Prophylactic lymphedema surgery in lower limb soft tissue sarcomas: A clinical paradigm in a promising field.

INTRODUCTION: Oncological treatments, such as radiotherapy and surgery, are high-risk factors for the development of secondary lymphedema in the upper and lower limbs, as well as the genitalia. Prophylactic lymphedema surgery (PLS) has previously demonstrated promising results in reducing secondary lymphedema in breast cancer and urogenital cancer patients. We conducted a study to adapt this principle for patients with lower-extremity sarcomas. MATERIAL AND METHODS: Inclusion criteria included patients with tumors on the medial aspect of the thigh and leg and tumor size larger than 5 cm. Group A (19 patients) comprised a prospective cohort (2020-2023) in which a PLS protocol was executed. Lymphaticovenous anastomosis (LVA) was performed when lymphatic channels were interrupted due to tumor resection, intraoperatively verified by indocyanine green. Lymph node transfer was employed exclusively in cases involving preoperative radiotherapy and inguinal lymph node resection. Measurements were collected both preoperatively and at 1, 3, 6, and 12 months postoperatively. Group B (26 patients) constituted a retrospective cohort (2017-2020) without PLS reconstruction, where the prevalence of lymphedema was determined. RESULTS: In total, we enrolled 45 patients with soft tissue sarcomas located on the inner aspect of the thigh and leg (26 in the control group vs. 19 in the prophylactic group). In the control group, lymphedema was observed in 10 out of 27 patients (37.04%). In the prophylactic group, two patients exhibited signs of lower-extremity lymphedema (2/19, 10.52%) with a median follow-up of 14.15 months (6 months-33months), demonstrating statistically significant differences between the two groups (p = 0.02931). CONCLUSIONS: PLS for lower limb soft tissue sarcomas shows promising results, although it is premature to reach solid conclusions. Multicentre studies, standardization of criteria, larger sample sizes and longer-term follow-up are imperative for further validation.

A new protocol for improving immediate monitoring of skin-island free flap with near-infrared spectroscopy and ultrasound.

BACKGROUND: Postoperative monitoring is essential for detecting early complications and improving the salvage rate of free flaps. We propose a new protocol for free flap monitoring based on the combination of near-infrared spectroscopy (NIRS) and ultrasound. METHODS: All free flaps with a skin paddle were included and divided into two groups according to the immediate postoperative monitoring method used: ultrasound examination (control group) or those monitored using our protocol (study group). The number of surgical revisions, intraoperative findings, immediate flap failure, sensitivity, and specificity were compared between the two groups. RESULTS: A total of 221 free flaps performed in 209 patients were included. The NIRS automatically detected vascular compromise in 21.8% of cases. A complication was confirmed in half of these cases by ultrasound examination, and surgical reintervention was indicated (10.9%), even in the absence of clinical changes in the skin paddle. In all the surgical revisions, the complication was confirmed, and there was no flap necrosis in the non-revised cases. The salvage rate for revised flaps and the flap survival rate were higher in the study group (salvage rate: 25% vs 72.7%; survival rate: 92.5% vs 97%). A sensitivity of 100% and a specificity of 100% were found for the combination of both monitoring methods. CONCLUSION: The proposed protocol is a non-invasive and reliable method for early identification of postoperative complications of free flaps that allows higher rates of salvage rate and reduces the need for specific staff with continuous on-site presence for flap monitoring.

Chimeric SCIP flap with iliac bone for reconstruction of foot first ray in a radiated surgical bed: A case report.

Surgical management of sarcoma has evolved from amputation to limb salvage. Nevertheless, subsequent resections in previously irradiated feet are still challenging to reconstruct. First foot ray functional reconstruction is relevant due to its function in weight-bearing and gait. The reconstruction should include a thin, pliable and non-shearing skin paddle with vascularized long cortical bone to mimic the first metatarsal. A clinical case of a 37-year-old patient with a second sarcoma recurrence of the first metatarsal is presented. The patient was irradiated before this new recurrence and had a previous reconstruction with fibula allograft, but subsequently developed a first metatarsal pseudoarthrosis. A wide resection was performed (3.5 cm bone defect) and immediate soft tissue and bone reconstruction with a chimeric SCIP flap with a 17 × 8 cm skin paddle and 3.5 × 1.5 cm iliac bone (cSCIP-IB). At 7 months post-operatively, the patient was able to resumed full weight-bearing. Three years later, remains without disease progression. CSCIP-IB is a good option for foot first ray reconstruction in irradiated beds. This flap has low donor site morbidity and a higher ossification success rate compared to bone allografts.