a été observée que le malade ait été soumis ou non à la radiothérapie et/ou à la chimiothérapie.