Intraarterial chemotherapy: the effects on free-tissue transfer

Multimodal therapy including intraarterial chemotherapy is recognized as state-of-the art therapy for soft-tissue cancer. Multimodal therapy often involves regional limb perfusion followed by sarcoma surgery with reconstruction of the resulting defect. This study was performed in an effort to evaluate the potential of free flap reconstruction after intraarterial therapy. A retrospective chart review of 52 patients who had undergone limb perfusion between 1988 and 1998 at the University of Texas M. D. Anderson Cancer Center and the Division of Plastic Surgery, University of Bochum, Germany, identified 16 patients who had undergone intraarterial limb perfusion that was then followed by surgical resection and free flap reconstruction. There were seven women and nine men, with an average age of 37.9 years. All sixteen patients had received preoperative adjuvant systemic chemotherapy. Reconstruction of the lower extremity was performed most commonly with rectus abdominis and latissimus dorsi free flaps. All vessels used for donor recipient anastomosis had been previously perfused. A vein graft was used in one case. Split-thickness skin grafting over the free flaps was used in four cases. The average length of hospitalization was 21.75 days, with an average follow-up of 20 months. No flap loss or infection was observed. Two flaps demonstrated partial edge necrosis. Three patients developed partial split-thickness skin graft loss and one developed a seroma that required no treatment. A draining sinus tract required resection in one patient. The overall flap success rate was 100 percent, with no flap failures. The overall surgical outcome was considered to be good in 12 patients on the basis of improved function and ambulation, and fair in four who had limitations in function and/or ambulation on the basis of both the patient self-evaluation and the physical therapy evaluation. Seven patients had recurrence of their disease. The overall mean survival time after surgery was 20.6 months. Currently, 10 patients are alive and six have died from their disease. The results of this study indicate that preoperative intraarterial chemotherapy does not significantly increase the risk of immediate free flap complications. Although our numbers are small, we believe that there is no clinical evidence justifying hesitation or refusal of free flap reconstruction after limb perfusion and intraarterial chemotherapy. Routine care in vessel selection and microsurgical technique should be performed to maximize favorable outcomes. Vessels should be inspected for their suitability before undertaking any free flap reconstruction.