Enrico Martin

212 Chapter 9 Introduction Soft tissue sarcomas (STS) are rare cancers occurring in approximately 4 cases per 100,000, half of which arise in extremities. 1,2 Ideal treatment of localized disease generally includes wide resection, radiotherapy, and in some cases chemotherapy. 3 Clear surgical margins are critical for decreasing local recurrence rates. 3,4 In extremity soft tissue sarcoma, limb-salvage surgery (LSS) has become standard of care as its combination with radiotherapy does not impair local control, yet improves functionality. 5,6 Although amputation rates have fallen in the last decades, major neurovascular involvement of STS in extremities is still seen as a reason for amputation. 7–9 In part, this may be due to the lack of literature on reconstruction of such nerve defects. Even though resection of nerves is rare in STS generally, their resection leads to significant functional deficits. 10,11 Reported rates of any nerve resection, excluding amputations, vary from 1.2-12%. 9,10,12–17 Incidence of nerve resection increases when sarcomas arise from nerve structures, like malignant peripheral nerve sheath tumors (MPNSTs), who have reported postoperative loss of motor function in up to 30%. 18 While rates of nerve reconstructions are as low as 0.4%. 19 As STS has a relatively high incidence at a younger age and treatment options are slowly improving, the amount of long-term survivors with life-long disabilities will increase. 20 The relatively rare nature of nerve resections is probably not the only cause of the paucity of literature. STS research has primarily focused on improving oncological outcomes and decreasing complications and the primary role of plastic surgery has traditionally only included soft tissue coverage while nerve reconstructions are not common practice. 21–23 Secondly, knowledge on nerve reconstructions is still growing, especially on the use of nerve transfers and nerve conduits. 24 Lastly, STS treatment will often involve the use of radiotherapy and chemotherapy which have uncertain effects on nerve regeneration, which already is notorious for being slow. 25 Altogether, these factors may preclude clinicians to consider nerve reconstructions as a possibility in STS management, even though the resection of nerves may cause both motor and sensory deficits. Contrarily, nerve reconstructions have been shown to increase quality of life after other tumor-ablative surgeries, for example in mastectomies or head and neck cancers. 26–29 This review set out to summarize all cases on nerve reconstruction in extremity STS and assess functional outcomes albeit the use of multimodal treatment. Consequently, indications of their use and considerations to be taken may be elucidated. As such, reconstructive surgeons can ameliorate their choice of reconstruction which should be in concurrence with oncological treatments proposed in sarcoma teams.