Enrico Martin

190 Chapter 8 Introduction With an annual incidence of approximately 4 cases per 100,000, soft-tissue sarcomas (STS) comprise 1% of adult cancers. 1 Around 15% and 35% of all STS arise in upper and lower extremities respectively. 2 Resection with clear margins remains key to improve survival and diminish local and distant recurrences. 3,4 While amputation was not uncommon in the past, limb-sparing surgery (LSS) has become standard of care as it improves functionality providing it does not decrease local control. 5,6 Radiotherapy is often part of limb-sparing treatment for local control and many centers are increasingly preferring preoperative to postoperative radiotherapy because it has lower long-term toxicities, albeit its higher postoperative complication rates. 7–12 The rise of limb-salvage surgery has partly been due to a combination of improved local control using radiotherapy and an increase in reconstructive possibilities, but the main goal of plastic surgery has traditionally been soft tissue coverage. 13 Functional reconstructions, the replacement of lost functions due to complete muscle, tendon, or nerve resections, are gaining popularity in trauma cases but still little can be found in STS literature. 13–15 This is in contrast with the reconstruction of major arteries, and to a lesser extend veins, which are more common practice in centrally located sarcoma, especially in leiomyosarcoma where the tumor derives from a vein. Several reasons may underlie the latter. Firstly, in most cases where muscles are resected, the remaining muscles are able to hypertrophy after resection and partially replace the function of the resected muscle. 16 Secondly, about a quarter of STS grow superficially, obviating the need for large muscle resection. 17 Thirdly, the focus of treatment is obtaining adequate margins and improving oncological outcome, as well as preventing major complications or wound healing problems. Therefore, research has not focused on the potential role of functional reconstructions so far. Finally, the rather poor prognosis of some STS patients and limited knowledge of rehabilitation may withhold surgeons to consider such reconstructions. As a result functional reconstructions are often not implemented as common practice. 13,14,18 It should be noted that not only motor deficits are regarded as functional deficits; sensory loss may also be present after resection of sensory or mixed nerves. Achieving clear margins in LSS may often be compromised by involvement of critical structures such as nerves, bones, or arteries. 19 Resection of aforementioned structures can result in large functional deficits. 19–24 Techniques as preoperative limb perfusion, preoperative radiotherapy, and epineural dissection are several ways that have shown to diminish the need for resection of such critical structures. 8,25–27 However, their resection is sometimes inevitable, especially when the tumors are encasing major structures or are deriving from major structures such as MPNSTs which may originate from large nerves. Frequently, such involvement is considered an indication for amputation because of its anticipated functional deficit. 19,28,29 However, since STS has a