Outcomes of Limb Salvage following BrachyVAC Therapy: the University of Pittsburgh Experience
Edward J. Ruane, Jr., M.D., Wesley N. Sivak, M.D., Ph.D., Mark A. Goodman, M.D., Richard L. McGough, M.D., Kurt R. Weiss, M.D., Steven A. Burton, M.D., William M. Swartz, M.D., Jeffrey A. Gusenoff, M.D., Michael L. Gimbel, M.D..
University of Pittsburgh, Pittsburgh, PA, USA.
Background: Treatment of musculoskeletal malignancies has evolved from amputation to a multimodal limb-sparing approach. Radiation can be delivered via brachytherapy catheters temporarily covered under a VAC device (brachyVAC), followed by staged reconstruction. Benefits of this approach include avoidance of flap or graft irradiation, as well as ensuring adequacy of resection margins prior to reconstruction; however, data remains limited. Herein, we review our tertiary care center experience with reconstruction after tumor extirpation and brachyVAC therapy for limb salvage.
Methods: A retrospective review was performed on all patients who underwent staged reconstruction following musculoskeletal malignancy resection and brachyVAC therapy from 2010-2016. Collected data points included patient demographics/comorbidities, tumor characteristics, treatment specifics, margin status, defect details, reconstructive procedures, complications, and recurrences.
Results: A total of 19 patients were identified (9 male) with average age of 72.7 years. Co-morbidities included hypertension (68.4%), diabetes (31.6%), coronary artery disease (26.3%), and renal insufficiency (26.3%). Smoking (5.3%) and prior radiation (15.8%) were relatively uncommon. Myxofibrosarcoma (52.6%) was the most common underlying pathology, followed by squamous cell carcinoma (15.8%) and leiomyosarcoma (15.8%). Lower extremity tumors (68.4%) were more than twice as common as those of the upper extremity (31.6%). Median number of prior resections was one. Clear surgical margins were obtained in 63.2% of patients. All patients received high dose brachytherapy (28-35 Gy distributed over 8-10 fractions) beginning 4 days (median) after resection. Removal of brachyVAC occurred 7 days (median) following resection. Average defect size was 228.4 cm2 with exposed structures including bone (89.5%), tendon (21.1%), joint (21.1%), nerve (15.8%), and major blood vessel (5.3%). Reconstructions included free flaps (47.4%), pedicled flaps (47.4%) and skin grafts (5.3%), occurring 13 days (median) after extirpation. Major complications included infection (38.5%) and thrombosis/bleeding (23.1%). Recurrence was 41.7% for patients with clear margins at an average follow-up of 1.6 years. Functional use of the limb was regained in 78.9% of patients.
Conclusions: Reconstruction of musculoskeletal malignancies remains a challenge. Patients regain functional use of the limb in the majority of cases. The frequent tumor recurrences in our study are comparable to other published reports utilizing traditional limb-sparing approaches.
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