Limb-Sparing Resection with Prophylactic Tibial Fixation and Medial Gastrocnemius Flap Reconstruction for Recurrent Leiomyosarcoma in a Previously Irradiated Leg: A Case Report

Abstract

Background and Clinical Significance: Local recurrence of extremity leiomyosarcoma after multiple operations and radiotherapy presents a major therapeutic challenge. Adequate oncologic clearance must be balanced against preservation of skeletal stability and reliable wound coverage within a scarred and poorly vascularized tissue bed; Case presentation: A 78-year-old woman presented with a painful recurrent leiomyosarcoma of the anterior proximal third of the right leg after three previous operations and adjuvant radiotherapy. Preoperative magnetic resonance imaging demonstrated a recurrent soft-tissue lesion extending to the anterior surface of the proximal tibia. Staging computed tomography of the chest, abdomen, and pelvis showed no distant metastatic disease before definitive surgery. A one-stage limb-sparing procedure was performed, including resection of the recurrent tumor bed and an approximately 7-cm anterior cortical lamella of the proximal tibia containing an area considered suspicious for neoplastic involvement. A locking tibial plate was applied prophylactically to reduce the risk of pathological fracture. The approximately 12 × 10-cm soft-tissue defect was covered with a muscle flap from the medial head of the gastrocnemius and a free skin graft harvested from the paraumbilical region. Gross pathological examination identified an 8-cm subcutaneous tumor formation. Histopathological examination demonstrated well-differentiated leiomyosarcoma; the spindle cells expressed vimentin, actin, and desmin. All examined resection lines were free of tumor infiltration. No pathogenic microorganism was isolated, and no early postoperative complication was documented. The patient mobilized with walking aids and protected weight bearing for 30 days. At approximately 16 months, the flap and skin graft provided stable coverage, no postoperative tibial fracture or clinically apparent implant-related complication had occurred, and the patient was independently ambulatory. Postoperative MRI demonstrated expected postoperative changes and a small indeterminate subcutaneous focus without diffusion restriction, requiring continued surveillance; Conclusions: This case illustrates the feasibility of combining oncologic resection, prophylactic tibial stabilization, and vascularized soft-tissue reconstruction in a previously irradiated extremity. The documented early functional and reconstructive outcome supports this individualized limb-sparing approach, although longer oncologic surveillance is required.