PAPER Major Blood Vessel Reconstruction During Sarcoma Surgery Tae K. Song, MD; E. John Harris Jr, MD; Shyam Raghavan, BS; Jeffrey A. Norton, MD Objective: To evaluate the outcomes of major vessel re- (7 high grade and 6 low grade) and 1, benign (leio- construction as part of surgery to remove sarcomas. myoma). Seven patients had replacement of artery and vein; 5, artery only; and 2, vein only. In all, 16 arteries Design: Retrospective review. were reconstructed (2 common femoral; 5 iliac; 2 super- ficial femoral; 1 brachial; 1 popliteal; and 2 aorta, one with Setting: Tertiary academic medical center. implantation of both iliac arteries and the other with im- plantation of the left renal, superior mesenteric, and he- Patients: Fourteen patients (10 female) with retroperi- patic arteries). Eight patients (57%) had 9 veins recon- toneal or extremity sarcomas and major blood vessel in- structed (3 external iliac, 3 superficial femoral, 2 vena volvement who underwent surgery to remove the tu- cava, and 1 popliteal). Primary arterial patency was 58% mor and had blood vessel reconstruction between 2003 and primary-assisted patency was 83%. Venous patency and 2008. Each patient underwent computed tomogra- was 78%. Local recurrence occurred in 3 patients (21%). phy angiography. Five-year disease-free and overall survival were 52% and 68%, respectively. Limb salvage was achieved in 93%. Main Outcome Measures: Early (Ͻ30 days) and late (Ͼ30 days) operative morbidity and mortality, freedom Conclusion: Involvement of vascular structures is not from disease, and graft patency. a contraindication for resection of sarcomas, but appro- priate planning is necessary to optimize outcome. Results: Seven patients had retroperitoneal sarcomas and 7, extremity sarcomas. Thirteen tumors were malignant Arch Surg. 2009;144(9):817-822 URGICAL RESECTION IS THE previous studies have investigated the role only potentially curative of venous reconstruction in sarcoma sur- therapy for soft tissue sarco- gery.4,6 We hypothesize that arterial and mas. For retroperitoneal sar- venous involvement of soft tissue sarco- comas, involvement of ma- mas is not a contraindication to sarcoma Sjor vessels has traditionally been a relative resection. contraindication for resection because of 1,2 poor prognosis and high surgical risk. METHODS Likewise, historical local control of an ex- tremity sarcoma was achieved by ampu- tation.3,4 More recently, standard therapy This was a retrospective review at a tertiary aca- demic medical center using a multidisci- for resection of soft tissue sarcomas of the plinary team approach for the treatment of pa- extremity is limb preservation surgery and tients with soft tissue sarcomas. The team 3-6 radiotherapy. The goal of resection is to included a vascular surgeon, surgical oncolo- obtain negative surgical margins.3 Often gist, orthopedic surgeon, medical oncologist, and the ability to completely remove the tu- radiation oncologist. Fourteen consecutive, pro- mor is affected by its relationship to ma- spective patients (4 male, 10 female) were treated jor blood vessels. This serves as a major between September 2003 and December 2008. factor in determining the “resectability” of All patients with soft tissue sarcomas who re- Author Affiliations: Divisions sarcomas. quired vascular reconstruction for curative re- of Vascular Surgery (Drs Song This study reviews our experience with section and/or limb-preserving resection were and Harris) and General included. Vascular reconstruction was neces- Surgery (Dr Norton), blood vessel reconstruction as an inte- sary when a soft tissue sarcoma encased or in- Department of Surgery, and gral part of surgery to remove soft tissue vaded an adjacent major vessel. Each patient un- School of Medicine sarcomas. Further, venous reconstruc- derwent a preoperative computed tomography (Mr Raghavan), Stanford tion was a major component of the vas- angiogram and prospectively met with the vas- University, Stanford, California. cular reconstruction in this series. Very few cular surgeon to assess resectability and plan vas- (REPRINTED) ARCH SURG/ VOL 144 (NO. 9), SEP 2009 WWW.ARCHSURG.COM 817 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 cular reconstruction. All patients had chest computed tomog- survival was confirmed through either clinic visits or direct com- raphy to diagnose pulmonary metastases. munication by telephone. Main outcome measures were early (Ͻ30 days) and late (Ͼ30 Approval for this study was obtained from the Stanford Uni- days) operative morbidity and mortality, disease-free and over- versity institutional review board. Statistical analysis was per- all survival, and assessment of graft patency. Secondary out- formed using Microsoft Excel software (Microsoft Inc, Red- come measures included reinterventions. mond, Washington). Kaplan-Meier estimations were used to Patients were seen in the vascular clinic at 4 weeks, 6 months, analyze overall and disease-free survival and arterial and ve- and yearly thereafter. In addition, patients were assessed in the nous patency from the time of surgery. oncology clinic as part of routine surveillance. Clinical exami- nations and duplex ultrasonography or computed tomogra- phy angiography/magnetic resonance angiography follow-up RESULTS examinations evaluating tumor recurrence were used to as- sess patency of the arterial or venous reconstructions. Patient Fourteen patients (4 male, 10 female) with major vascu- lar involvement were treated for soft tissue sarcomas of the extremity (7) or retroperitoneum (7) (Table 1). Median Table 1. Patient Demographics age was 45 years (range, 11-80 years). One patient had sig- nificant medical comorbid conditions (American Society Characteristic No. (%) (N=14) of Anesthesiologists scoreϽ3, 93%), 1 patient had coro- Male 4 (29) nary artery disease, and no patients had peripheral vascu- Female 10 (71) lar disease. Preoperative median creatinine value was 0.75 Age Ͻ50 y 8 (57) ASA score Ͻ3 13 (93) mg/dL (to convert to micromoles per liter, multiply by 88.4) CAD 1 (7) for all patients and 1.0 mg/dL for patients with retroperi- PVD 0 toneal sarcomas. Symptoms were abdominal or extremity Retroperitoneal 7 (50) pain or an enlarging mass. Patients required replacement Extremity 7 (50) of both artery and vein (7), artery only (5), or vein only Tumor grade (2) at the time of sarcoma resection (Table 2). Low 6 (43) Intermediate 1 (7) Surgery was performed for a primary mass (9) or re- High 6 (43) current mass (5), with 2 patients having lung metastasis at the time of surgical resection. Average tumor size was Abbreviations: ASA, American Society of Anesthesiologists; CAD, coronary 14 cm (range, 6-29 cm), with 10 patients (71%) having artery disease; PVD, peripheral vascular disease. sarcomas more than 10 cm. Diagnoses included malig- nant fibrous histiocytoma (2), leiomyosarcoma (2), ma- lignant peripheral nerve sheath tumor (1), liposarcoma Table 2. Type of Vascular Reconstruction (1), fibromyxoid sarcoma (1), synovial sarcoma (2), chon- drosarcoma (1), and desmoid (3). One patient had a “be- No. (%) nign” tumor that invaded the inferior vena cava (leio- Table 3 Extremity Retroperitoneal Total myoma) ( ). Four patients with retroperitoneal Type (n=7) (n=7) (N=14) sarcomas had positive margins and 2 with extremity sar- Artery and vein 5 2 7 (50) comas had close 1-mm margins (Table 3). Two patients Artery 2 3 5 (36) with retroperitoneal sarcomas had intraoperative radia- Vein 0 2 2 (14) tion. Two patients received upfront chemoradiation therapy prior to undergoing repeated surgery for a re- Table 3. Sarcoma Characteristics and Adjuvant Treatment Pathohistology Size, cm Site Margin Adjuvant Treatment Malignant PNST 22 R Positive IORTa Malignant fibrous histiocytoma 7 R Negative Chemotherapy Malignant fibrous histiocytoma 15 E Negative None Leiomyosarcoma 12.5 R Negativeb Chemotherapy Leiomyosarcoma 9.5 R Positivec IORT ϩ Chemotherapy/XRT Liposarcoma 29 R Positivec Chemotherapy/XRTa Fibromyxoid sarcoma 18 R Positive None Synovial sarcoma 15 E Negative Chemotherapy Synovial sarcoma 6.5 E Negative None Chondrosarcoma 6.8 R Negative Chemotherapy/XRTa Desmoid 13 E Negative None Desmoid 17 E Negativec None Desmoid 12 E Negativeb None Leiomyoma 11 R Negative None Abbreviations: E, extremity; IORT, intraoperative radiation therapy; PNST, peripheral nerve sheath tumor; R, retroperitoneal; XRT, radiation therapy. a Planned but did not receive. b Negative margins less than 1 mm. c Recurrence. (REPRINTED) ARCH SURG/ VOL 144 (NO. 9), SEP 2009 WWW.ARCHSURG.COM 818 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Table 4. Vascular Reconstructions of Involved Vessels 100 90 83% No. of Reconstructions 80 Vessel (N=25) 70 58% Aorta 2 60 Viscera 3 50 40 Iliac 5 % Patency, Common femoral artery 2 30 Superficial femoral artery 2 20 Primary Popliteal artery 1 10 Assisted primary Brachial artery 1 Vena cava 2 0 10 20 30 40 50 60 70 Iliac vein 3 Time, mo Femoral vein 3 Popliteal vein 1 Figure 1. Primary and assisted-primary patency of arterial reconstructions. Table 5. Conduits Used in Vascular Reconstructions 100 90 80 78% Type No. (%) (N=29) 70 Primary 2 (7) 60 Saphenous vein 12 (41) 50 Femoral vein 3 (10) 40 Patency, % Patency, Polyethylene terephthalate 8 (28) 30 PTFE 1 (3) 20 Allograft 3 (10) 10 Abbreviation: PTFE, polytetrafluoroethylene. 0 10 20 30 40 50 60 70 Time, mo current mass. Adjuvant chemoradiation