Lymphatic complications after thigh soft tissue sarcoma resection in the era before lymphatic reconstructive surgery – a retrospective cohort analysis
DOI:
https://doi.org/10.2340/jphs.v60.43991Keywords:
Lymphatic fistula, lymphedema, lymphatic complications, soft-tissue sarcomaAbstract
Introduction: Patients undergoing curative treatment for soft-tissue sarcomas (STS) of the thigh bear the risk of developing lymphatic fistula and lymphedema. Innovative microsurgical concepts such as primary preventive lymphatic reconstruction show promising results. To discuss the likelihood of lymphatic complications after limb-preserving treatment of STS in the era before lymphatic reconstructive surgery and depending on the sarcoma location in the thigh became paramount in treating these patients.
Methods: We reviewed clinical data of 471 patients who underwent curative lower limb sarcoma treatment at our institution during the period from 2005 to 2019. We allocated patients into cohorts depending on the tumor location in the thigh respecting anatomical compartments as medial, posterior and the anterior compartment. We primarily analyzed incidences of postoperative lymphatic fistula and lymphedema.
Results: We included 69 patients into this study. Mean follow-up period was 36 months. The overall incidence of lymphatic complications was 69.6% (48 of 69 patients). Lymphatic fistulas in general (symptomatic and asymptomatic, ±lymphedema) were observed in 55% of all patients (38 of 69), whereas lymphedema occurred in 47.8% of all our patients (33 of 69). Lymphatic fistula alone occurred in 15 patients (21.7%) and lymphedema alone occurred in 10 patients (14.5%).
Conclusions: Incidences of lymphatic complications after limb-preserving curative treatment of STS of the thigh are high and vary depending on the exact tumor location. Medial and anterior thigh sarcomas are at high risks for lymphatic complications. Our results might facilitate selecting high-risk patients and aid in justifying preventive microsurgical strategies.
Downloads
References
DeVita VT, Rosenberg SA, Lawrence TS. DeVita, Hellman, and Rosenberg’s cancer: principles & practice of oncology. 11th ed. Wolters Kluwer; 2018. Riverwoods, Illinois, USA
Collin C, Hadju S, Godbold J, et al. Localized, operable soft tissue sarcoma of the lower extremity. Arch Surg. 1986; 121(12): 1425–1433. https://doi.org/10.1001/archsurg.1986.01400120075013 DOI: https://doi.org/10.1001/archsurg.1986.01400120075013
Friedmann D, Wunder JS, Ferguson P, et al. Incidence and severity of lymphoedema following limb salvage of extremity soft tissue sarcoma. Sarcoma. 2011; 2011(1): 289673. https://doi.org/10.1155/2011/289673 DOI: https://doi.org/10.1155/2011/289673
Sanniec KJ, Swanson S, Casey WJ, et al. Predictive factors of wound complications after sarcoma resection requiring plastic surgeon involvement. Ann Plast Surg. 2013; 71(3): 283–285. https://doi.org/10.1097/SAP.0b013e31827c7973 DOI: https://doi.org/10.1097/SAP.0b013e31827c7973
Chang AE, Steinberg SM, Culnane M, et al. Functional and psychosocial effects of multimodality limb-sparing therapy in patients with soft tissue sarcomas. J Clin Oncol. 1989; 7(9): 1217–1228. https://doi.org/10.1200/JCO.1989.7.9.1217 DOI: https://doi.org/10.1200/JCO.1989.7.9.1217
Schreiber D, Bell RS, Wunder JS, et al. Evaluating function and health related quality of life in patients treated for extremity soft tissue sarcoma. Qual Life Res. 2006; 15(9): 1439–1446. https://doi.org/10.1007/s11136-006-0001-4 DOI: https://doi.org/10.1007/s11136-006-0001-4
Kruiswijk AA, Van de Sande MAJ, Verhoef C, et al. Changes in health-related quality of life following surgery in patients with high-grade extremity soft-tissue sarcoma: a prospective longitudinal study. Cancers (Basel). 2024; 16(3): 547. https://doi.org/10.3390/cancers16030547 DOI: https://doi.org/10.3390/cancers16030547
Campione, E. Immediate lymphatic reconstruction: The future of lymphedema risk reduction? Rehabil Oncol. 2023; 41(3): 157–159. https://doi.org/10.1097/01.REO.0000000000000344 DOI: https://doi.org/10.1097/01.REO.0000000000000344
Chun MJ, Saeg F, Meade A, et al. Immediate lymphatic reconstruction for prevention of secondary lymphedema: a meta-analysis. J Plast Reconstr Aesthet Surg. 2022; 75(3): 1130–1141. https://doi.org/10.1016/j.bjps.2021.11.094 DOI: https://doi.org/10.1016/j.bjps.2021.11.094
Marangi GF, Segreto F, Coppola MM, et al. Management of chronic seromas: a novel approach with the use of vacuum assisted closure therapy. Int Wound J. 2020; 17(5): 1153–1158. https://doi.org/10.1111/iwj.13447 DOI: https://doi.org/10.1111/iwj.13447
Uyulmaz S, Grünherz L, Giovanoli P, et al. Primary lymphovenous anastomosis after extended soft tissue resection in the medial thigh for reduction of lymphocele and lymphedema. Ann Plast Surg. 2024; 93(2): 221–228. https://doi.org/10.1097/SAP.0000000000003994 DOI: https://doi.org/10.1097/SAP.0000000000003994
Baldini EH, Lapidus MR, Wang Q, et al. Predictors for major wound complications following preoperative radiotherapy and surgery for soft-tissue sarcoma of the extremities and trunk: importance of tumor proximity to skin surface. Ann Surg Oncol. 2013; 20(5): 1494–1499. https://doi.org/10.1245/s10434-012-2797-1 DOI: https://doi.org/10.1245/s10434-012-2797-1
Focássio CCM, Gamboa RAB, De Marco LFS, et al. Treatment of lymphocele with negative pressure wound therapy post inguinal mass excision: a case-report. Int J Surg Case Rep. 2020; 66: 43–47. https://doi.org/10.1016/j.ijscr.2019.11.017 DOI: https://doi.org/10.1016/j.ijscr.2019.11.017
Slump J, Bastiaannet E, Halka A, et al. Risk factors for postoperative wound complications after extremity soft tissue sarcoma resection: a systematic review and meta-analyses. J Plast Reconstr Aesthet Surg. 2019; 72(9): 1449–1464. https://doi.org/10.1016/j.bjps.2019.05.041 DOI: https://doi.org/10.1016/j.bjps.2019.05.041
Moore J, Isler M, Barry J, et al. Major wound complication risk factors following soft tissue sarcoma resection. Eur J Surg Oncol. 2014; 40(12): 1671–1676. https://doi.org/10.1016/j.ejso.2014.10.045 DOI: https://doi.org/10.1016/j.ejso.2014.10.045
Wu P, Elswick SM, Akhavan AA, et al. Risk factors for lymphedema after thigh sarcoma resection and reconstruction. Plast Reconstr Surg Glob Open. 2020; 8(7): e2912. https://doi.org/10.1097/GOX.0000000000002912 DOI: https://doi.org/10.1097/GOX.0000000000002912
Eichler M, Hentschel L, Richter S, et al. The PROSa Study Group. The health-related quality of life of sarcoma patients and survivors in Germany-cross-sectional results of a nationwide observational study (PROSa). Cancers (Basel). 2020; 12(12): 3590. https://doi.org/10.3390/cancers12123590 DOI: https://doi.org/10.3390/cancers12123590
Uyulmaz S, Planegger A, Grünherz L, et al. Lymphovenous anastomoses and microscopic lymphatic ligations for the treatment of persistent lymphocele. Plast Reconstr Surg Glob Open. 2021; 9(2): e3407. https://doi.org/10.1097/GOX.0000000000003407 DOI: https://doi.org/10.1097/GOX.0000000000003407
Uyulmaz S, Puippe G, Büyükakyüz N, et al. Sclerotherapy with OK-432 for the treatment of symptomatic lymphocele after lymph node dissection: a retrospective comparative cohort study. Ann Plast Surg. 2020; 85(4): 407–412. https://doi.org/10.1097/SAP.0000000000002251 DOI: https://doi.org/10.1097/SAP.0000000000002251
Watfa W, Campisi C, Ryan M, et al. Lymphatic leaks of the thigh and inguinal region: combined plastic surgery approaches for an effective treatment algorithm. Ann Plast Surg. 2020; 85(6): 661–667. https://doi.org/10.1097/SAP.0000000000002310 DOI: https://doi.org/10.1097/SAP.0000000000002310
Desar IME, Rothermundt C. Personalized therapy of sarcomas. Cancers (Basel). 2023; 15(20): 5110. https://doi.org/10.3390/cancers15205110 DOI: https://doi.org/10.3390/cancers15205110
Montella L, Altucci L, Sarno F, et al. Toward a personalized therapy in soft-tissue sarcomas: state of the art and future directions. Cancers (Basel). 2021; 13(10): 2359. https://doi.org/10.3390/cancers13102359 DOI: https://doi.org/10.3390/cancers13102359
Aho JM, Nickerson TP, Thiels CA, et al. Prevention of postoperative seromas with dead space obliteration: a case-control study. Int J Surg. 2016; 29: 70–73. https://doi.org/10.1016/j.ijsu.2016.03.004 DOI: https://doi.org/10.1016/j.ijsu.2016.03.004
Bercial ME, Neto MS, Calil JA, et al. Suction drains, quilting sutures, and fibrin sealant in the prevention of seroma formation in abdominoplasty: which is the best strategy? Aesthetic Plast Surg. 2012; 36(2): 370–373. https://doi.org/10.1007/s00266-011-9807-8 DOI: https://doi.org/10.1007/s00266-011-9807-8
Brunetti B, Morelli Coppola M, Tenna S, et al. Thigh reconstruction between form and function: an algorithm for flap selection based on a series of 70 oncological patients. Microsurgery. 2024; 44(1): e31121. https://doi.org/10.1002/micr.31121 DOI: https://doi.org/10.1002/micr.31121
Elswick SM, Wu P, Arkhavan AA, et al. A reconstructive algorithm after thigh soft tissue sarcoma resection including predictors of free flap reconstruction. J Plast Reconstr Aesthet Surg. 2019; 72(8): 1304–1315. https://doi.org/10.1016/j.bjps.2019.04.016 DOI: https://doi.org/10.1016/j.bjps.2019.04.016
Franchi A, Schnegg JR, Di Summa PG. Taps, wicks, bridges and LIFTs: clarification on the origins of lymphatic flaps. J Plast Reconstr Aesthet Surg. 2024; 98: 240–243. https://doi.org/10.1016/j.bjps.2024.09.018 DOI: https://doi.org/10.1016/j.bjps.2024.09.018
Yamamoto T, Yamamoto N, Kageyama T, et al. Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis. J Plast Reconstr Aesthet Surg. 2021; 74(10): 2604–2612. https://doi.org/10.1016/j.bjps.2021.03.014 DOI: https://doi.org/10.1016/j.bjps.2021.03.014
Taylor GI, Pan WR. The angiosome concept and tissue transfer, Thieme, Stuttgart, Germany (2013).
Guillier D, Guiotto M, Cherix S, et al. Lymphatic flow through (LyFT) ALT flap: an original solution to reconstruct soft tissue loss with lymphatic leakage or lower limb lymphedema. J Plast Surg Hand Surg. 2023; 57(1–6): 216–224. https://doi.org/10.1080/2000656X.2022.2039680 DOI: https://doi.org/10.1080/2000656X.2022.2039680
Di Summa PG, Guillier D. The Lymphatic Flow-Through (LyFT) flap: proof of concept of an original approach. J Plast Reconstr Aesthet Surg. 2020; 73(5): 983–1007. https://doi.org/10.1016/j.bjps.2020.01.014 DOI: https://doi.org/10.1016/j.bjps.2020.01.014
Yoshimatsu H, Cho MJ, Karakawa R, et al. The role of lymphatic system transfer (LYST) for treatment of lymphedema: a long-term outcome study of SCIP flap incorporating the lymph nodes and the afferent lymphatic vessels. J Plast Reconstr Aesthet Surg. 2025; 101: 15–22. https://doi.org/10.1016/j.bjps.2024.11.052 DOI: https://doi.org/10.1016/j.bjps.2024.11.052
Martini F, Meroni M, Scaglioni MF. Pedicled SCIP-based vascularized lymphnode and lymphatic vessels transfer for deep lymphatic system reconstruction and dead space obliteration after medial thigh sarcoma resection: a case report. Microsurgery. 2024; 44(5): e31205. https://doi.org/10.1002/micr.31205 DOI: https://doi.org/10.1002/micr.31205
Lipman K, Luan A, Stone K, et al. Lymphatic microsurgical preventive healing approach (LYMPHA) for lymphedema prevention after axillary lymph node dissection – a single institution experience and feasibility of technique. J of Clinl Med. 2022; 11(1): 92. https://doi.org/10.3390/jcm11010092 DOI: https://doi.org/10.3390/jcm11010092
Boccardo F, Valenzano M, Costantini S, et al. LYMPHA technique to prevent secondary lower limb lymphedema. Ann Surg Oncol. 2016; 23(11): 3558–3563. https://doi.org/10.1245/s10434-016-5282-4 DOI: https://doi.org/10.1245/s10434-016-5282-4
Agarwal, S, Garza, RM, Chang, DW. Lymphatic microsurgical preventive healing approach (LYMPHA) for the prevention of secondary lymphedema. Breast J. 2020; 26(4): 721–724. https://doi.org/10.1111/tbj.13667 DOI: https://doi.org/10.1111/tbj.13667
Ward J, King I, Monroy-Iglesias M, et al. A meta-analysis of the efficacy of VLNT in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema. Eur J Cancer. 2021; 151: 233–244. https://doi.org/10.1016/j.ejca.2021.02.043 DOI: https://doi.org/10.1016/j.ejca.2021.02.043
Pak CS, Suh HP, Kwon JG, et al. Lymph node to vein anastomosis for lower extremity lymphedema. J Plast Reconstr Aesthet Surg. 2021; 74(9): 2059–2067. https://doi.org/10.1016/j.bjps.2021.01.005 DOI: https://doi.org/10.1016/j.bjps.2021.01.005
Bailey EA, Pandey SK, Chen WF. Advances in surgical lymphedema management: the emergence and refinement of lymph node-to-vein anastomosis. Curr Surg Rep. 2024; 12: 83–88. https://doi.org/10.1007/s40137-024-00395-y DOI: https://doi.org/10.1007/s40137-024-00395-y
Additional Files
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Nicole Lindenblatt, Sema Simões de Almeida, Isabelle Obrecht, Lisanne Grünherz, Bruno Fuchs, Pietro Giovanoli, Semra Uyulmaz
This work is licensed under a Creative Commons Attribution 4.0 International License.
Acta Chirurgica Scandinavica Society owns the copyright for all material published until Volume 57 (2023) unless otherwise specified. As from 2024 all published articles, unless otherwise specified, are published under CC-BY licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, with the condition of proper attribution to the original work.
