Spierer Marnee M, Alektiar Kaled M, Zelefsky Michael J, Brennan Murray F, Cordiero Peter G
Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
Int J Radiat Oncol Biol Phys. 2003 Jul 15;56(4):1112-6. doi: 10.1016/s0360-3016(03)00200-1.
Treatment of extremity sarcomas occasionally requires tissue transfer in the form of pedicle flaps, free flaps, or skin grafts to repair surgical defects. These tissues are often subject to radiation (RT) and are therefore at risk for wound breakdown requiring reoperation. This study reviews a single center's experience with tissue transfer and postoperative RT. METODS AND MATERIALS: Between 1983 and 2000, 43 adult patients (>16 years old) with primary high-grade soft tissue extremity sarcomas underwent limb-sparing surgery and reconstruction of their surgical defects, followed by adjuvant RT. The reconstructions were as follows: pedicle flaps (n = 14), free flaps (n = 10), skin grafts (n = 4), or a combination (n = 15). Postoperative external beam radiation therapy (EBRT) (median dose: 63 Gy) alone was given to 27 patients (63%). Adjuvant brachytherapy (BRT) was given to 16 patients (37%); BRT alone (median dose: 45 Gy) was given to 12 patients and combined with EBRT for 4 patients (EBRT: 45 Gy; BRT: 20 Gy). Comorbid conditions such as diabetes, hypertension, tobacco use, and obesity (calculated using body mass index >or=30) were present in 30 patients (70%). Tumor characteristics were as follows: 26 were >5 cm in size, 37 were deep, and 30 were in the lower extremity. The median follow-up time, calculated from the date of operation, was 32 months. Five of 43 patients suffered wound complications necessitating reoperation; however, 3 patients developed complications before initiation of RT and were therefore excluded from the analysis. Two of 43 patients (5%) required reoperation for wound complications after RT; 1 of these patients ultimately required amputation for necrosis. The 5-year overall wound reoperation rate was 6% (95% confidence interval: 0-14%). The influence of patient and tumor characteristics, as well as the type of RT, on the wound reoperation rates is as follows: BRT vs. EBRT (17% vs. 0%, p = 0.06); upper vs. lower extremity (0% vs. 8%, p = 0.41); <or=5 cm vs. >5 cm (8% vs. 4%, p = 0.9); comorbidity vs. no comorbidity (3% vs. 13%, p = 0.8); age <or=50 vs. >50 (8% vs. 4%, p = 0.8).
Based on this review, most tissue transfers (95%) tolerated subsequent adjuvant radiation therapy well. Although more wound complications necessitating reoperation were seen in patients who received BRT, whether this is because of the inherent susceptibility of flaps and skin grafts to breakdown in the immediate postoperative period vs. the direct result of BRT needs further investigation.
肢体肉瘤的治疗有时需要采用带蒂皮瓣、游离皮瓣或植皮等组织移植方式来修复手术缺损。这些组织常接受放疗（RT），因此有伤口裂开的风险，可能需要再次手术。本研究回顾了单一中心在组织移植及术后放疗方面的经验。
1983年至2000年间，43例成年（>16岁）原发性高级别肢体软组织肉瘤患者接受了保肢手术并修复手术缺损，随后进行辅助放疗。重建方式如下：带蒂皮瓣（n = 14）、游离皮瓣（n = 10）、植皮（n = 4）或联合使用（n = 15）。27例患者（63%）仅接受术后外照射放疗（EBRT）（中位剂量：63 Gy）。16例患者（占37%）接受辅助近距离放疗（BRT）；12例患者仅接受BRT（中位剂量：45 Gy），4例患者BRT与EBRT联合使用（EBRT：45 Gy；BRT：20 Gy）。30例患者（70%）存在糖尿病（DM）、高血压、吸烟及肥胖（体重指数≥30计算得出）等合并症。肿瘤特征如下：26例肿瘤大小>5 cm，37例肿瘤位置深，30例肿瘤位于下肢。从手术日期开始计算，中位随访时间为32个月。43例患者中有5例出现伤口并发症，需要再次手术；然而，3例患者在放疗开始前就出现了并发症，因此被排除在分析之外。43例患者中有2例（5%）在放疗后因伤口并发症需要再次手术；其中1例患者最终因坏死需要截肢。5年总体伤口再次手术率为6%（95%置信区间：0 - 14%）。患者及肿瘤特征以及放疗类型对伤口再次手术率的影响如下：BRT与EBRT（17%对0%，p = 0.06）；上肢与下肢（0%对8%，p = 0.41）；≤5 cm与>5 cm（8%对4%，p = 0.9）；有合并症与无合并症（3%对13%，p = 0.8）；年龄≤50岁与>50岁（8%对4%，p = 0.8）。
基于本综述，大多数组织移植（95%）能很好地耐受后续辅助放疗。尽管接受BRT的患者出现更多需要再次手术的伤口并发症，但这是因为皮瓣和植皮在术后早期本身就易发生裂开，还是BRT的直接结果，尚需进一步研究。
