CHAPTER

84
Anterior Thigh Tumor
Resection
Fritz C. Eilber, MD, and Frederick R. Eilber, MD

I. SPECIAL PREOPERATIVE PREPARATION

◆ Physical exam: Any mass of the anterior thigh that is large, deep to the subcutaneous tissue, nonmobile,
and/or firm should be considered to be a soft tissue sarcoma until proven otherwise. In the presence
of any clinical features that raise the suspicion of soft tissue sarcoma, cross-sectional imaging and tissue
diagnosis are critical in guiding appropriate care.
◆ Imaging: Plain radiographs and ultrasounds are of little value, and angiograms are not necessary. Cross-
sectional imaging is critical, because it provides the anatomic information necessary to guide surgical
resection. Cross-sectional imaging can be performed by either computed tomography (CT) or magnetic
resonance imaging (MRI) and should include the appropriate intravenous contrast agent to delineate
the vascular anatomy (Figs. 84-1 and 84-2).
◆ CT versus MRI: Too much emphasis is placed on this distinction, and there are very few instances in
which one modality is preferred over another. Although certain soft tissue sarcomas image better with
MRI and others better with CT, this choice should be driven by both the surgeon’s comfort with the
imaging technique and the availability and ease of obtaining the study.
◆ Tissue diagnosis: CT-guided core biopsy is the optimal method to obtain tissue diagnosis. CT guidance
allows for precise tissue sampling, including targeting specific areas of concern within a tumor. Fine-
needle aspiration is inadequate. Core biopsies needs to be done with large-bore needles, as this allows
for adequate tissue collection for histologic diagnosis, grade, and often critical ancillary studies such
as cytogenetics and electron microscopy. In the rare instance (<5%) that a CT-guided core biopsy is
unable to provide an adequate histologic diagnosis, an incisional biopsy can be performed. Such a
biopsy should be placed in line with the incision required for definitive surgical resection, with atten-
tion to hemostasis to avoid a hematoma. Transverse incisions in the extremity are to be avoided.
◆ Staging: Patients with high-grade thigh sarcomas should have a CT scan of the chest, as this is the most
common site of metastatic disease. Staging for high-grade liposarcomas should also include a CT of
the abdomen and pelvis because these lesions can metastasize to other sites. For low-grade sarcomas,
the routine preoperative chest radiograph is sufficient. Positron emission tomography scans have not
been validated as a screening modality and are not done in the setting of primary disease unless under
a study protocol.
◆ Neoadjuvant therapy: Patients with large (≥5 cm), high-grade, deep sarcomas should be considered for
protocol neoadjuvant therapy (chemotherapy, radiation therapy, and/or chemoradiation), which should
only be administered at a sarcoma center or cancer center with expertise in sarcomas.

II. OPERATIVE TECHNIQUE

Position
◆ The patient is placed in the supine position. A Foley catheter should be placed. It is generally best to
prep the entire extremity including the groin. Stockinet is placed over the foot and ankle, and the
extremity is draped free to allow it to be moved during the operation. The groin and knee should be
included in the field.

644
 Chapter 84 • Anterior Thigh Tumor Resection 645

Incision
◆ A vertical incision is made over the palpable mass or over its location based on cross-sectional imaging.
The incision should ellipse out the previous incisional biopsy site if present. A generous incision should
be made that extends both above and below the lesion to allow for appropriate exposure (Fig. 84-3).

1
2
Rectus femoris Vastus lateralis
Vastus medialis muscle muscle
muscle 14

3
Superficial
femoral artery Vastus
and vein intermedius
muscle
13
4 Sartorius
muscle
Adductor magnus
adductor muscle
12
Adductor magnus 5
ischiocondylar muscle Biceps femoris
short head muscle 11
Gracilis
muscle Biceps femoris
6 long head muscle 10
7 9
Semimembranosus
muscle Sciatic nerve
8
Semitendinosus muscle
Figure 84-1. Computed tomography scan illustrating the normal anatomy of the left thigh.

Iliopsoas muscle
12

1 Pectineus muscle 11
Inguinal ligament

Tensor fasciae latae muscle 2 10

Adductor
longus muscle
Area of tumor
3

Incision line Gracilis

4 muscle
9
Rectus femoris muscle
5
Sartorius
muscle
Vastus lateralis muscle 6
8
Vastus medialis muscle 7

Figure 84-2. Computed tomography scan of a left anterior thigh sarcoma. Figure 84-3.
646 Section XVI • Soft Tissue/Bone Resection

Main Dissection
◆ Flaps of skin and subcutaneous fat are raised off the fascia of the anterior thigh both medially and
laterally (Fig. 84-4).
◆ The initial aspect of any dissection is becoming anatomically oriented, as these tumors are often large
and can distort normal anatomy. Because most tumors of the anterior thigh are within the general prox-
imity of the femoral vessels, it is important to identify them before beginning the resection of the tumor.
The femoral artery, vein, and nerve are easily identified proximally as they enter the anterior thigh below
the inguinal ligament. More distally in the midthigh, the superficial femoral artery, vein, and saphenous
nerve can be found within the adductor canal underneath the sartorius muscle (Fig. 84-5).
◆ En bloc resection of the tumor is the primary surgical goal, with dissection being performed through
normal adjacent tissue planes. A clamp (tonsil or right angle) and Bovie cautery are used for the dis-
section. Vessels are ligated as necessary with 2-0 or 3-0 silk ties.
◆ Surgical resection should include normal soft tissue adjacent to the tumor. At a minimum, the patho-
logic specimen needs to be free of tumor at the resection margins, and this can be accomplished without
a complete muscle group resection. There is no role for an incomplete resection or “debulking” of a
soft tissue sarcoma.
◆ Tumors of the anterior thigh are often are close to either the superficial or deep (profunda) femoral
vessels. Resection of these structures en bloc with the tumor is usually not necessary. Exposure of the
vessels both proximally and distally allows meticulous dissection to be performed along their length
(Fig. 84-6), and if necessary, the adventitia of the artery and vein can be removed with the tumor.

Biopsy site 1

Figure 84-4.

Figure 84-5.

Rectus femoris
muscle (cut)

1
 Chapter 84 • Anterior Thigh Tumor Resection 647
◆ Resection of neurovascular structures is essentially never done for a primary low-grade tumor. If a
primary high-grade tumor directly involves or arises from a neurovascular structure, then that structure
should be resected en bloc with the sarcoma.
◆ The deep femoral artery can be resected without the need for an arterial reconstruction. Resection of
the superficial femoral artery requires reconstruction with autologous vein or polytetrafluoroethylene.
◆ The deep femoral veins and the saphenous vein can usually be resected without causing severe extrem-
ity swelling. Resection of the superficial femoral vein puts the patient at risk for permanent, severe
venous swelling of the extremity. Unlike the arteries of the thigh, the veins cannot be reconstructed
with any degree of success.
◆ Because the femoral nerve branches to innervate the muscles of the anterior thigh just below the
inguinal ligament, it is rarely directly involved by an anterior thigh tumor. Loss of motor function
following resection of an anterior thigh tumor usually has more to do with the muscular resection than
any neural resection or injury.
◆ Marking sutures are placed on the resected tumor to allow for orientation and appropriate margin
assessment by the pathologist. If the tumor is close to a particular resection margin, additional tissue
at that region of the resection cavity can be sent for pathologic results and an additional margin
assessed. The resection bed is inspected for the integrity of the vessels, and hemostasis is achieved
(Fig. 84-7).

1
Adductor longus muscle

Pectineus muscle
Figure 84-6.
2

3
Sartorius muscle

1
Femoral
artery Femoral
vein
7
2
Sartorius muscle
Rectus
femoris muscle (cut)

3
Figure 84-7.
Pectineus muscle

4 6
Adductor
longus muscle

Gracilis 5
muscle
648 Section XVI • Soft Tissue/Bone Resection

Closure
◆ At least one and often two round 19-Fr Jackson-Pratt drains are placed into the resection cavity. They
are brought through the skin through a separate stab incision and anchored to the skin with a stitch.
◆ Subcutaneous fat and skin are approximated using 2-0 Vicryl, and the skin is closed with staples. After
a gauze dressing has been applied to the incision, the leg is wrapped with two 6-inch Ace wraps, and
a knee immobilizer is placed.

III. ALTERNATIVE TECHNICAL APPROACHES (PRO/CON) AND PEARLS

◆ If an extensive vascular dissection is required, resulting in exposure of the femoral vessels, they should
be covered with additional layer of tissue before the skin closure in the event the wound opens or
becomes infected. Rotation of a sartorius muscular flap is the easiest way to accomplish this coverage.
The sartorius is divided at its origin at the anterior superior iliac spine and rotated in a medial manner
to lie over the femoral vessels. It is then anchored to the inguinal ligament and adductor fascia.
◆ By far the most common anterior thigh tumor is a soft-tissue sarcoma. These are rare, high-risk malig-
nancies that are best managed by an experienced multidisciplinary team of physicians at a sarcoma
center or a cancer center that has expertise in these tumors.
◆ A multidisciplinary team of surgeons is intermittently needed for resection of these lesions, and thor-
ough preoperative planning is therefore critical. Complex reconstruction by plastic surgery, with either
a local rotational flap or a free flap, and vascular reconstructions by vascular surgery are occasionally
required.
◆ The development of locally recurrent disease is a morbid and potentially limb-threatening event that
is associated with decreased survival. The optimal treatment of locally recurrent disease is to prevent
it, which necessitates aggressive and definitive surgery in the setting of the primary disease.

IV. SPECIAL POSTOPERATIVE CARE

◆ While the patient is in bed, the extremity should be elevated.
◆ Patients should have a physical therapy evaluation on postoperative day 1 and are encouraged to
perform touch-down weight bearing with the physical therapist. The Ace wrap and knee immobilizer
placed while in the operating room should be continued for the first several weeks. Significant range
of motion of the knee is thus limited over this time period. Patients are discharged home with either
crutches or a walker depending on their strength and age.
◆ Patients are taught Jackson-Pratt drain care and sent home with the drains in place. The drains are not
removed until the output is less than 20 mL/day. Staples are left in for at least 1 week and often up
to 2 weeks if there are concerns for neoadjuvant radiation therapy or the condition of the wound.
◆ The most common immediate postoperative complications include infection, hematoma, and wound
dehiscence or slough.
◆ The most common delayed complications include seroma and leg edema.

SUGGESTED READINGS

Eilber FC, Brennan MF, Eilber FR, Kattan MF: Validation of the postoperative nomogram for 12-year sarcoma specific death, Cancer
101:2270–2275, 2004.
Eilber FC, Rosen G, Nelson SD, et al: High grade extremity soft tissue sarcomas: factors predictive of local recurrence and its effect on
morbidity and mortality, Ann Surg 237:218–226, 2003.
Eilber FC, Tap WD, Nelson SD, et al: Advances in chemotherapy for patients with extremity soft tissue sarcoma, Orthop Clin North Am
37:15–22, 2006.