Ghost Protocol: Greatest Healing Opportunity for Soft Tissue, a Treatment Paradigm for Complex Sarcoma Reconstruction

Modern sarcoma treatment has created new challenges for plastic surgeons. This study was designed to review the recent experience and practice patterns following complex sarcoma resection at a large sarcoma center. All cases from October 2013 to October 2014 involving rare nonepithelial tumors, a multidisciplinary surgical team, radiation and/or chemotherapy treatments, and plastic surgical reconstruction were included in the analysis. In addition to evaluating clinical outcomes, cases were reviewed to identify factors associated with excellent or poor patient care. Review of these cases formed the basis of the greatest healing opportunity for soft tissue (GHOST) protocol. Our patient population included seven males (64%) and four females (36%). All except one patient was exposed to radiotherapy, chemotherapy, or some combination. Diverse procedures were used for reconstruction. Early complications occurred in two patients (18%), and late complications in four patients (36%). Sarcoma resection was found to be highly morbid in our series. Patients with poor preoperative nutritional status were more likely to experience complications postoperatively. The decision to stage a reconstruction was complex and influenced by several factors. Multimodal sarcoma treatments may involve highly morbid procedures and create complex wounds. The GHOST protocol is a useful reference for plastic surgeons.

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Autogenous soft tissue grafting for periodontal and peri‐implant plastic surgical reconstruction

Journal of Periodontology ◽

10.1002/jper.19-0350 ◽

2019 ◽

Vol 91 (1) ◽

pp. 9-16 ◽

Cited By ~ 17

Author(s):

Giovanni Zucchelli ◽

Lorenzo Tavelli ◽

Michael K. McGuire ◽

Giulio Rasperini ◽

Stephen E. Feinberg ◽

...

Keyword(s):

Soft Tissue ◽

Surgical Reconstruction ◽

Plastic Surgical Reconstruction

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Tumours and hand reconstruction

10.1093/med/9780199550647.003.006012 ◽

2011 ◽

Author(s):

D. Glynn Bolitho

Keyword(s):

Soft Tissue ◽

Bone Grafting ◽

Giant Cell Tumour ◽

Tendon Sheath ◽

Surgical Reconstruction ◽

Radical Excision ◽

Marginal Excision ◽

Partial Amputation ◽

Plastic Surgical Reconstruction ◽

Work Up

♦ Hand tumours are common♦ The vast majority are benign♦ Soft tissue – commonest Giant cell tumour of tendon sheath. Treatment marginal excision♦ Bone – commonest – Enchondroma. Treatment – leave if incidental or currette +/− bone grafting♦ Malignant – need full work up with detailed clinical examination, investigation, and planning in a multidisciplinary meeting♦ Treatment is wide/radical excision often with partial amputation +/− plastic surgical reconstruction.

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Achilles Tenorrhaphy in Five Dogs: A Modified Surgical Technique and Evaluation of a Cranial Half Cast

Veterinary and Comparative Orthopaedics and Traumatology ◽

10.1055/s-0038-1632549 ◽

1998 ◽

Vol 11 (04) ◽

pp. 205-210 ◽

Cited By ~ 13

Author(s):

H. Burbidge ◽

E. Firth ◽

S. Fox ◽

S. Guerin

Keyword(s):

Soft Tissue ◽

Surgical Technique ◽

Surgical Procedure ◽

Normal Function ◽

Surgical Reconstruction ◽

Bone Apposition ◽

Cast Material ◽

Bilateral Lesions ◽

Bone Tunnels

SummaryAchilles mechanism rupture in four of five dogs was treated with tenorrhaphy using a modified surgical technique designed to optimise accurate apposition of tendon to bone. Two bone tunnels were drilled in the calcaneal tuber from a plantomedial - dorsolateral, and plantolateral – dorsomedial direction respectively. The distal ends of the tendons were sutured to the calcaneal tuber using a Krachow suture pattern. The remaining dog had a mid-tendon Achilles mechanism rupture. A resinous half cast was placed on the cranial aspect of the tarsocrural joint of all five dogs, for a minimum of six weeks, in order to provide limited post operative support. Du e to insufficient cast material two of the support splints failed and one of these cases also required a second surgical procedure. A varying amount of soft tissue irritation was noted in each case. All of the five Achilles mechanisms healed, and all of the dogs returned to normal function.Five dogs with surgical reconstruction of the Achilles mechanism were stabilised postoperatively with a resinous half cast placed on the cranial aspect of the tarsocrural joint for a minimum of six weeks. Two of these casts failed at the tarsocrural joint when six folds of casting material were used; all subsequent cases had eight folds applied. Variable soft tissue irration was observed under the cast in each case. A modified surgical technique using a Krachow suture pattern allowed good tendon-bone apposition. All five Achilles mechanisms healed, and all dogs returned to normal function. Bilateral lesions were identified in 3 of the 4 dogs examined.

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Translating Molecular Profiling of Soft Tissue Sarcomas into Daily Clinical Practice

Diagnostics ◽

10.3390/diagnostics11030512 ◽

2021 ◽

Vol 11 (3) ◽

pp. 512

Author(s):

Celine Jacobs ◽

Lore Lapeire

Keyword(s):

Soft Tissue ◽

Unmet Need ◽

Soft Tissue Sarcomas ◽

Molecular Profiling ◽

Point Of View ◽

Molecular Techniques ◽

Mesenchymal Tumors ◽

The Past ◽

Cancer Types ◽

Sarcoma Treatment

Soft tissue sarcomas are a group of rare mesenchymal tumors with more than 70 subtypes described. Treatment of these subtypes in an advanced setting is mainly according to a one-size-fits-all strategy indicating a high unmet need of new and more targeted therapeutic options in order to optimize survival. The introduction of advanced molecular techniques in cancer has led to better diagnostics and identification of new therapeutic targets, leading to more personalized treatment and improved prognosis for several cancer types. In sarcoma, a likewise evolution is seen, albeit at a slower pace. This manuscript describes how in the past years advanced molecular profiling in soft tissue sarcomas was able to identify specific and often pathognomonic aberrations, deferring standard sarcoma treatment in favor of more targeted treatment from an oncologist’s point of view.

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Outcome and Toxicity of an Ifosfamide-Based Soft Tissue Sarcoma Treatment Protocol in Children. The Importance of Local Therapy

Sarcoma ◽

10.1080/13577149877939 ◽

1998 ◽

Vol 2 (3-4) ◽

pp. 171-177

Author(s):

S. Murray Yule ◽

Roderick Skinner ◽

Martin W. English ◽

Mike Cole ◽

Andrew D. J. Pearson ◽

...

Keyword(s):

Soft Tissue ◽

Soft Tissue Sarcoma ◽

Primary Tumour ◽

Treatment Protocol ◽

Disease Free Survival ◽

Local Therapy ◽

Complete Response ◽

One Year ◽

Sarcoma Treatment

Background.Although the survival of children with soft tissue sarcoma (STS) has improved considerably, the outcome of patients with metastatic disease, and those with primary tumours of the extremities or parameningeal sites remains disappointing. We describe the clinical outcome of an ifosfamide-based regimen with local therapy directed only to children who failed to achieve a complete response to initial chemotherapy.Patients and Methods.Twenty-one children with STS (16 rhabdomyosarcoma) who presented with unresectable tumours were treated with five courses of ifosfamide (9 g/m2) and etoposide (600 mg/m2). Patients who did not achieve a complete response then received local therapy. Chemotherapy with ifosfamide combined with etoposide, vincristine (1.5 mg/m2and doxorubicin (60 mg/m2) or vincristine and actinomycin D (1.5 mg/m2) was continued for one year.Results and Discussion.Objective responses to five courses of ifosfamide and etoposide were seen in all patients. Disease free survival (DFS) at a median follow up of 59 months was 57% (95% CI 29–75%). The DFS of children who received local therapy was 89% compared with 33% in those who received chemotherapy alone (p=0.027). Locoregional recurrences did not occur in children who received radiotherapy to the site of the primary tumour. Ifosfamide-based chemotherapy does not reduce the incidence of loco-regional recurrence in children who do not receive local therapy.

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Practice patterns and management strategies for purulent skin and soft-tissue infections in an urban academic ED

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2010.11.033 ◽

2012 ◽

Vol 30 (2) ◽

pp. 302-310 ◽

Cited By ~ 17

Author(s):

Larissa May ◽

Katherine Harter ◽

Kabir Yadav ◽

Ryan Strauss ◽

Jameel Abualenain ◽

...

Keyword(s):

Soft Tissue ◽

Practice Patterns ◽

Management Strategies ◽

Soft Tissue Infections

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Peripheral Aneurysms in Children—A Link to Trauma

PEDIATRICS ◽

10.1542/peds.82.5.786 ◽

1988 ◽

Vol 82 (5) ◽

pp. 786-788

Author(s):

CHARLES E. BAGWELL ◽

H. HOLLIS CAFFEE ◽

JAMES L. TALBERT

Keyword(s):

Soft Tissue ◽

Axillary Artery ◽

Pediatric Population ◽

Blood Gas Analysis ◽

Gas Analysis ◽

Recent Experience ◽

Common Component ◽

History Of ◽

Soft Tissue Masses ◽

Axillary Mass

Evaluation of soft tissue masses is a common component of pediatric practice and usually includes adenopathy v soft tissue neoplasia in the differential diagnosis. Recent experience with a young child referred for an enlarging axillary mass, which was found to be an aneurysm of the axillary artery, illustrates the natural history ofthis uncommon lesion and its frequent association with trauma in the pediatric population. CASE REPORT A 45/12-year-old boy had a 3-month history of an enlarging right axillary mass. Although the child remained asymptomatic, gradual enlargement of the mass was described. The parents could recall no history of injury to the affected extremity (including arterial puncture for blood gas analysis) but, when questioned further, did describe transient discomfort several months previously when an adolescent sibling had grabbed him suddenly by the upper arm while running alongside and lifted him from the ground when he tripped and fell.

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659 Non-Burn Etiologies Treated with Autologous Skin Cell Suspension: A Case Series Demonstrating the Efficacy in Complex Wounds

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.324 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S195-S195

Author(s):

Nicole M Kopari ◽

Yazen Qumsiyeh

Keyword(s):

Soft Tissue ◽

Cell Suspension ◽

Negative Pressure ◽

Wound Closure ◽

Negative Pressure Wound Therapy ◽

Case Series ◽

Dermal Substitute ◽

Wound Therapy ◽

Skin Cell ◽

Complex Wounds

Abstract Introduction Complex wounds (CW) resulting from necrotizing soft tissue infections (NSTIs) and soft tissue traumatic injuries create unique challenges. Radical debridement is often the first step in management but can result in disfigurement with impaired function and compromised cosmesis. The standard of care at our institution for full-thickness burn injuries of similar complexity is widely meshed autografting with application of autologous skin cell suspension (ASCS). Our study is a case series reviewing outcomes using ASCS for CW from non-burn etiology. Methods A retrospective chart review from March 2019 through July 2020 was performed to evaluate the effectiveness of ASCS and widely meshed autografting in CW. Patients presenting with CW underwent serial excisions of devitalized tissue by acute care and burn surgeons. Dermal substitute utilization for wound preparation was at the discretion of the surgeon. Definitive wound closure was achieved using ASCS in combination with a widely meshed autograft. The wounds were covered with a non-adherent, non-absorbent, small pore primary dressing along with bismuth-impregnated, petroleum-based gauze or negative pressure wound therapy dependent on wound bed contour. Further padding with gauze was applied along with compressive dressing. Results In total, 8 patients with CW were included in this review. The mean age was 58 years (range 27-85) with an equal number of males and females. Wound etiology included NSTI (n=5), degloving injury (n=2), and traumatic amputation (n=1). The average wound size measured 1,300cm2 (range 300-3,000). 50% of the patients were treated with a dermal substitute and negative pressure wound therapy prior to ASCS and autograft placement. 7 of 8 patients received split-thickness skin grafting in the ratio of 3:1 with one patient grafted at a 2:1 expansion. 7 of the 8 patients had >90% wound closure within 8-10 days of ASCS and autograft application. One patient had significant graft failure after removing surgical dressings and autograft in the early post-operative period secondary to dementia. One patient expired during the follow-up period secondary to medical comorbidities. The 6 remaining patients had durable wound closure and acceptable cosmetic outcome. All patients were discharged within 10 days of ASCS application with 4 patients discharging home and 4 patients discharging to an acute inpatient rehabilitation. Conclusions This study is the first case series to review ASCS in combination with widely meshed skin grafts in the management of CW from a non-burn etiology. Durable, timely wound closure and an acceptable cosmetic outcome was achieved in these often-challenging CW.

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Acellular fish skin grafts for the management of wounds in dogs and cats: 17 cases (2019–2021)

American Journal of Veterinary Research ◽

10.2460/ajvr.21.09.0140 ◽

2021 ◽

pp. 1-5

Author(s):

Elise S. Mauer ◽

Elizabeth A. Maxwell ◽

Christina J. Cocca ◽

Justin Ganjei ◽

Daniel Spector

Keyword(s):

Soft Tissue ◽

Clinical Outcomes ◽

Medical Records ◽

Complete Healing ◽

Wound Management ◽

Skin Grafts ◽

Fish Skin ◽

Secondary Intention ◽

Management Techniques ◽

Complex Wounds

Abstract OBJECTIVE To report the clinical outcomes of the use of acellular fish skin grafts (FSGs) for the management of complex soft tissue wounds of various etiologies in dogs and cats. ANIMALS 13 dogs and 4 cats with complex wounds treated with FSGs between February 2019 and March 2021. PROCEDURES Medical records were reviewed for information regarding cause, location, size of the wound, management techniques, complications, and clinical outcomes. RESULTS In dogs, the number of FSG applications ranged from 1 to 4 (median, 2 graft applications). The time between each application ranged from 4 to 21 days (median, 9.5 days). Time to application of the first FSG ranged from 9 to 210 days (median, 19 days). Wounds closed by second-intention healing following the first fish skin application between 26 and 145 days (median, 71 days; n = 12). In cats, 1 or 2 FSGs were used, and the wounds of 3 of 4 cats healed completely by secondary intention. The wounds of 1 dog and 1 cat did not heal. There were no adverse events attributed to the use of the FSGs. CLINICAL RELEVANCE For dogs and cats of the present study, complete healing of most wounds occurred with the use of FSGs, the application of which did not require special training, instruments, or bandage materials.

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