Tolerance of tissue transfers to adjuvant radiation therapy in primary soft tissue sarcoma of the extremity.

PURPOSE: Treatment of extremity sarcomas occasionally requires tissue transfer in the form of pedicle flaps, free flaps, or skin grafts to repair surgical defects. These tissues are often subject to radiation (RT) and are therefore at risk for wound breakdown requiring reoperation. This study reviews a single center's experience with tissue transfer and postoperative RT. METODS AND MATERIALS: Between 1983 and 2000, 43 adult patients (>16 years old) with primary high-grade soft tissue extremity sarcomas underwent limb-sparing surgery and reconstruction of their surgical defects, followed by adjuvant RT. The reconstructions were as follows: pedicle flaps (n = 14), free flaps (n = 10), skin grafts (n = 4), or a combination (n = 15). Postoperative external beam radiation therapy (EBRT) (median dose: 63 Gy) alone was given to 27 patients (63%). Adjuvant brachytherapy (BRT) was given to 16 patients (37%); BRT alone (median dose: 45 Gy) was given to 12 patients and combined with EBRT for 4 patients (EBRT: 45 Gy; BRT: 20 Gy). Comorbid conditions such as diabetes, hypertension, tobacco use, and obesity (calculated using body mass index >or=30) were present in 30 patients (70%). Tumor characteristics were as follows: 26 were >5 cm in size, 37 were deep, and 30 were in the lower extremity. The median follow-up time, calculated from the date of operation, was 32 months. Five of 43 patients suffered wound complications necessitating reoperation; however, 3 patients developed complications before initiation of RT and were therefore excluded from the analysis. Two of 43 patients (5%) required reoperation for wound complications after RT; 1 of these patients ultimately required amputation for necrosis. The 5-year overall wound reoperation rate was 6% (95% confidence interval: 0-14%). The influence of patient and tumor characteristics, as well as the type of RT, on the wound reoperation rates is as follows: BRT vs. EBRT (17% vs. 0%, p = 0.06); upper vs. lower extremity (0% vs. 8%, p = 0.41); 5 cm (8% vs. 4%, p = 0.9); comorbidity vs. no comorbidity (3% vs. 13%, p = 0.8); age 50 (8% vs. 4%, p = 0.8). CONCLUSION: Based on this review, most tissue transfers (95%) tolerated subsequent adjuvant radiation therapy well. Although more wound complications necessitating reoperation were seen in patients who received BRT, whether this is because of the inherent susceptibility of flaps and skin grafts to breakdown in the immediate postoperative period vs. the direct result of BRT needs further investigation.

Treatment of hydroxyapatite scaffolds with fibronectin and fetal calf serum increases osteoblast adhesion and proliferation in vitro.

BACKGROUND: The use of hydroxyapatite in reconstructive surgery has been hampered by the fact that it is very slowly invaded by host tissues, a process that is critical to graft incorporation. Implant compatibility may be augmented by providing cellular binding sites and by seeding cells before implantation. METHODS: Bone-forming cells were seeded onto hydroxyapatite disks, and precoated with fibronectin and fetal calf serum or phosphate-buffered saline. Cellular adhesion and proliferation was analyzed in vitro. For in vivo studies, experimental and control hydroxyapatite disks were seeded with green fluorescent protein-expressing cells and implanted into mice. RESULTS: Fibronectin/fetal calf serum pretreatment improved cell attachment and cell growth significantly in vitro. After 48 hours, experimental disks (n = 5) contained 2.8 times more attached cells than controls (p < 0.001), and after 7 days this difference had increased further (4.2 times) (p < 0.001). In the in vivo part of the study, sections from implants (n = 4) harvested 3 days after implantation demonstrated an average of 122 +/- 50 green fluorescent protein-labeled cells/mm in the fibronectin/fetal calf serum group compared with 85 +/- 21 cells/mm in the phosphate-buffered saline controls. After 10 days, the cells had in general decreased in number in both groups, but the relation in cell density was similar to the first time point (19 +/- 11 versus 12 +/- 11 cells/mm). CONCLUSION: In vitro attachment and proliferation of bone-forming cells on hydroxyapatite is significantly increased by pretreatment with fibronectin/fetal calf serum, but this difference is less profound and not significant in vivo.

Management of salivary fistulas after microvascular head and neck reconstruction.

UNLABELLED: Salivary fistulas after head and neck microvascular reconstruction are difficult problems whose treatment remains controversial. Although aggressive, early operative intervention has been suggested by some groups, we have found that many patients respond to conservative management with bedside debridement and aggressive local wound care. The purpose of this study was, therefore, to review our experience with the management of postoperative salivary fistulas. METHODS: A retrospective review was performed and all patients who developed a salivary fistula after microvascular head and neck reconstruction over a 7-year period at Memorial Sloan-Kettering Cancer Center were identified and evaluated. RESULTS: Six hundred thirty-seven patients underwent reconstruction during the study period. Of these, 35 patients developed a postoperative salivary fistula (5.4%). The majority of patients (81%) who developed fistulas shortly after the index procedure (<30 days) were successfully treated with conservative management. Similarly, 50% of late salivary fistulas (>30 days) responded to bedside debridement and wound care. There were no significant differences in the rate of total flap loss, carotid artery blowout, delay in onset of adjuvant radiation therapy (>6 weeks), or return to oral feeds between the conservative and operatively managed groups. CONCLUSIONS: Aggressive surgical intervention in early postoperative salivary fistulas is usually not necessary, although the treatment plan should be individualized. Bedside debridement and aggressive wound care are adequate in most cases of early salivary fistulas. This approach is not associated with an increased rate of complications.