CTOS, Berlin 2014

The influence of time interval between preoperative radiation and surgical resection on

the development of wound healing complications in extremity soft tissue sarcoma

Anthony M. Griffin, MSc

Colleen I. Dickie, MRT(T)(M.R.)

Charles N. Catton, MD, FRCPC

Peter W.M. Chung, MD, FRCPC

Peter C. Ferguson, MD, FRCSC

Jay S. Wunder, MD, FRCSC

Brian O’Sullivan, MD, FRCPC

CTOS, Berlin 2014

Introduction

• Preop RT & extremity STS: smaller volume, lower dose, fewer late complications (fibrosis, fracture)

• Increased wound complications1

• 30-45% in lower extremity

11O’Sullivan, Lancet 2002; 359:2235O’Sullivan, Lancet 2002; 359:2235

CTOS, Berlin 2014

Introduction

• Surgery usually 4-6 weeks post rads

• Cumulative effect of RT• Timing of surgery after

RT- influence outcome?• But no empirical

evidence for optimum time interval for minimizing WC.

CTOS, Berlin 2014

Purpose

• To determine if the time interval between completion of RT and surgery affects the development of wound complications in patients with extremity STS

CTOS, Berlin 2014

Methods

• Retrospective review of prospectively collected database

• Extremity STS• Preoperative RT• Chemotherapy excluded• 1989-2013: 798 cases

CTOS, Berlin 2014

MethodsWound complications defined as:

•Secondary operations (debridement, flap, STSG) •Invasive procedures for wound care (drainage of hematoma, seroma)•Use of VAC•Prolonged dressing changes, including packing of the wound for greater than six weeks from wound breakdown•Readmission to hospital for wound care

CTOS, Berlin 2014

Methods

• Means compared with t-test

• Proportions compared with Chi-square test

CTOS, Berlin 2014

Results

• Mean age 56.1 (15-95) years• 56% male (448); 44% female (350)• 93% (743) primary presentations, 32 had

metastases (2/55 with LR)• 238 patients (30%) had prior unplanned

excision• Mean tumour size 8.8 cm (1-36 cm), Median

7.5 cm

CTOS, Berlin 2014

Results- Anatomic Site

• Upper Extremity 233 (29%)

• Lower extremity 565 (71%)

Anatomic site Number

Shoulder girdle 69

Shoulder 50

Elbow 63

Wrist/ Hand 51

Pelvic girdle 42

Hip 184

Knee 272

Foot/ ankle 67

Total 798

CTOS, Berlin 2014

Results

• Subtype formerly known as MFH most common- did not re-classify

MFH UPS

tgg

1

CTOS, Berlin 2014

Results

• 654 (82%) deep• Grade 1: 87 (11%) • Grade 2: 293 (37%); Grade 3: 408 (51%)• 10 not graded

• RT: external beam, planned to 50 Gy• 56 patients (7%) had boost (10-16 Gy)

CTOS, Berlin 2014

Results- Flap or STSG usage

• Secondary closure in 324 (41%)

Type of surgery Number Percentage

Excision 445 55.8

Rotation flap 57 7.1

Rotation flap + STSG 111 13.9

Free flap 35 4.4

Free flap +STSG 54 6.8

STSG 67 8.4

Amputation 10 1.3

Vascular reconstruction 19 2.4

Total 798 100

CTOS, Berlin 2014

Results: RT-Surgery time & wound complications

Total Mean time interval (days)

Median (days)

Range (days)

P-value

Entire group 798 41.3 40.0 4-470

CTOS, Berlin 2014

Results: RT-Surgery time & wound complications

Total Mean time interval (days)

Median (days)

Range (days)

P-value

Entire group 798 41.3 40.0 4-470

Upper extremity 233 42.0 38.0 4-470*

Lower extremity 565 41.1 40.0 4-109 0.6

* If outlier is excluded, largest interval is 105 days

CTOS, Berlin 2014

Results: RT-Surgery time & wound complications

Total Mean time interval (days)

Median (days)

Range (days)

P-value

Entire group 798 41.3 40.0 4-470

Upper extremity 233 42.0 38.0 4-470*

Lower extremity 565 41.1 40.0 4-109 0.6

Complication 242 40.9 40.5 4-100

No complication 556 41.5 40.0 4-470 0.7

* If outlier is excluded, largest interval is 105 days

CTOS, Berlin 2014

Results: RT-Surgery time & wound complications

Total Mean time interval (days)

Median (days)

Range (days)

P-value

Entire group 798 41.3 40.0 4-470

Upper extremity 233 42.0 38.0 4-470*

Lower extremity 565 41.1 40.0 4-109 0.6

Complication 242 40.9 40.5 4-100

No complication 556 41.5 40.0 4-470 0.7

UE- complication 36 38.0 37.0 4-65

UE- no comp. 197 42.7 39.0 5-470 0.4

* If outlier is excluded, largest interval is 105 days

CTOS, Berlin 2014

Results: RT-Surgery time & wound complications

Total Mean time interval (days)

Median (days)

Range (days)

P-value

Entire group 798 41.3 40.0 4-470

Upper extremity 233 42.0 38.0 4-470*

Lower extremity 565 41.1 40.0 4-109 0.6

Complication 242 40.9 40.5 4-100

No complication 556 41.5 40.0 4-470 0.7

UE- complication 36 38.0 37.0 4-65

UE- no comp. 197 42.7 39.0 5-470 0.4

LE- complication 206 41.4 41.0 8-100

LE- no comp. 359 40.9 40.0 4-109 0.6

* If outlier is excluded, largest interval is 105 days

CTOS, Berlin 2014

Results: RT-surgery interval & wound complications

Time Period N=798 Complication P-value

3 weeks 39 (5%) 15 (38%)

> 3 weeks 759 (95%) 227 (30%) 0.3

CTOS, Berlin 2014

Results: RT-surgery interval & wound complications

Time Period N=798 Complication P-value

3 weeks 39 (5%) 15 (38%)

> 3 weeks 759 (95%) 227 (30%) 0.3

4 weeks 129 (16%) 39 (30%)

> 4 weeks 669 (84%) 203 (30%) 1.0

5 weeks 295 (37%) 88 (30%)

> 5 weeks 503 (63%) 154 (31%) 0.8

CTOS, Berlin 2014

Results: RT-surgery interval & wound complications

Time Period N=798 Complication P-value

3 weeks 39 (5%) 15 (38%)

> 3 weeks 759 (95%) 227 (30%) 0.3

4 weeks 129 (16%) 39 (30%)

> 4 weeks 669 (84%) 203 (30%) 1.0

5 weeks 295 (37%) 88 (30%)

> 5 weeks 503 (63%) 154 (31%) 0.8

6 weeks 476 (60%) 133 (28%)

> 6 weeks 322 (40%) 109 (34%) 0.08

CTOS, Berlin 2014

Results: RT-surgery interval & wound complications- lower extremity

Time Period N=565 Complication P-value

3 weeks 22 (4%) 10 (45%)

> 3 weeks 543 (96%) 196 (36%) 0.4

4 weeks 86 (15%) 30 (35%)

> 4 weeks 479 (85%) 176 (37%) 0.7

5 weeks 204 (36%) 74 (36%)

> 5 weeks 361 (64%) 132 (36%) 0.9

6 weeks 333 (59%) 112 (34%)

> 6 weeks 232 (41%) 94 (41%) 0.09

Results- Secondary closure and wound complications

• Excludes 10 patients with amputations and 19 who required vascular reconstruction

CTOS, Berlin 2014

N Complication P-value

Primary closure 445 141 (32%)

Secondary closure 324 89 (28%) 0.2

Results- Secondary closure and wound complications

• Excludes 10 patients with amputations and 19 who required vascular reconstruction

CTOS, Berlin 2014

N Complication P-value

Primary closure 445 141 (32%)

Secondary closure 324 89 (28%) 0.2

LE- primary 329 123 (37%)

LE- secondary 209 71 (34%) 0.4

Results- IMRT vs. Pre-IMRT

• POP & conformal 1989-2005• Regular IMRT commenced in 2005, although foot and hand/

forearm still tend to be treated with POP (limited tissue sparing opportunities)

CTOS, Berlin 2014

N Complication P-value

Pre-IMRT 453 134 (30%)

IMRT 345 108 (31%) 0.6

Results- IMRT vs. Pre-IMRT

• POP & conformal 1989-2005• Regular IMRT commenced in 2005, although foot and hand/

forearm still tend to be treated with POP (limited tissue sparing opportunities)

CTOS, Berlin 2014

N Complication P-value

Pre-IMRT 453 134 (30%)

IMRT 345 108 (31%) 0.6

LE Pre-IMRT 310 110 (35%)

LE IMRT 255 96 (38%) 0.6

CTOS, Berlin 2014

Discussion

• Interval between RT completion & surgery had minimal influence on development of wound complications

• Small numbers within 3 weeks (39 patients)

• Interval of 4 or 5 weeks showed equivalent complication rates- optimal interval?

CTOS, Berlin 2014

Discussion

• Trend towards significance for surgery after 6 weeks

• Acute toxicities during treatment lead to delay in surgery?

• No difference with use of flap closure

CTOS, Berlin 2014

Thank You