Posters— Surgical Treatment of Sarcomas

INDICATIONS AND ADVANTAGES OF FREE FLAPS IN THE MANAGEMENT OF SOFT TISSUE SARSOMAS: A RETROSPECTIVE STUDY OF 22 CASES

S. Bonvalot, K. Mamlouk, F. Kolb, C. Le Péchoux, A. Le Cesne Department of surgery, Institut Gustave Roussy. Villejuif. France

Objective: The medical charts of patients from the same institution presenting locally advanced soft tissues sarcomas of the limbs and trunk and reconstructed with free flaps were reviewed.

Patients and methods: From October 1997 to March 2000, 22 patients presenting locally advanced soft tissue sarcomas were treated with large local resection and free flap reconstruction. A neoadjuvant chemotherapy was instituted in 10 cases and post-operative radiation was performed in 16 cases. The average age of patients was 46 years (SD :17). There was 14 females and 8 males. Fifteen tumors were located on the limbs and 7 on the trunk. The tumor mean size was 11,5 cm with 5 grade I, 5 grade II and 12 grade III according to the FNLCC classification. Two patients presented radio-induced sarcomas. The treatment was primary in 12 cases and 10 patients presented a recurrent tumor, two of whom had previous external beam radiation. Free tissue transfer to cover the excision site was necessary after: large skin defects secondary to direct superficial extension in 16 cases or dictated by an aberrant previous incision in 2 cases, recurrence after pedicled flap in 2 cases, filling of dead space in 1 case and exposition of major vessels in irradiated areas in 2 cases. Major vessels and nerves resections were done concomitantly in 5 cases. A total of 23 free flaps were performed with 19 latissimus dorsi and 4 transversal rectus abdomini musculo-cutaneous flaps. To insure the vitality of the free tissue transfer when a vital organ exposition was programmed, such as in trans-thoracic resection, 4 flaps were elevated in two stages according to the “chausson aux pommes” technique advocated by Servant.

Results: Mean follow-up was 14 months . Margin’s quality was: R0 in 17 cases (³ 5mm, n = 11; < 5mm, n = 6), three of whom developed pulmonary metastasis, R1 in 4 cases, 2 of whom developed local recurrence after 5 and 6 months and R2 in 1 patient who had no local control post-operatively. Flap failure was experienced in 2 cases (one in a 78 years old patient and one in a previously irradiated field. A successful second free flap was performed in this latter patient) .Twenty patients (91%) had an uneventful healing which allowed undelayed adjuvant radiotherapy when indicated.

Conclusion: Free flap transfer is a safe and reliable technique (with a 91% success rate in our study) which enables broadening of limb salvage indications, full thickness thoracic resection and improvement of margin status.

It provides well vascularized tissue to cover exposed vital structures and allow precocious adjuvant radiotherapy.

The use of a distant donor site does not compromise the function of an already damaged limb as would a local flap and may enhance motor results in cases of neuro-muscular reanimation. Tissue transferred from a distant site of the excision area decreases local dissection and the potential area of local recurrence.

Performing flap transfer before tumor excision allows safe procedure in the case when vital structures exposition is programmed.