The Therapeutic Role of Plastic and Reconstructive Surgery in the Interdisciplinary Treatment of Soft-Tissue Sarcomas in Germany—Cross-Sectional Results of a Prospective Nationwide Observational Study (PROSa)

Abstract

Although the involvement of plastic surgery has been deemed important in the treatment of sarcoma patients to avoid oncological compromises and ameliorate patient outcomes, it is not ubiquitously available. The accessibility of defect reconstruction and its therapeutic impact on sarcoma care is the subject of this analysis. Cross-sectional data from 1309 sarcoma patients were collected electronically at 39 German study centers from 2017 to 2019. A total of 621 patients with surgical treatment for non-visceral soft-tissue sarcomas were included. The associated factors were analyzed exploratively using multifactorial logistic regression to identify independent predictors of successful defect reconstruction, as well Chi-squared and Cochran–Mantel–Haenszel tests to evaluate subgroups, including limb-salvage rates in extremity cases. A total of 76 patients received reconstructive surgery, including 52 local/pedicled versus 24 free flaps. Sarcomas with positive margins upon first resection (OR = 2.3, 95%CI = 1.2–4.4) that were excised at centers with lower degrees of specialization (OR = 2.2, 95%CI = 1.2–4.2) were independently associated with the need for post-oncological defect coverage. In this context, the inhouse availability of plastic surgery (OR = 3.0, 95%CI = 1.6–5.5) was the strongest independent predictor for successful flap-based reconstruction, which in turn was associated with significantly higher limb-salvage rates (OR = 1.4, 95%CI = 1.0–2.1) in cases of extremity sarcomas (n = 366, 59%). In conclusion, consistent referral to specialized interdisciplinary sarcoma centers significantly ameliorates patient outcomes by achieving higher rates of complete resections and offering unrestricted access to plastic surgery. The latter in particular proved indispensable for limb salvage through flap-based defect reconstruction after sarcoma resection. In fact, although there remains a scarcity of readily available reconstructive surgery services within the current sarcoma treatment system in Germany, plastic and reconstructive flap transfer was associated with significantly increased limb-salvage rates in our cohort.

Immediate Plastic Surgery Intervention after Soft Tissue Sarcoma Resection: Examining Wound Healing, Readmission, and Reoperation

“…The goals and benefits of early plastic surgeon involvement include preserving patient function, limiting limb amputation, meeting the increased need of flap reconstruction, and optimizing closure and postoperative healing outcomes. [25][26][27][28][29][30] The purpose of this study is to build upon research examining collaboration between plastic surgeons and orthopedic or surgical oncologists by investigating and comparing complication rates of the following two cohorts: (1) patients who underwent index STS resection with immediate plastic surgeon intervention and (2) patients who underwent STS resection without a plastic reconstructive surgeon attending the case. The authors hypothesize minimal variation in primary outcomes of short-term any-cause readmission, same-site reoperation, and wound healing complications despite expectedly longer and potentially more complicated surgeries for patients whose cases involve plastic surgeon intervention.…”

“…The goals and benefits of early plastic surgeon involvement include preserving patient function, limiting limb amputation, meeting the increased need of flap reconstruction, and optimizing closure and postoperative healing outcomes. 25–30…”

A Systematic Review of the Orthoplastic Approach in Adult Lower Extremity Soft Tissue Sarcoma Flap Reconstruction

“…The benefit of plastic surgery involvement in soft tissue reconstruction after sarcoma excision is documented in many studies, describing decreases in complication rates, secondary procedures, and duration of hospital stay. 1,6 Conversely, other studies have described poorer outcomes with plastic surgery involvement, possibly due to recruitment in more complex cases, namely, patients with larger defects and higher grade or recurrent tumors. 7–11 However, studies investigating flap reconstruction in particular have described comparable functional and clinical outcomes in patients with high grade and recurrent tumors compared with lower grade and primary tumors reconstructed with less complex reconstructive techniques.…”

“…1 Although heterogenous in subtype and location, a majority of cases affect the extremities, most commonly the thigh. 1,2 Incidence increases with age, with a median age of 66 years and equal distribution among sexes. 1 Surgical excision is the mainstay of treatment, with management historically involving radical amputation with wide margins.…”

“…Soft tissue sarcomas (STSs) are rare malignancies with an annual incidence of approximately five in 100,000. 1 Although heterogenous in subtype and location, a majority of cases affect the extremities, most commonly the thigh. 1,2 Incidence increases with age, with a median age of 66 years and equal distribution among sexes.…”