In Reply

We thank our correspondents for their valuable comments. Both letters re-emphasize the importance of the interplay between clinical diagnostic evaluation and imaging diagnostics of soft-tissue tumors as well as the necessity of multimodal treatment in centers.

Rudert, Holzapfel, and Jakubietz rightly question the rationale behind simultaneous reconstruction, which we perform in our center. We wish to make a differentiation here:

A consecutive approach makes sense for tumor localizations where temporary wound coverage and a mostly uninterrupted work-up of the resection margin are possible−for example, on the scalp, if complex reconstruction with local transposition flaps is planned. In an R1 situation, technically simple repeat resection would not be possible, and the elaborate reconstruction would have to be sacrificed.

Generous resection of the extremities distally to the knees and elbows often results in very large defects with several sensitive structures lying exposed. These can mostly not be vacuum-sealed for the duration of the histopathological work-up of the specimens (the sheer size of the specimens means anyway that genuinely uninterrupted work-up of the resection margin is not actually possible). Simultaneous reconstruction with large flap grafts has proved useful in this setting, but we wish to underline again that radical resections that spare the extremities can often only be done thanks to reconstructive procedures (1). R1 situations at the resection margin are rare in this setting; an R1 situation deeper within the tissue will sometimes have to be treated by lifting the flap and repeated resection—if required, in combination with intraoperative radiotherapy. This does not, however, result in a loss of the reconstruction (2).

Rechl, Röper, and Wörtler point out again that any soft-tissue tumor will have to be regarded as malignant until it has been proved to be benign. They request magnetic resonance imaging for every soft-tissue tumor, as well as asking for treatment at a center. This is unfortunately impracticable.

Small tumors that have been in situ for a long time and are sonographically confirmed to be epifascial (that is, subcutaneous) can be removed (even outside specialist centers) by excision biopsy. If histopathological analysis then confirms a sarcoma, a wide further resection will have to be performed in the context of a multimodal therapeutic approach. For epifascial tumors, repeated resection is mostly unproblematic for surgeons specializing in all oncoplastic options and does not affect the prognosis negatively.

DOI: 10.3238/arztebl.2011.0554

PD Dr. med. Holger Bannasch

Abteilung Plastische und Handchirurgie, Universitätsklinik Freiburg

holger.bannasch@uniklinik-freiburg.de

Conflict of interest statement

All authors declare that no conflict of interest exists.