Houston, Texas From the Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center.
Plast Reconstr Surg. 2012 Mar;129(3):675-682. doi: 10.1097/PRS.0b013e3182412a39.
Sarcoma patients often require radiation therapy in addition to surgical resection. Although neoadjuvant irradiation possesses advantages over adjuvant irradiation related to smaller doses and field sizes, existing studies suggest adverse effects on wound healing and possibly microvascular free flap success. Conversely, microvascular reconstruction may counteract some of the negative effects of irradiation by replacing irradiated tissue with well-vascularized unirradiated tissue from a distant site.
A review of sarcoma patients who underwent resection, microsurgical reconstruction, and either neoadjuvant or adjuvant irradiation was performed.
A total of 119 patients met inclusion criteria, of which 73 underwent neoadjuvant irradiation and 46 underwent adjuvant irradiation. Sarcomas were located in the head and neck (n = 47), trunk (n = 7), upper extremity (n = 15), and lower extremity (n = 50). The rate of perioperative (≤ 30 days) complications was 26.9 percent, whereas the rate of late recipient-site complications was 14.3 percent. No significant differences in perioperative recipient-site (p = 0.19), donor-site (p = 1.00), or medical complications (p = 0.30) were observed between patients undergoing neoadjuvant and adjuvant irradiation. Free flap loss rates were lower in patients undergoing neoadjuvant irradiation (0 percent versus 8.7 percent, respectively; p = 0.02). Late recipient-site complications occurred less often in patients undergoing neoadjuvant radiation (6.8 percent versus 26.1 percent, respectively; p = 0.006).
Neoadjuvant irradiation does not increase the risk of acute wound or microvascular complications when combined with free flap reconstruction, and is associated with fewer late recipient-site complications than adjuvant irradiation. These factors should be considered when determining the timing of radiation therapy in sarcoma patients undergoing oncologic resections and microsurgical reconstruction.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
肉瘤患者通常需要在手术切除之外接受放射治疗。虽然新辅助照射比辅助照射具有剂量和照射野较小的优势，但现有研究表明，它会对伤口愈合产生不利影响，并且可能会降低微血管游离皮瓣的成功率。相反，微血管重建可以通过用来自远处未照射组织的血流丰富的未照射组织替代照射组织，来抵消照射的一些负面影响。
对接受切除、显微外科重建以及新辅助或辅助照射的肉瘤患者进行了回顾。
共有 119 名患者符合纳入标准，其中 73 名患者接受了新辅助照射，46 名患者接受了辅助照射。肉瘤位于头颈部（n = 47）、躯干（n = 7）、上肢（n = 15）和下肢（n = 50）。围手术期（≤30 天）并发症发生率为 26.9%，而晚期受区并发症发生率为 14.3%。新辅助和辅助照射组患者的围手术期受区（p = 0.19）、供区（p = 1.00）或医疗并发症（p = 0.30）发生率无显著差异。新辅助照射组游离皮瓣失效率较低（分别为 0%和 8.7%；p = 0.02）。新辅助照射组晚期受区并发症发生率较低（分别为 6.8%和 26.1%；p = 0.006）。
在接受游离皮瓣重建的同时，新辅助照射不会增加急性伤口或微血管并发症的风险，并且与辅助照射相比，晚期受区并发症较少。在确定接受肿瘤切除和显微外科重建的肉瘤患者放射治疗时机时，应考虑这些因素。
临床问题/证据水平：治疗性，III 级。
