Preoperative Planning Using Three-Dimensional Multimodality Imaging for Soft Tissue Sarcoma of the Axilla: A Pilot Study

SIMPLE SUMMARY: Soft tissue sarcoma (STS) of the axilla, with its proximity to vital neurovascular bundles and occasional involvement, is a challenge for surgeons. Conventionally, surgeons need to build the whole tumour model with its adjacent anatomical structures by absorbing necessary information from each separate preoperative 2D and 3D image, which is very experience-demanding and potentially inaccurate. Therefore, a computer-generated 3D tumour model revealing tumour and adjacent key anatomical structures from multimodal images was developed, and we attempted to explore whether this digital model could facilitate surgical planning and outcomes for axillary STS. This study suggested significantly better performance in reducing surgical blood loss, operative time, and length of hospital stay. Considering that the surgeries were performed by two specialists with 15 years of experience, the real-world benefit might be even greater, especially for less-experienced STS surgeons. Therefore, this technology might change how preoperative planning is performed for complex STS in the future. ABSTRACT: Axillary soft tissue sarcoma (STS) is challenging due to its proximity to vital neurovascular bundles. We conducted a prospective observational pilot study to explore whether 3D multimodality imaging (3DMMI) can improve preoperative planning for and surgical outcomes of patients with axillary STS. Twenty-one patients with STS (diameter > 5 cm) of the axilla were allocated, at their discretion, to either a control group undergoing traditional preoperative planning with separate computed tomography angiography, magnetic resonance imaging, and magnetic resonance neurography, or an intervention group where 3DMMI, digitally created based on these images, revealed the tumour and adjacent skeletomuscular and neurovascular structures in three dimensions. Primary outcome measures were surgical margins and surgical complications. Secondary outcomes included operative time, blood loss, serum C-reactive protein and interleukin-6, length of hospital stay, and limb function. The 3DMMI group had a lower, although not significantly different, inadvertent positive margin rate (1/12 vs. 3/9, p = 0.272), a significantly shorter operative time (p = 0.048), reduced blood loss (p = 0.038), and reduced length of hospital stay (p = 0.046). This endorses larger trials to improve complex surgical procedures and study how preoperative planning could be performed in the future.