System describing surgical field extension associated with flap reconstruction after resection of a superficial malignant soft tissue tumor

Akio Sakamoto; Takashi Noguchi; Shuichi Matsuda

doi:10.5306/wjco.v14.i11.471

System describing surgical field extension associated with flap reconstruction after resection of a superficial malignant soft tissue tumor

World J Clin Oncol. 2023 Nov 24;14(11):471-478. doi: 10.5306/wjco.v14.i11.471.

Authors

Akio Sakamoto¹, Takashi Noguchi², Shuichi Matsuda²

Affiliations

¹ Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan. akiosaka@kuhp.kyoto-u.ac.jp.
² Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan.

Abstract

Background: Flap reconstruction after resection of a superficial malignant soft tissue tumor extends the surgical field and is an indicator for potential recurrence sites.

Aim: To describe a grading system for surgical field extension of soft tissue sarcomas.

Methods: Grading system: CD-grading is a description system consisting of C and D values in the surgical field extension, which are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. C1/D1 are positive values and C0/D0 are negative. With a known location, 1/0 values can be "p" (proximal), "d" (distal), and "b" (in the tumor bed), and the description method is as follows: flap type, CxDx [x = 0, 1, p, d or b].

Results: Four representative patients with subcutaneous sarcomas who underwent reconstruction using fasciocutaneous flaps are presented. The cases involved a distal upper arm (elbow) synovial sarcoma reconstructed using a pedicled latissimus dorsi (pedicled flap: CpDp); a distal upper arm (elbow) pleomorphic rhabdomyosarcoma reconstructed using a transpositional flap from the forearm (transpositional flap: CdD0); an undifferentiated pleomorphic sarcoma in the buttocks reconstructed using a transpositional flap (transpositional flap: C0D0); and a myxofibrosarcoma in the buttocks reconstructed using a propeller flap from the thigh (pedicled flap: CdDd).

Conclusion: The reconstruction method is chosen by the surgeon based on size, location, and other tumor characteristics; however, the final surgical field cannot be determined based on preoperative images alone. CD-grading is a description system consisting of C and D values in the surgical field extension that are related to the compartmental position of the flap beyond the nearby large joint and deeper extension for the pedicle, respectively. The CD-grading system gives a new perspective to the flap reconstruction classification. The CD-grading system also provides important information for follow-up imaging of a possible recurrence.

Keywords: Grading system; Sarcoma; Soft tissue; Surgery; Surgical flap.