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Matsuoka M, Onodera T, Yokota I, Iwasaki K, Hishimura R, Suzuki Y, Hamasaki M, Iwata A, Kondo E, Iwasaki N. Amputation surgery associated with shortened survival in patients with localized soft tissue sarcoma. J Orthop Sci 2024; 29:637-645. [PMID: 36931976 DOI: 10.1016/j.jos.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND The objectives of this study were to clarify whether localized extremity soft tissue sarcoma (STS) patients who underwent amputation surgery experienced worsened survival and to identify those patients for whom amputation surgery worsened survival. METHODS Using the Surveillance, Epidemiology, and End Results database, we identified 8897 patients with localized extremity STS between 1983 and 2016. Of these 6431 patients, 733 patients underwent amputation surgery (Amputation group), and 5698 underwent limb-sparing surgery (Limb-sparing group). RESULTS After adjusting for patient background by propensity score matching, a total of 1346 patients were included. Patients in the Amputation group showed worsened survival (cancer-specific survival (CSS): hazard ratio (HR) = 1.42, 95% confidence interval (CI) 1.15-1.75, overall survival (OS): HR = 1.41, 95%CI 1.20-1.65). In subclass analysis, patients with high-grade STS, spindle cell sarcoma and liposarcoma in the Amputation group showed shortened survival (high-grade-CSS: HR = 1.44, 95%CI 1.16-1.77, OS: HR = 1.38, 95%CI 1.18-1.62; spindle cell sarcoma-CSS: HR = 4.75, 95%CI 1.56-14.4, OS: HR = 2.32, 95%CI 1.45-3.70; liposarcoma-CSS: HR = 2.91, 95%CI 1.54-5.50, OS: HR = 2.32, 95%CI 1.45-3.70). CONCLUSIONS Survival was shortened in localized extremity STS patients who received amputation surgery.
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Affiliation(s)
- Masatake Matsuoka
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Koji Iwasaki
- Department of Functional Reconstruction for the Knee Joint, Hokkaido University, Kita-15, Nish-7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Ryosuke Hishimura
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Yuki Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Masanari Hamasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Akira Iwata
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
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Kim Y, Kim HS, Han I. Amputation in patients with extremity soft tissue sarcoma: the experience of an East Asian referral center. BMC Cancer 2024; 24:61. [PMID: 38212719 PMCID: PMC10782674 DOI: 10.1186/s12885-023-11813-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/31/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND This study aimed to investigate the characteristics and clinical outcomes in a series of patients with extremity soft tissue sarcoma (STS) who underwent amputation at a large East Asian referral center. PATIENTS AND METHODS Of the 652 patients who underwent surgery for extremity STS, data of 37 consecutive patients who underwent amputation were reviewed retrospectively. The median follow-up period was 96.0 months (range, 15-216). The patients were classified in to three cohorts. The primary localized (PL) group included patients who underwent amputation as a primary surgical procedure with curative intent. The recurrent localized (RL) group included patients who underwent amputation as a revision procedure after failure of previous limb sparing surgeries. The metastatic group included patients who underwent amputation as a palliative procedure. RESULTS There were 22 cases of amputation in 596 STS patients and the amputation rate was 3.6% (22/596). Further, 1.8% (9/490) of patients with primary localized STS underwent amputation. Patients with localized STS who underwent amputation had a 5-year disease-specific survival (DSS) rate of 89.9% (95% Confidence Interval (CI), 87.1-92.7%), a local-recurrence-free survival (LRFS) of 84.1% (95% CI, 80.5-87.6%), and a metastasis-free survival (MFS) of 84.6%. (95% CI, 81.1-88.0%) Compared with previous studies, our results showed higher DSS and MFS rates with similar LRFS. CONCLUSIONS The amputation rate of extremity STS in our institute in East Asia was similar but slightly lower than that reported in Western studies. The oncologic outcome of amputation reported in this study was higher than that indicated in Western studies and oncologic outcome of amputation was not statistically different from those of limb salvage surgery. However, considering the small cohort in single institute study, there is a possibility of selection bias and future multi-center study is necessary. From our results, amputation is still a feasible option for appropriately selected patients unsuitable for limb-conserving surgery.
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Affiliation(s)
- Yongsung Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno- gu, 03080, Seoul, Korea
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Korea
| | - Han-Soo Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno- gu, 03080, Seoul, Korea
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, 03080, Seoul, Korea
| | - Ilkyu Han
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno- gu, 03080, Seoul, Korea.
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, 03080, Seoul, Korea.
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Sacchetti F, Alsina AC, Muratori F, Scoccianti G, Neri E, Kaya H, Sabah D, Capanna R, Campanacci DA. Tumor size and surgical margins are important prognostic factors of synovial sarcoma - A retrospective study. J Orthop 2023; 42:74-79. [PMID: 37533628 PMCID: PMC10391603 DOI: 10.1016/j.jor.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 08/04/2023] Open
Abstract
Background Synovial Sarcoma (SS) is a rare soft tissue sarcoma. Mean time to get a SS diagnosis from the onset of symptoms is 10 years, furthermore, SS is associated with late metastasis. Surgery is the main treatment option, whose quality deeply affects SS outcomes, and it can be associated to preoperative or post-operative radiotherapy. Chemotherapy is considered very effective in Children, while in adults its efficacy is still under debate. The aim of this study was to investigate the oncologic results in SS treatment and to identify the risk factors for local and systemic control of the disease. Methods From 1994 to 2018, 211 patients affected by SS were treated in 3 Referral Centres of Orthopaedic Oncology. One hundred seventy-seven patients were included in the study, the median follow-up length was 96 months (5-374). Results Overall Survival on the Kaplan Meier Analyses was 80%, 70% and 56% at 5, 10 and 20 years. In multivariate analyses, OS correlated with tumour size and negative surgical margins. Chemotherapy use wasn't associated with better survival although patients who underwent CT had bigger and more aggressive tumours. Conclusions Our findings suggests that surgery with negative margins is the most important factor in Synovial Sarcoma. Adjuvant treatments as chemotherapy and radiation therapy didn't change the disease's course.
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Affiliation(s)
| | - Andac Celasun Alsina
- Ege University, Faculty of Medicine, Department of Orthopedics and Traumatology, Turkey
| | | | | | | | - Huseyin Kaya
- Ege University, Faculty of Medicine, Department of Orthopedics and Traumatology, Turkey
| | - Dundar Sabah
- Ege University, Faculty of Medicine, Department of Orthopedics and Traumatology, Turkey
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Arjunan R, Dharanikota A, Chowdappa R, Althaf S, Dasappa A, Shetty NS. Impact of Level of Surgery on the Functional Outcomes in Patients with Lower Extremity Bone Tumors Undergoing Amputation Versus Limb Salvage Surgery. Indian J Surg Oncol 2022. [DOI: 10.1007/s13193-022-01627-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Hagi T, Nakamura T, Nagano A, Koike H, Yamada K, Aiba H, Fujihara N, Wasa J, Asanuma K, Kozawa E, Ishimura D, Kawanami K, Izubuchi Y, Shido Y, Sudo A, Nishida Y. Clinical outcome in patients who underwent amputation due to extremity soft tissue sarcoma: Tokai Musculoskeletal Oncology Consortium study. Jpn J Clin Oncol 2021; 52:157-162. [PMID: 34875695 DOI: 10.1093/jjco/hyab184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Soft tissue sarcomas are a diverse group of rare malignant tumours, mostly occurring in the lower extremities. Amputations are necessary for achieving local control when the soft tissue sarcomas are too large and/or have neurovascular involvement. Patients who require amputation have a poorer prognosis than those who undergo limb-salvage surgery. PATIENTS AND METHODS We investigated the tumour characteristics and the clinical outcomes in 55 patients with primary soft tissue sarcomas, who underwent amputation. We excluded patients with amputation performed distal to the wrist or ankle joints and those with recurrent soft tissue sarcomas. RESULTS The mean tumour size was 11.1 cm. Hip disarticulation was performed in 6 patients, 20 underwent above the knee amputation, 8 underwent knee disarticulation and 12 underwent below the knee amputation. Shoulder disarticulation was performed in three patients, five underwent above the elbow amputation, and one underwent below the elbow amputation. The 5-year disease-specific survival rate was 52.8%. The 5-year recurrence-free survival rate and 5-year metastasis-free survival rates were 90.1% and 38.5%, respectively. Larger tumour size, age and the distant metastases at first presentation were predictors of poor prognosis for survival in multivariate analysis. Twenty-eight patients could walk using artificial limbs. The level of amputation (above versus below the knee) showed a significant difference in achieving independent gait. CONCLUSION Amputation is a useful treatment option for achieving local control in patients with large soft tissue sarcomas. Patients had an opportunity of walking, especially for those who underwent below the knee amputation.
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Affiliation(s)
- Tomohito Hagi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akihito Nagano
- Department of Orthopaedic Surgery, Gifu University, Gifu, Japan
| | - Hiroshi Koike
- Department of Orthopaedic Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Kenji Yamada
- Department of Orthopaedic Oncology, Okazaki City Hospital, Okazaki, Japan
| | - Hisaki Aiba
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nasa Fujihara
- Division of Orthopaedic Surgery, Aichi Cancer Centre Hospital, Nagoya, Japan
| | - Junji Wasa
- Division of Orthopaedic Oncology, Shizuoka Cancer Centre Hospital, Shizuoka, Japan
| | - Kunihiro Asanuma
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Eiji Kozawa
- Department of Orthopaedic Surgery, Nagoya Memorial Hospital, Nagoya, Japan
| | - Daisuke Ishimura
- Department of Orthopaedic Surgery, Fujita Medical University, Nagoya, Japan
| | - Katsuhisa Kawanami
- Department of Orthopaedic Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yuya Izubuchi
- Department of Orthopaedic Surgery, Fukui University Graduate School of Medicine, Fukui, Japan
| | - Yoji Shido
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yoshihiro Nishida
- Department of Orthopaedic Surgery, Nagoya University Hospital, Nagoya, Japan.,Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
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Hasan O, Nasir M, Jessar M, Hashimi M, An Q, Miller BJ. Is local recurrence in bone and soft tissue sarcomas just a local recurrence or does it impact the overall survival, retrospective cohort from a sarcoma referral center. J Surg Oncol 2021; 124:1536-1543. [PMID: 34472103 DOI: 10.1002/jso.26663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/01/2021] [Accepted: 08/25/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Sarcoma local recurrence (LR) is often associated with metastasis, but it is unclear if LR can be a causal event leading to metastasis. We question if LR is best viewed as an independent oncologic event or as a worrisome harbinger threatening a patient's overall survival. METHODS We identified patients with LR and/or metastasis from an ongoing cohort of 629 patients with primary sarcoma and performed a detailed review to assess the timing of metastasis resulting in the following groups: (1) Isolated LR, (2) LR before metastasis, (3) LR within 6 months of metastasis, (4) LR 6-12 months after metastasis, (5) LR >12 months after metastasis, and (6) metastasis at diagnosis. RESULTS Overall, 43 patients met the inclusion criteria with an LR rate of 7%. Ten patients (2% of the entire cohort, 23% of LR) developed an LR before or within 6 months of metastasis. For patients without systemic disease preceding LR, 3 of 23 soft tissue sarcoma STS (13%) and 7 of 10 bone sarcoma (70%) subsequently developed metastasis (p < 0.01). CONCLUSION LR with subsequent metastasis is a rare event. LR appears to be best viewed as a marker of tumor aggressiveness rather than the cause of metastasis and poor survival. LR in bone sarcoma patients should warn providers of a high risk of imminent metastasis.
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Affiliation(s)
- Obada Hasan
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Momin Nasir
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Muneeba Jessar
- Chandka Medical College Teaching Hospital, Larkana, Pakistan
| | - Mustafa Hashimi
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Qiang An
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Benjamin J Miller
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
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Hız M, Karaismailoglu B, Ulutas S, Camurdan VB, Gorgun B, Oner Dincbas F. The effect of preoperative radiotherapy on local control and prognosis in high-grade non-metastatic intramedullary osteosarcoma of the extremities. Arch Orthop Trauma Surg 2021; 141:1083-1089. [PMID: 32506177 DOI: 10.1007/s00402-020-03494-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/31/2020] [Indexed: 01/25/2023]
Abstract
INTRODUCTION This study aimed to analyse the effect of preoperative radiotherapy on survival, recurrence and necrosis rates in osteosarcoma patients treated with neoadjuvant chemotherapy and limb-salvage surgery. MATERIALS AND METHODS Osteosarcoma patients who referred to our clinic from 1998 to 2015 were investigated retrospectively. 141 patients with non-metastatic osteosarcoma of the limb who received neoadjuvant chemotherapy and underwent limb-sparing surgery with or without preoperative radiotherapy were included in the study. 73 patients had neoadjuvant chemotherapy only (CT group), while 68 patients had additional preoperative radiotherapy (CT + RT group). 5-year survival, disease-free survival, limb survival, local recurrence, metastasis, complication and necrosis rates were compared between the two groups. RESULTS Overall 5-year survival, 5-year disease-free survival, 5-year limb survival rates were 68.5, 64.3, 65.7 for CT group and 72.1, 67.6, 64.7 for CT + RT group, respectively. Preoperative radiotherapy gave similar survival and disease-free survival rates. Limb survival, recurrence and metastasis rates were similar between the groups. The necrosis rate of the lesions was significantly higher in the CT + RT group compared to the CT group. CONCLUSION Preoperative radiotherapy can provide a higher necrosis rate and may allow the resection of unresectable lesions in the treatment of osteosarcoma. CT + RT provided similar 5-year survival despite the larger tumour size compared to CT group. Due to the higher wound complication rate (8.2% in CT, 23.5% in CT + RT group, p = 0.01), CT + RT should be restricted to the lesions with large size or close proximity to neurovascular structures. LEVEL OF EVIDENCE Level III; Therapeutic, Retrospective comparative study.
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Affiliation(s)
- Murat Hız
- Cerrahpasa Medical Faculty, Department of Orthopaedics and Traumatology, Istanbul University-Cerrahpasa, Istanbul, 34093, Turkey
| | - Bedri Karaismailoglu
- Cerrahpasa Medical Faculty, Department of Orthopaedics and Traumatology, Istanbul University-Cerrahpasa, Istanbul, 34093, Turkey.
| | - Suat Ulutas
- Cerrahpasa Medical Faculty, Department of Orthopaedics and Traumatology, Istanbul University-Cerrahpasa, Istanbul, 34093, Turkey
| | - Vedat Burkay Camurdan
- Cerrahpasa Medical Faculty, Department of Orthopaedics and Traumatology, Istanbul University-Cerrahpasa, Istanbul, 34093, Turkey
| | | | - Fazilet Oner Dincbas
- Cerrahpasa Medical Faculty, Department of Radiation Oncology, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Baysal Ö, Toprak CŞ, Günar B, Erol B. Soft tissue sarcoma of the upper extremity: oncological and functional results after surgery. J Hand Surg Eur Vol 2021; 46:659-664. [PMID: 33641492 DOI: 10.1177/1753193421998252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This retrospective study evaluates outcomes after treatment of upper-extremity soft tissue sarcoma in 44 patients. We re-resected 19 tumours that had been resected elsewhere without adequate preoperative planning, and we made 25 well-planned primary resections. Four patients in the unplanned group and five in the planned group eventually received amputations. Thirty-three patients were alive at a median follow-up time of 33 months (IQR 18 to 57). Tumour size > 7 cm, tumour Grade 3 and the presence of distant organ metastases were the main factors affecting the oncological outcomes. We found no statistical differences between the planning groups. Functional outcomes and quality of life were significantly worse after amputation or major nerve resections. We conclude with this sized sample that the lack of planning in itself did not influence the final results, but there were differences in tumour size, grade and localization between the groups that may play a role.Level of evidence: IV.
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Affiliation(s)
- Özgür Baysal
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Canan Şanal Toprak
- Department of Physical Therapy and Rehabilitation, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Berkin Günar
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Bülent Erol
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
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Sacchetti F, Alsina AC, Morganti R, Innocenti M, Andreani L, Muratori F, Scoccianti G, Totti F, Campanacci DA, Capanna R. Re-excision after unplanned excision of soft tissue sarcoma: A systematic review and metanalysis. The rationale of systematic re-excision. J Orthop 2021; 25:244-251. [PMID: 34099954 PMCID: PMC8165293 DOI: 10.1016/j.jor.2021.05.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/09/2021] [Indexed: 01/14/2023] Open
Abstract
In Soft Tissue Sarcomas (STS) referral centre many patients have already had an incomplete tumour resection. In the majority of specimen, tumoral residual is detected and linked to a worsen prognosis. Systematic surgical re-resection of the scar tissue area is often performed. Some authors suggested to postpone re-resections until a clinically evident local recurrence is detected. A searching strategy was applied to Pubmed-Central and Ovid Medline. Odds ratio (OR) for local recurrence (LR), distant metastasis (MTS) or overall survival (OS) were calculated comparing patients who had tumour residual to people who hadn't. OR of local recurrences, distant metastasis and OS were calculated in planned vs unplanned-excisions groups. OR to develop a metastasis and OS after a local recurrences were calculated. Residual tumour led to an OR for LR of 3,56, OR of MTS was 3,42; OR of decreased OS was 3,42. Having a LR lead to a OR of 1,55 for MTS and to a OR of decreased OS of 2,32. Patients who underwent a re-excision compared to planned surgery did not have an increased OR of LR and had an OR to develop a MTS of 0,56. Our data confirm that there is a strong correlation between local recurrences, distant relapses and overall survival. Although there is a selection bias; this analysis highlights the optimal oncological outcome in patients who underwent re-resection. The rationale for systematic re-resection after unplanned excision of soft tissue sarcomas is very strong and this treatment remains the gold standard of care in these patients.
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Affiliation(s)
| | | | - Riccardo Morganti
- Department of Statistics for Clinical Study, University Hospital of Cisanello, Pisa, Italy
| | - Matteo Innocenti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Lorenzo Andreani
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Italy
| | - Francesco Muratori
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Guido Scoccianti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Francesca Totti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Domenico Andrea Campanacci
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Rodolfo Capanna
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Italy
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Farzaliyev F, Touma A, Taeger G, Steinau HU, Hardes J, Streitbürger A, Podleska LE. Efficacy of hyperthermic isolated limb perfusion in the treatment of locally recurrent high-grade soft tissue sarcoma of the extremities. World J Surg Oncol 2020; 18:332. [PMID: 33349267 PMCID: PMC7754588 DOI: 10.1186/s12957-020-02110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/08/2020] [Indexed: 11/23/2022] Open
Abstract
Background This novel study compared the use of tumor necrosis factor (TNF)-alpha and melphalan-based isolated limb perfusion (TM-ILP) to the standard treatment of locally recurrent soft tissue extremity sarcoma. The aim was to assess whether TM-ILP positively influences the recurrence-free survival of locally recurrent high-grade soft tissue sarcoma (STS) of the extremities. Methods We retrospectively analyzed our clinical database for patients with STS. Variables were analyzed using chi-square test or Mann-Whitney rank-sum test. Furthermore, Kaplan-Meier survival plots were calculated and a proportional hazard regression model was developed. Results Out of 448 patients with extraabdominal STS treated between August 2012 and December 2015, 52 cases involving 47 patients had locally recurrent STS. Twenty-eight of these patients were treated with TM-ILP prior to surgical resection (TM-ILP-group), and 24 were treated with standard therapy (without TM-ILP). The 3-year recurrence-free survival for the TM-ILP-group was estimated at 75% (95% confidence interval (CI), 71.5–78.5). Local recurrence-free survival in the standard group was significantly lower (LRFS: 43.4%, 95% CI 38.7–48.1, p = 0.026). Multivariable analysis revealed resection with negative margins, lower number of previous recurrences, and TM-ILP as positive predictors for recurrence-free survival. Conclusions TM-ILP and consecutive resection of residual tumor with negative resection margins significantly improves local recurrence-free survival for patients with a first local recurrence of high-grade STS in the extremities.
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Affiliation(s)
- Farhad Farzaliyev
- Department of General, Visceral and Transplantation Surgery, Division of Plastic and Reconstructive Surgery, University Hospital Essen, University Essen-Duisburg, Hufelandstr.55, 45147, Essen, Germany.
| | - Alexander Touma
- Department of General, Visceral and Transplantation Surgery, Division of Plastic and Reconstructive Surgery, University Hospital Essen, University Essen-Duisburg, Hufelandstr.55, 45147, Essen, Germany
| | - Georg Taeger
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
| | - Hans-Ulrich Steinau
- Department of General, Visceral and Transplantation Surgery, Division of Plastic and Reconstructive Surgery, University Hospital Essen, University Essen-Duisburg, Hufelandstr.55, 45147, Essen, Germany
| | - Jendrik Hardes
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
| | - Arne Streitbürger
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
| | - Lars Erik Podleska
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
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Dilday JC, Nelson DW, Fischer TD, Goldfarb M. Disparities in Amputation Rates for Non-metastatic Extremity Soft Tissue Sarcomas and the Impact on Survival. Ann Surg Oncol 2020; 28:576-584. [PMID: 32409968 DOI: 10.1245/s10434-020-08586-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are no definitive recommendations guiding amputation use in extremity soft tissue sarcomas (STSs). This study explores disparities in amputation rates and survival in patients with non-metastatic adult-type extremity STSs. METHODS Patients with non-metastatic adult-type extremity STSs were identified from the 1998-2012 National Cancer Database. Factors affecting amputation were examined across all ages and separately in adults (> 40 years), adolescent/young adults (AYA: ages 15-39), and children (age < 15). Impact on 10-year overall survival (OS) was explored. RESULTS Of 15,886 patients, 4.65% had an amputation. AYAs had the most amputations (6.4%) compared to children (5.9%) and adults (4.2%) (p < 0.001). Patients with public insurance (OR 1.3, CI 1.08-1.58) and from central states (OR 1.5, CI 1.2-1.86) were more likely to undergo amputation, whereas those from high income brackets (OR 0.8, CI 0.62-0.94) and treated at community cancer centers were less likely (OR 0.7, CI 0.62-0.90). Amputation was an independent risk factor for death at 10 years, with the greatest impact in AYAs compared to older adults (HR 1.7, p < 0.001). Treatment in eastern or central states, lower income, lack of private insurance, and comorbidities were all associated with decreased OS (all p < 0.05). Female gender (HR 0.8, CI 0.78-0.89) and high-volume centers (HR 0.8, CI 0.74-0.94) were associated with improved OS. CONCLUSIONS Although amputations for extremity STSs are rare, disparities exist across age groups, insurance and geography when it comes to the use of amputation in patients with extremity STSs. Moreover, having an amputation is an independent risk factor for death, with the greatest impact in AYAs.
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Affiliation(s)
- Joshua C Dilday
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Trevan D Fischer
- Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Melanie Goldfarb
- Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA. .,Center for Endocrine Tumors and Disorders, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA.
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12
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Gamboa AC, Gronchi A, Cardona K. Soft-tissue sarcoma in adults: An update on the current state of histiotype-specific management in an era of personalized medicine. CA Cancer J Clin 2020; 70:200-229. [PMID: 32275330 DOI: 10.3322/caac.21605] [Citation(s) in RCA: 262] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 12/13/2022] Open
Abstract
Soft-tissue sarcomas (STS) are rare tumors that account for 1% of all adult malignancies, with over 100 different histologic subtypes occurring predominately in the trunk, extremity, and retroperitoneum. This low incidence is further complicated by their variable presentation, behavior, and long-term outcomes, which emphasize the importance of centralized care in specialized centers with a multidisciplinary team approach. In the last decade, there has been an effort to improve the quality of care for patients with STS based on anatomic site and histology, and multiple ongoing clinical trials are focusing on tailoring therapy to histologic subtype. This report summarizes the latest evidence guiding the histiotype-specific management of extremity/truncal and retroperitoneal STS with regard to surgery, radiation, and chemotherapy.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University Hospital Midtown, Atlanta, Georgia
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13
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Aiba H, Yamada S, Mizutani J, Yamamoto N, Okamoto H, Hayashi K, Takeuchi A, Miwa S, Higuchi T, Abe K, Taniguchi Y, Tsuchiya H, Otsuka T. Efficacy of radio-hyperthermo-chemotherapy as salvage therapy for recurrent or residual malignant soft tissue tumors. Int J Hyperthermia 2018; 35:658-666. [PMID: 30295115 DOI: 10.1080/02656736.2018.1518545] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Recurrence after wide excision or residual tumor after an unplanned excision of a malignant soft tissue sarcoma (STS) is a complex problem, due to a higher recurrence rate and poorer survival rate compared with primary resection. Regional hyperthermia was used, with the expectation that it will enhance the anti-tumor effects of chemotherapy and radiotherapy. This study aimed to assess the efficacy of neoadjuvant concomitant radiotherapy, hyperthermia, and chemotherapy (RHC) for salvage of recurrent or residual malignant STS. METHODS We identified 64 patients with recurrent or residual STS treated between 1994 and 2013. After excluding those with low-grade malignancy, with recurrent bone tumor in the soft tissues, with truncal STS, and who declined to participate, 23 patients (7 with recurrence and 16 with residual tumor) underwent RHC. The histologic diagnoses were undifferentiated pleomorphic sarcoma (n = 11), synovial sarcoma (n = 3), leiomyosarcoma and myxoid liposarcoma (n = 2 each), and other histologic types. As primary outcomes, the 5-year overall survival (OS), distant metastasis-free survival (D-MFS), and local control (LC) rates were evaluated by Kaplan-Meier analysis. RESULTS The median follow-up period was 112.3 months. The 5-year OS, D-MFS, and LC were 86.4%, 77.4%, and 86.7%, respectively. In the univariate analysis, tumor depth was considered as a negative prognostic factor for OS and D-MFS, and a positive margin was also a negative prognostic factor for OS, D-MFS LC with retained on Cox proportional hazards model in OS, and D-MFS. CONCLUSION RHC is an effective option for salvage treatment of recurrent and residual STS.
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Affiliation(s)
- Hisaki Aiba
- a Department of Orthopaedic Surgery , Nagoya City University Graduate School of Medical Sciences , Nagoya , Japan.,b Department of Orthopaedic Surgery , Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
| | - Satoshi Yamada
- a Department of Orthopaedic Surgery , Nagoya City University Graduate School of Medical Sciences , Nagoya , Japan
| | - Jun Mizutani
- a Department of Orthopaedic Surgery , Nagoya City University Graduate School of Medical Sciences , Nagoya , Japan
| | - Norio Yamamoto
- b Department of Orthopaedic Surgery , Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
| | - Hideki Okamoto
- a Department of Orthopaedic Surgery , Nagoya City University Graduate School of Medical Sciences , Nagoya , Japan
| | - Katsuhiro Hayashi
- b Department of Orthopaedic Surgery , Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
| | - Akihiko Takeuchi
- b Department of Orthopaedic Surgery , Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
| | - Shinji Miwa
- a Department of Orthopaedic Surgery , Nagoya City University Graduate School of Medical Sciences , Nagoya , Japan.,b Department of Orthopaedic Surgery , Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
| | - Takashi Higuchi
- b Department of Orthopaedic Surgery , Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
| | - Kensaku Abe
- b Department of Orthopaedic Surgery , Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
| | - Yuta Taniguchi
- b Department of Orthopaedic Surgery , Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
| | - Hiroyuki Tsuchiya
- b Department of Orthopaedic Surgery , Graduate School of Medical Science, Kanazawa University , Kanazawa , Japan
| | - Takanobu Otsuka
- a Department of Orthopaedic Surgery , Nagoya City University Graduate School of Medical Sciences , Nagoya , Japan
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What Is the Success of Repeat Surgical Treatment of a Local Recurrence After Initial Wide Resection of Soft Tissue Sarcomas? Clin Orthop Relat Res 2018; 476:1791-1800. [PMID: 30794216 PMCID: PMC6259807 DOI: 10.1007/s11999.0000000000000158] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment for patients with locally recurrent soft tissue sarcomas after wide resection is challenging, and few studies have examined the results of treating these patients. In treatment of recurrent tumors, it has been reported that positive margins are correlated to local rerecurrence, but the relationship between surgical margin and survival remains controversial and risk factors for local recurrences after wide resection of soft tissue sarcomas are not well established. This study examined clinical outcomes and factors associated with survival and local rerecurrence in patients with local recurrence after initial surgical treatment who underwent another resection with a goal of negative margins. QUESTIONS/PURPOSES The purpose of this study was to determine (1) oncologic outcomes (survival rates and local rerecurrence-free rates) of surgical treatment for patients with local recurrence after wide resection; (2) whether factors associated with survival and local rerecurrence-free rates can be determined; and (3) the proportion of patients treated by amputation at final followup. METHODS Between 1992 and 2013, we treated 530 patients with soft tissue sarcoma without metastasis. Of those, 26 (5%) were lost before 3 years of followup but were not known to have died. Of the remainder, 59 have had a local recurrence. Of those with a local recurrence, 34 (58%) were treated with wide resection, whereas 25 (42%) were treated with nonsurgical treatment including chemotherapy and radiotherapy. During that period, our general indications for wide resection were patients (1) without distant metastasis; or (2) without distant lymph node metastasis, and contraindications were distant organ metastasis and/or distant lymph node metastasis. Of those treated with wide resection, 30 (88%) were available for followup. We conducted a retrospective analysis of these 30 patients with local recurrence (17 men, 13 women) who had previously undergone wide resection. Patient followup ranged from 1 to 12 years (median, 5 years). Survivorship (including overall survival and survival free from repeat recurrence) was ascertained by the Kaplan-Meier method. Factors associated with survival were evaluated by the log-rank test. Amputations were performed when limb-sparing surgery was deemed unsuitable because of extensive involvement of the limb by tumor, including invasion of multiple muscle compartments and neurovascular components. Survivorship free from amputation was ascertained by the Kaplan-Meier method. RESULTS Overall 5- and 10-year Kaplan-Meier survival rates after resection were 70% (95% confidence interval [CI], 50%-91%) and 44% (95% CI, 12%-76%), respectively, and 12 patients (40%) developed distant metastases after the second operation. Ten patients (33%) had additional local recurrences, and overall 5- and 10-year local rerecurrence-free rates were 66% (95% CI, 48%-85%) and 50% (95% CI, 18%-81%), respectively. A positive margin was associated with further recurrence (5-year local rerecurrence-free rates of positive margin: 20% [95% CI, 0%-52%], negative margin: 89% [95% CI, 74%-100%], p < 0.01) and with survival (5-year survival rates of positive margin: 36% [95% CI, 0%-75%], negative margin: 91% [95% CI, 74%-100%], p < 0.01). The survival rate was lower in patients with recurrence developing after 2 years (5-year survival rates of within 2 years: 46% [95% CI, 2%-90%], after 2 years: 83% [95% CI, 62%-100%], p = 0.01). The overall 5- and 10-year amputation-free rates were 86% (95% CI, 74%-99%) and 81% (95% CI, 67%-96%), respectively. CONCLUSIONS A surgical procedure with negative margins appears to be important for reducing the likelihood of local recurrences and improving survival of patients with rerecurrence after wide resection of soft tissue sarcomas. Although these findings need to be confirmed in larger studies, it appears that when tumor recurrence is evident within 2 years from the primary surgery, it is associated with a poor prognosis. Local recurrence within 2 years after wide resection may also be an indicator of aggressive tumor biology. LEVEL OF EVIDENCE Level IV, therapeutic study.
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15
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Harati K, Lehnhardt M. The changing paradigm of resection margins in sarcoma resection. Innov Surg Sci 2017; 2:165-170. [PMID: 31579750 PMCID: PMC6754025 DOI: 10.1515/iss-2017-0043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 11/15/2022] Open
Abstract
Soft tissue sarcomas (STS) are a heterogeneous group of rare mesenchymal tumors that account for approximately 1% of all adult malignancies. They can arise throughout the body due to their mesenchymal origin, although 60% of all STS occur in the extremities. Locally advanced STS can lead to significant functional morbidity and tend to local recurrences despite surgical resection. About 30% of all STS patients develop distant metastases with a median overall survival of less than 15 months. The treatment of choice in patients with localized disease is still surgical resection with negative margins. However, there has been a paradigm shift in the last few decades. Large retrospective analyses could not establish a strong association between radical resections and improved local control or survival. Previous radical concepts in STS surgery have been gradually replaced by more moderate approaches with function- and limb-sparing resections combined with radiotherapy. Here, the margin status appears to be of prognostic significance. However, several large retrospective analyses have presented inconsistent results, questioning the independent prognostic impact of surgical margins. This article reviews the literature critically, focusing on the changing role of surgical margins in STS surgery.
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Affiliation(s)
- Kamran Harati
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, Bochum, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, Bochum, Germany
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16
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Erstad DJ, Ready J, Abraham J, Ferrone ML, Bertagnolli MM, Baldini EH, Raut CP. Amputation for Extremity Sarcoma: Contemporary Indications and Outcomes. Ann Surg Oncol 2017; 25:394-403. [PMID: 29168103 DOI: 10.1245/s10434-017-6240-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Amputation for localized extremity sarcoma (ES), once the primary therapy, is now rarely performed. We reviewed our experience to determine why patients with sarcoma still undergo immediate or delayed amputation, identify differences based on amputation timing, and evaluate outcomes. METHODS Records of patients with primary, nonmetastatic ES who underwent amputation at our institution from 2001 to 2011 were reviewed. Univariate analysis was performed, and survival outcomes were calculated. RESULTS We categorized 54 patients into three cohorts: primary amputation (A1, n = 18, 33%), secondary amputation after prior limb-sparing surgery (A2, n = 22, 41%), and hand and foot sarcomas (HF, n = 14, 26%). Median age at amputation was 54 years (range 18-88 years). Common indications for amputation (> 40%) were loss of function, bone involvement, multiple compartment involvement, and large tumor size (A1); proximal location, joint involvement, neurovascular compromise, multiple compartment involvement, multifocal or fungating tumor, loss of function, and large tumor size (A2); and joint involvement and prior unplanned surgery (HF). There was no difference in disease-specific survival (DSS) (p = 0.19) or metastasis-free survival (MFS) (p = 0.31) between early (A1) and delayed (A2) amputation. Compared with cohorts A1/A2, HF patients had longer overall survival (OS) (p = 0.04). CONCLUSIONS Indications for amputation for extremity sarcoma vary between those who undergo primary amputation, delayed amputation, and amputation for hand or foot sarcoma. Amputations chosen judiciously are associated with excellent disease control and survival. For patients who ultimately need amputation, timing (early vs. delayed) does not affect survival.
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Affiliation(s)
- Derek J Erstad
- Department of Surgery, Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA. .,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - John Ready
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - John Abraham
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marco L Ferrone
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Monica M Bertagnolli
- Department of Surgery, Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA.,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Elizabeth H Baldini
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA
| | - Chandrajit P Raut
- Department of Surgery, Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA.,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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17
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Stevenson MG, Musters AH, Geertzen JH, van Leeuwen BL, Hoekstra HJ, Been LB. Amputations for extremity soft tissue sarcoma in an era of limb salvage treatment: Local control and survival. J Surg Oncol 2017; 117:434-442. [DOI: 10.1002/jso.24881] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 09/18/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Marc G. Stevenson
- Department of Surgical Oncology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Annelie H. Musters
- Department of Surgical Oncology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Jan H.B. Geertzen
- Department of Rehabilitation Medicine; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Barbara L. van Leeuwen
- Department of Surgical Oncology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Harald J. Hoekstra
- Department of Surgical Oncology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
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18
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Xu L, Li X, Wang Z, Xiong J, Wang S. Functional evaluation for patients with lower extremity sarcoma: application of the Chinese version of Musculoskeletal Tumor Society scoring system. Health Qual Life Outcomes 2017; 15:107. [PMID: 28526051 PMCID: PMC5438502 DOI: 10.1186/s12955-017-0685-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/15/2017] [Indexed: 02/07/2023] Open
Abstract
Background The Musculoskeletal Tumor Society (MSTS) scoring system is a disease-specific instrument to determine the physical and mental health for patients with extremity sarcoma. This study aims to investigate the reliability and validity of the Chinese version of the MSTS, and to evaluate functional outcomes of the surgical treatment of lower extremity sarcoma using the Chinese MSTS. Methods A cohort of 98 patients who had undergone surgery for lower extremity sarcoma were included. All the patients completed the clinical assessment with the Chinese MSTS and the Chinese Toronto Extremity Salvage Score (TESS). Assessment of psychometric properties was carried out through reliability and validity test. The reliability of Chinese MSTS was evaluated through test-retest analysis, inter-observer analysis and internal consistency. The inter-observer and test-retest reliability was analyzed with intra-class correlation coefficient (ICC). The internal consistency was evaluated by Cronbach’s α, with a value >0.70 considered acceptable. The discriminant validity was evaluated through comparison of the MSTS score between patients undergoing amputation surgeries and those undergoing limb-salvage surgeries. The construct validity was evaluated with the factor analysis. Results The mean MSTS score was 21.5 ± 7.1. The ICC was 0.91 (95% confidence interval (CI) = 0.85–0.96) for the test-retest reliability and 0.90 (95% CI = 0.86–0.93) for the inter-observer analysis. The test for internal consistency showed a Cronbach’s α of 0.86 for the MSTS. Patients undergoing amputation surgery had remarkably lower MSTS score than patients undergoing limb-salvage surgeries (18.8 ± 5.4 vs. 23.5 ± 6.3, p = 0.005), which indicated a good discrinimant validity of the Chinese MSTS. The factor analysis indicated a 1-factor model with acceptable goodness of fit. Conclusions The Chinese MSTS scoring system is a reliable and valid instrument with well-accepted psychometric properties. Through application of the Chinese MSTS, we demonstrated that patients receiving limb-salvage surgeries may have better functional outcome and QoL than those undergoing amputation surgeries. Electronic supplementary material The online version of this article (doi:10.1186/s12955-017-0685-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leilei Xu
- Department of Orthopedic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Xinhua Li
- Department of Orthopedic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Zhou Wang
- Department of Orthopedic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Jin Xiong
- Department of Orthopedic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Shoufeng Wang
- Department of Orthopedic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
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Abstract
Most of tumours of the foot are tumour-like (synovial cyst, foreign body reactions and epidermal inclusion cyst) or benign conditions (tenosynovial giant cells tumours, planta fibromatosis). Malignant tumours of the soft-tissue and skeleton are very rare in the foot and their diagnosis is often delayed with referral to specialised teams after initial inappropriate procedures or unplanned excisions. The adverse effect of these misdiagnosed tumours is the increasing rate of amputation or local recurrences in the involved patients. In every lump, imaging should be discussed before any local treatment. Every lesion which is not an obvious synovial cyst or plantar fibromatosis should have a biopsy performed. After the age of 40 years, chondrosarcoma is the most usual malignant tumour of the foot. In young patients bone tumours such as osteosarcoma or Ewing’s sarcoma, are very unusually located in the foot. Synovial sarcoma is the most frequent histological diagnosis in soft tissues. Epithelioid sarcoma or clear cell sarcoma, involve more frequently the foot and ankle than other sites. The classic local treatment of malignant conditions of the foot and ankle was below-knee amputation at different levels. Nowadays, with the development of adjuvant therapies, some patients may benefit from conservative surgery or partial amputation after multidisciplinary team discussions. The prognosis of foot malignancy is not different from that at other locations, except perhaps in chondrosarcoma, which seems to be less aggressive in the foot. The anatomy of the foot is very complex with many bony and soft tissue structures in a relatively small space making large resections and conservative treatments difficult to achieve.
Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160078. Originally published online at www.efortopenreviews.org
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Affiliation(s)
- E Mascard
- Necker University Hospital, 75015 Paris, France
| | - N Gaspar
- Department of Pediatrics, Institute Gustave Roussy, 94805 Villejuif, France
| | - L Brugières
- Department of Pediatrics, Institute Gustave Roussy, 94805 Villejuif, France
| | - C Glorion
- Orthopedic Surgery Department, Necker University Hospital, 149 rue de Sèvres, 75015 Paris, France
| | - S Pannier
- Orthopedic Surgery Department, Necker University Hospital, 149 rue de Sèvres, 75015 Paris, France
| | - A Gomez-Brouchet
- Laboratoire d'anatomie et cytologie pathologiques, Institut Universitaire du Cancer de Toulouse- Oncopole, 1 avenue Irène Joliot-Curie. 31059 Toulouse Cedex 9, France
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20
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Katz SC. Tailoring Surgical Therapy for Extremity Soft Tissue Sarcoma. Ann Surg Oncol 2016; 24:13-14. [DOI: 10.1245/s10434-016-5468-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Indexed: 11/18/2022]
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Ring A, Kirchhoff P, Goertz O, Behr B, Daigeler A, Lehnhardt M, Harati K. Reconstruction of Soft-Tissue Defects at the Foot and Ankle after Oncological Resection. Front Surg 2016; 3:15. [PMID: 27014697 PMCID: PMC4781863 DOI: 10.3389/fsurg.2016.00015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 02/24/2016] [Indexed: 01/12/2023] Open
Abstract
Introduction Solid malignancies at the foot and ankle region are rare and include mainly soft-tissue sarcomas, bone sarcomas, and skin malignancies. Complete surgical resection with clear margins still remains the mainstay of therapy in these malignancies. However, attainment of negative surgical margins in patients with locally advanced tumors of the foot and ankle region may require extensive surgery and could result in loss of extremity function. In these circumstances, plastic surgical techniques can frequently reduce functional impairment and cover soft-tissue defects, particularly in cases of large tumor size or localization adjacent to critical anatomic structures, thereby improving the quality of life for these patients. The aim of this article is to illustrate the various treatment options of plastic surgery in the multimodal therapy of patients with malignant tumors of the foot and ankle region. Materials and methods This article is based on the review of the current literature and the evaluation of the author’s own patient database. Results The local treatment of malignant extremity tumors has undergone major changes over the last few decades. Primary amputations have been increasingly replaced by limb-sparing techniques, preserving extremity function as much as possible. Although defect coverage at the foot and ankle region is demanding due to complex anatomical features and functional requirements, several plastic surgical treatment options can be implemented in the curative treatment of patients with malignant solid tumors in this area. Soft-tissue defects after tumor resection can be covered by a variety of local flaps. If local flaps are not applicable, free flap transfers, such as the anterolateral thigh flap, parascapular flap, or latissimus dorsi flap, can be utilized to cover nearly all kinds of defects in the foot and ankle region. Conclusion Soft-tissue reconstruction in the foot and ankle region is a vital component of limb-sparing surgery. It enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. Modern plastic surgical techniques should, therefore, be integrated in the multimodal treatment concept of malignancies in the foot and ankle region.
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Affiliation(s)
- Andrej Ring
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Pascal Kirchhoff
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Ole Goertz
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Bjorn Behr
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Adrien Daigeler
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Marcus Lehnhardt
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
| | - Kamran Harati
- Department for Plastic and Hand Surgery, Burn Center/Sarcoma Reference Center, Ruhr-University Bochum , Bochum , Germany
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22
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Surgical procedures and prognostic factors for local recurrence of soft tissue sarcomas. J Orthop Sci 2014; 19:141-9. [PMID: 24081391 DOI: 10.1007/s00776-013-0469-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 08/28/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients with local recurrence of soft tissue sarcomas are predisposed to future recurrences because treatment is challenging and complicated by prior therapy. This study investigated clinical outcomes following surgical procedures for locally recurrent soft tissue sarcomas and risk factors for re-recurrence and metastasis. METHODS A retrospective analysis was conducted with 105 patients (52 males, 53 females) who underwent surgical procedures for local recurrence without distant metastasis of soft tissue sarcoma between 1987 and 2009. Patient follow-up ranged from 1 to 12 years (mean 4.9 years). RESULTS Overall 5- and 10-year survival rates were 83.4 and 67.7%, respectively. Twenty-one patients (20.0%) had additional local recurrences, and 23 (21.9%) had distant metastases. Amputation rate was 10.5% at the time of surgical procedures and 17.1% at final follow-up. Locations deep within muscles in the upper limb or trunk and surgical margins <1 cm wide were risk factors for further local recurrence. Locations deep within muscles, tumor sizes >10 cm, high-grade malignancy, and local recurrence after radical surgery were risk factors for distant metastasis. CONCLUSIONS Surgical margin and location were independent prognostic factors for local control, and a wider margin was especially important for recurrent tumors located in the trunk and upper extremity. For high-grade sarcomas with local recurrence after radical surgery, new approaches are needed to prevent distant metastases.
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Alamanda V, Crosby S, Archer K, Song Y, Schwartz H, Holt G. Amputation for extremity soft tissue sarcoma does not increase overall survival: A retrospective cohort study. Eur J Surg Oncol 2012; 38:1178-83. [DOI: 10.1016/j.ejso.2012.08.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 08/23/2012] [Indexed: 01/22/2023] Open
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Sugahara S, Kamada T, Imai R, Tsuji H, Kameda N, Okada T, Tsujii H, Tatezaki S. Carbon ion radiotherapy for localized primary sarcoma of the extremities: results of a phase I/II trial. Radiother Oncol 2012; 105:226-31. [PMID: 23068710 DOI: 10.1016/j.radonc.2012.09.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 08/29/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To determine the effectiveness of carbon ion radiotherapy (CIRT) for localized primary sarcomas of the extremities in a prospective study. PATIENTS AND MATERIALS From April 2000 to May 2010, 17 (male/female: 12/5) patients with localized primary sarcoma of the extremities received CIRT. The median age was 53 years (range: 14-87 years). Nine patients had primary diseases and eight had recurrent diseases. Of the 17 patients, eight refused amputation, and the remaining nine refused surgical resection. Tumors were located in the upper limbs in four patients and lower limbs in 13. Histological diagnosis was osteosarcoma in three patients, liposarcoma in two, synovial sarcoma in two, rhabdomyosarcoma in two, pleomorphic sarcoma in two, and miscellaneous in six. The CIRT dose to the limb was 52.8 GyE for one patient, 64 GyE for three, 70.4 GyE for 13 in 16 fixed fractions over 4 weeks. Records were reviewed and outcomes including radiologic response, local control (progression-free), and survival were analyzed. RESULTS The median follow-up was 37 months (range: 11-97 months). Radiological response rate was 65% (PR in 11, SD in 5, and PD in 1). The local control rate at 5 years was 76%. The overall survival rate at 5 years was 56%. Of the 17 patients, 10 survived without disease progression. Four patients had local recurrences, one was salvaged by repeated CIRT and the other three died due to systemic diseases. Distant failure was observed in six patients. One patient suffered from femoral fracture (grade 3) and received surgical fixation 27 months after CIRT. No other severe reactions (grade 3) were observed. CONCLUSIONS CIRT is suggested to be an effective and safe treatment for patients who refuse surgery for localized primary sarcomas of the extremities.
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Major upper-limb amputations for malignant tumors. J Hand Surg Am 2012; 37:1235-41. [PMID: 22483175 DOI: 10.1016/j.jhsa.2012.02.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 01/26/2012] [Accepted: 02/02/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE With the continued advancement of limb salvage surgery, major upper-limb amputations are being performed less frequently and are generally reserved for patients with large, multifocal, or recurrent tumors for whom limb salvage is no longer an option. We conducted a retrospective review of the current indications and patient outcomes after major upper-limb amputations for malignant tumors. METHODS Using the institution surgical database, we identified 43 patients who underwent major upper-limb amputation for primary and metastatic malignant tumors from 1996 to 2008. RESULTS Of these 43 patients, 25 had soft tissue sarcoma, 7 had bone sarcoma, and 11 had carcinoma. Two patients had stage I, 3 had stage II, 21 had stage III, and 17 had stage IV disease. We performed 45 amputations: 5 below the elbow, 14 above the elbow, and 26 at the forequarter. Among the 45 amputations, 2 patients underwent a second more proximal amputation for local tumor recurrence. Of the 17 patients with stage IV disease, 10 underwent palliative amputation for symptom control. A total of 28 patients (65%) died. Median survival after amputation was 13 months (95% confidence interval, 8-19 mo). The 6-month cumulative incidence of local recurrence was 22%. Overall survival after forequarter amputations was 42% at 1 year. CONCLUSIONS Survival after major upper-limb amputation is poor, especially because amputations are reserved for patients with advanced tumors. However, amputation remains an option for local tumor control and can palliate symptoms in selected patients. Improvement of survival requires more effective systemic treatment strategies. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Parsons CM, Pimiento JM, Cheong D, Marzban SS, Gonzalez RJ, Johnson D, Letson GD, Zager JS. The role of radical amputations for extremity tumors: a single institution experience and review of the literature. J Surg Oncol 2011; 105:149-55. [PMID: 21837679 DOI: 10.1002/jso.22067] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 07/24/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Major amputations are indicated for advanced tumors when limb-preservation techniques have been exhausted. Radical surgery can result in significant palliation and possible cure. METHODS We identified 40 patients who underwent forequarter (FQ) or hindquarter (HQ) amputations between May 2000 and January 2011. Patient demographics, tumor-related factors, and outcomes were reviewed. RESULTS There were 30 FQ and 10 HQ amputations. The most common diagnoses were sarcoma (55%) and squamous cell carcinoma (25%). Patients presented with primary tumors (35%), regional recurrence (57.5%), or unresectable limb metastatic disease (7.5%). Presenting symptoms included fungating wounds (35%), intractable pain (78%), and limb dysfunction (65%). Operations were performed with curative intent (10%), curative/palliative intent (70%), or palliation alone (20%). Wound complications occurred in 35%. Pain was improved in 78% of patients following surgery. Despite a 91% negative margin rate, 79% of patients recurred either locally or distantly. Median overall survival was 10.9, 13.2, and 3.4 months in the curative, curative/palliative, and palliative groups, respectively. CONCLUSIONS In the absence of conservative options, major amputations are indicated for the management of advanced tumors. These operations can be performed safely, resulting in effective palliation of debilitating symptoms. While recurrence rates remain high, some patients can achieve prolonged survival.
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Nonreferral of possible soft tissue sarcomas in adults: a dangerous omission in policy. Sarcoma 2009; 2009:827912. [PMID: 20066170 PMCID: PMC2804052 DOI: 10.1155/2009/827912] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 09/18/2009] [Accepted: 10/22/2009] [Indexed: 12/18/2022] Open
Abstract
Introduction. The aim of this study is to compare outcomes in three groups of STS patients treated in our specialist centre: patients referred immediately after an inadequate initial treatment, patients referred after a local recurrence, and patients referred directly, prior to any treatment. Patients and methods. We reviewed all our nonmetastatic extremity-STS patients with a minimum follow-up of 2 years. We compared three patient groups: those referred directly to our centre (group A), those referred after an inadequate initial excision (group B), and patients with local recurrence (group C). Results. The study included 174 patients. Disease-free survival was 73%, 76%, and 28% in groups A, B, and C, respectively (P < .001). Depth, size, and histologic grade influenced the outcome in groups A and B, but not in C. Conclusion. Initial wide surgical treatment is the main factor that determines local control, being even more important than the known intrinsic prognostic factors of tumour size, depth, and histologic grade. The influence on outcome of initial wide local excision (WLE), which is made possible by referral to a specialist centre, is paramount.
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Bonvalot S, Rimareix F, Causeret S, Le Péchoux C, Boulet B, Terrier P, Le Cesne A, Muret J. Hyperthermic Isolated Limb Perfusion in Locally Advanced Soft Tissue Sarcoma and Progressive Desmoid-Type Fibromatosis with TNF 1 mg and Melphalan (T1-M HILP) Is Safe and Efficient. Ann Surg Oncol 2009; 16:3350-7. [DOI: 10.1245/s10434-009-0733-9] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Indexed: 11/18/2022]
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Taeger G, Grabellus F, Taeger G, Grabellus F, Podleska LE, Müller S, Ruchholtz S. Effectiveness of regional chemotherapy with TNF-α/Melphalan in advanced soft tissue sarcoma of the extremities. Int J Hyperthermia 2009; 24:193-203. [DOI: 10.1080/02656730701868387] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Rickelt J, Hoekstra H, van Coevorden F, de Vreeze R, Verhoef C, van Geel AN. Forequarter amputation for malignancy. Br J Surg 2009; 96:792-8. [DOI: 10.1002/bjs.6555] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Forequarter amputation (FQA) is an important treatment for malignant disease of the shoulder girdle. The aim of this study was to elucidate its role in surgical oncology.
Methods
This retrospective study analysed 40 patients who had an FQA. In nine, the chest wall was resected. The most frequent diagnoses were soft-tissue sarcoma (28 patients) and recurrent breast cancer (five).
Results
Median follow-up was 16 (range 1–184) months. The 1-year, 2-year and 5-year overall survival for patients with malignant disease was 71, 59 and 38 per cent respectively. The median time to local recurrence (eight patients) was 4 (range 1–19) months. Thirty-two patients had curative FQA with a 1-year, 2-year and 5-year overall survival of 90, 75 and 48 per cent respectively, and a median overall survival of 51 months. The 5-year overall and disease-free survival for soft-tissue sarcoma was 41 and 26 per cent respectively. Eight patients had a palliative FQA with a median survival of 5 (range 1–12) months.
Conclusion
In locoregional disease such as sarcoma, FQA may offer the only possibility of cure. However, in patients with axillary metastasis, FQA has no impact on survival, although local control may improve the patient's quality of life.
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Affiliation(s)
- J Rickelt
- Department of Surgical Oncology, Erasmus Medical Centre/Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - H Hoekstra
- Department of Surgical Oncology, University Medical Centre Groningen/University of Groningen, Groningen, The Netherlands
| | - F van Coevorden
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Huis, Amsterdam, The Netherlands
| | - R de Vreeze
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Huis, Amsterdam, The Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus Medical Centre/Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - A N van Geel
- Department of Surgical Oncology, Erasmus Medical Centre/Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
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Kenney RJ, Cheney R, Stull MA, Kraybill W. Soft Tissue Sarcomas: Current Management and Future Directions. Surg Clin North Am 2009; 89:235-47, x. [DOI: 10.1016/j.suc.2008.09.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Misra A, Mistry N, Grimer R, Peart F. The management of soft tissue sarcoma. J Plast Reconstr Aesthet Surg 2008; 62:161-74. [PMID: 19036655 DOI: 10.1016/j.bjps.2008.08.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Revised: 07/14/2008] [Accepted: 08/12/2008] [Indexed: 11/19/2022]
Abstract
SUMMARY Soft tissue sarcomas are a rare group of mesenchymal tumours that display cardinal signs, which can raise suspicion to their diagnosis. Management in a sarcoma treatment centre by its multidisciplinary team has improved outcome. Good local disease control with limb salvage and adjuvant radiotherapy has considerably reduced the morbidity of previous limb amputation. By the early involvement of a plastic surgeon, tissue reconstruction is optimised and wound complications reduced. This article looks at the contemporary management of soft tissue sarcoma and, in particular, its relevance to the plastic surgeon today.
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Affiliation(s)
- A Misra
- Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, UK
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Sarcoma de partes blandas: ¿existe posibilidad de rescate cuando la primera cirugía no fue resolutiva? Rev Esp Cir Ortop Traumatol (Engl Ed) 2008. [DOI: 10.1016/s1888-4415(08)74789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Duart-Clemente J, San-Julián M, Martínez-Monge R, Martín-Algarra S. Soft Tissue Sarcoma: Can a Rescue Procedure be Performed when the First Surgery was Unsuccessful? Rev Esp Cir Ortop Traumatol (Engl Ed) 2008. [DOI: 10.1016/s1988-8856(08)70064-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Wunder JS, Nielsen TO, Maki RG, O'Sullivan B, Alman BA. Opportunities for improving the therapeutic ratio for patients with sarcoma. Lancet Oncol 2007; 8:513-24. [PMID: 17540303 DOI: 10.1016/s1470-2045(07)70169-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Sarcomas are mesenchymal cancers, which, in many cases, have distinctive molecular features. Limb-sparing surgery delivered at specialised sarcoma centres as part of a multidisciplinary approach has become the standard treatment for most patients and usually provides excellent local control. Preoperative treatment with chemotherapy is most common for patients with bone sarcomas. The ideal sequence of surgery and radiation for local management of soft-tissue sarcoma remains controversial on the basis of early versus late treatment complications, although preoperative radiation can provide the best results for improved long-term function. New methods for radiation delivery and tumour sensitisation might provide further improvements. However, metastatic disease is common, and conventional chemotherapy provides for only a narrow therapeutic window outside of a few responsive pathological subtypes. Targeting underlying molecular events in specific sarcomas can provide for dramatic benefits, as has been seen with imatinib treatment for gastrointestinal stromal tumours and dermatofibrosarcoma protuberans. Trials of agents targeting the cell cycle and angiogenesis in soft-tissue sarcomas, and of those targeting osteoclasts in bone sarcomas, are currently underway. Biological data and preclinical studies support trials using inhibitors of hedgehog signalling in chondrosarcoma, inhibitors of wnt/beta-catenin in osteosarcoma and aggressive fibromatosis, and inhibitors of histone deacetylases in synovial sarcoma and Ewing sarcoma. Pharmacogenetic approaches will be needed to identify individual determinants of response and outcome in order to maximise the benefits of targeting specific molecular events and keep side-effects to a minimum. Research in stem-cell biology and nanotechnology holds promise for additional novel treatment options in the future.
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Affiliation(s)
- Jay S Wunder
- University Musculoskeletal Oncology Unit and Program in Molecular Biology and Cancer, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Canada.
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Menendez LR, Ahlmann ER, Savage K, Cluck M, Fedenko AN. Tumor necrosis has no prognostic value in neoadjuvant chemotherapy for soft tissue sarcoma. Clin Orthop Relat Res 2007; 455:219-24. [PMID: 17016226 DOI: 10.1097/01.blo.0000238864.69486.59] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Neoadjuvant chemotherapy for treatment of soft tissue sarcomas is controversial, and the correlation between local recurrence and survival is unclear. Histologic necrosis is a well-documented predictor of survival in patients with malignant bone tumors; however, the association is unknown in patients with soft tissue sarcomas. We assessed the prognostic significance of tumor necrosis for treatment of soft tissue sarcomas. We retrospectively collected data from 82 patients who received neoadjuvant chemotherapy for treatment of soft tissue sarcomas of the extremities. Patients had wide resections if tumors were high-grade, deep to the investing fascia, and had clear margins. We quantified the amount of necrosis and analyzed the relationship with local recurrence and overall survival. At an average followup of 65 months (range, 24-154 months), the 5-year local recurrence rates for patients with less than 95% and 95% or greater necrosis were 20% and 33%, respectively. The overall 5-year survivorship rates for patients with less than 95% necrosis and 95% or greater necrosis were 82% and 78%, respectively. There was no difference in recurrence-free survival or overall patient survival based on the amount of histologic necrosis. Tissue necrosis from neoadjuvant chemotherapy does not seem to predict outcome in soft tissue sarcomas.
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Affiliation(s)
- Lawrence R Menendez
- Department of Orthopaedic Oncology, University of Southern California Keck School of Medicine, University Hospital, Los Angeles, CA 90033, USA
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Bonvalot S, Missana MC, Le Cesne A, Missenard G, Vanel D, Terrier P, Le Péchoux C. Chirurgie des sarcomes des tissus mous des membres chez l'adulte : historique et avancées thérapeutiques. Cancer Radiother 2006; 10:416-24. [PMID: 16890005 DOI: 10.1016/j.canrad.2006.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2006] [Indexed: 10/24/2022]
Abstract
In the seventies, limb-sparing surgery and radiation therapy appeared capable of successfully treating the great majority of adult patients with soft tissue sarcomas of the extremities. No survival benefit could be demonstrated in the patients selected for amputation. Microscopically positive surgical margins are related to a greater risk of local recurrence, whereas overall survival is compromised by high grade and large tumor size. Presurgery multidisciplinary discussion, management in reference center and management within cancer network independently predict conformity to the clinical practice guidelines. Reoperation should be a planned part of definitive management whenever the initial surgical procedure was done without a histologic diagnosis or was not planned to be a wide excision. Soft tissue flap reconstruction facilitates therapy for patients with locally advanced tumors so that patients with larger tumors can undergo resection, limiting complications and limb sacrifice. Vascular reconstruction is a feasible option in case of involvement of major vessels. Isolated limb perfusion (ILP) with TNF and chemotherapy is an efficient limb-sparing neoadjuvant therapy for locally advanced limb soft tissue sarcomas. Efficacy and safety of low-dose TNFalpha could greatly facilitate ILP procedures in the near future.
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Affiliation(s)
- S Bonvalot
- Département de Chirurgie, Institut Gustave-Roussy, 39, Rue Camille-Desmoulins, 94805 Villejuif Cedex, France.
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Hoy E, Granick M, Benevenia J, Patterson F, Datiashvili R, Bille B. Reconstruction of Musculoskeletal Defects Following Oncologic Resection in 76 Patients. Ann Plast Surg 2006; 57:190-4. [PMID: 16862001 DOI: 10.1097/01.sap.0000216255.18106.e1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Between 1990 and 2002, 76 patients underwent 102 muscle flap reconstructions for extremity sarcomas. The patients had radical resection with immediate reconstruction. Reconstructions were performed by the Musculoskeletal Oncology and Plastic Surgery services. The mean age of our patients was 39.1 years. Patients were studied for a mean of 25.4 months. There were 79 pedicle flaps and 23 free flaps. Complications occurred in 23.7% of patients, including wound necroses, seromas, postoperative bleeding, postoperative infections, and flap loss. Five patients required a secondary flap procedure. The overall flap survival rate was 98%. Three patients had local recurrences. Sixteen patients (21.1%) have died of their disease. Five patients are alive with metastases. In 54 patients, Musculoskeletal Tumor Society (MSTS) functional evaluation scores averaged 27.1 (range, 12-30). In this large series of patients, we have demonstrated that, although minor complications are common, functional limbs can be salvaged following oncologic resection from the extremities.
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Affiliation(s)
- Erik Hoy
- Department of Surgery, Division of Plastic Surgery, New Jersey Medical School, UMDNJ, Newark, NJ, USA
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Mocellin S, Rossi CR, Brandes A, Nitti D. Adult soft tissue sarcomas: Conventional therapies and molecularly targeted approaches. Cancer Treat Rev 2006; 32:9-27. [PMID: 16338075 DOI: 10.1016/j.ctrv.2005.10.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Revised: 09/21/2005] [Indexed: 01/12/2023]
Abstract
The therapeutic approach to soft tissue sarcomas (STS) has evolved over the past two decades based on the results from randomized controlled trials, which are guiding physicians in the treatment decision-making process. Despite significant improvements in the control of local disease, a significant number of patients ultimately die of recurrent/metastatic disease following radical surgery due to a lack of effective adjuvant treatments. In addition, the characteristic chemoresistance of STS has compromised the therapeutic value of conventional antineoplastic agents in cases of unresectable advanced/metastatic disease. Therefore, novel therapeutic strategies are urgently needed to improve the prognosis of patients with STS. Recent advances in STS biology are paving the way to the development of molecularly targeted therapeutic strategies, the efficacy of which relies not only on the knowledge of the molecular mechanisms underlying cancer development/progression but also on the personalization of the therapeutic regimen according to the molecular features of individual tumours. In this work, we review the state-of-the-art of conventional treatments for STS and summarize the most promising findings in the development of molecularly targeted therapeutic approaches.
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Affiliation(s)
- Simone Mocellin
- Surgery Branch, Department of Oncological and Surgical Sciences, University of Padova, Via Giustiniani 2, 35128 Padua, Italy.
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Grunhagen DJ, de Wilt JHW, Graveland WJ, Verhoef C, van Geel AN, Eggermont AMM. Outcome and prognostic factor analysis of 217 consecutive isolated limb perfusions with tumor necrosis factor-α and melphalan for limb-threatening soft tissue sarcoma. Cancer 2006; 106:1776-84. [PMID: 16541435 DOI: 10.1002/cncr.21802] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Extensive and mutilating surgery is often required for locally advanced soft tissue sarcoma (STS) of the limb. As it has become apparent that amputation for STS does not improve survival rates, the interest in limb-preserving approaches has increased. Isolated limb perfusion (ILP) with tumor necrosis factor-alpha (TNF) and melphalan is successful in providing local tumor control and enables limb-preserving surgery in a majority of cases. A mature, large, single-institution experience with 217 consecutive ILPs for STS of the extremity is reported. METHODS At a prospectively maintained database at a tertiary referral center, 217 ILPs were performed from July 1991 to July 2003 in 197 patients with locally advanced STS of the extremity. ILPs were performed at mild hyperthermic conditions with 1-4 mg of TNF and 10-13 mg/L limb-volume melphalan (M) for leg and arm perfusions, respectively. RESULTS The overall response rate was 75%. Limb salvage was achieved in 87% of the perfused limbs. Median survival post-ILP was 57 months and prognostic factors for survival were Trojani grade of the tumor and ILP for single versus multiple STS. The procedure could be performed safely, with a perioperative mortality of 0.5% in all patients with no age limit (median age, 54 yrs; range, 12-91). Systemic and locoregional toxicity were modest and easily manageable. CONCLUSION TNF+M-based ILP can provide limb salvage in a significant percentage of patients with locally advanced STS and has therefore gained a permanent place in the multimodality treatment of STS.
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Affiliation(s)
- Dirk J Grunhagen
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
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Corrêa DS, Cunha IWD, Carvalho AL, Soares FA, Fauzoni R, Lopes A. Sarcoma sinovial de extremidades com doença localizada ao diagnóstico: tratamento e padrões de recidiva em 57 casos. Rev Col Bras Cir 2005. [DOI: 10.1590/s0100-69912005000600004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVOS: Os sarcomas sinoviais são tumores raros e agressivos que acometem adultos jovens, com sobrevida doençaespecífica em cinco anos de 57 a 63%. O presente estudo analisa a experiência institucional com este tumor, dando ênfase à associação entre variáveis clínicas, padrões de recorrência e sobrevida. MÉTODO: Entre 1970 e 2001 foram identificados 57 pacientes com sarcomas sinoviais. Fatores demográficos, clínicos e anatomopatológicos foram pesquisados. Associações entre variáveis clínicas e a sobrevida livre de recidiva local, livre de metástases e doença-específica em cinco anos foram calculadas. RESULTADOS: A idade mediana dos pacientes foi 26 anos, 56% eram masculinos, 79% eram brancos. Localizavam-se em membro inferior em 74%, proximalmente em 53%. O sintoma mais comum foi a presença de tumor em 42%. Na admissão 18% eram intactos, 42% manipulados e 40% recidivados. A maioria era maior que 5 cm., e três pacientes apresentavam metástase linfonodal. A cirurgia mais freqüente foi ressecção ampla, 30% necessitou amputação. Margens amplas foram obtidas em 65%, 51% eram tumores bifásicos. Neoadjuvância foi utilizada em 46% e adjuvância em 58% dos casos. As sobrevidas livre de recidiva local , metástases e doença específica em cinco anos foram 60±8%, 47±7% e 58±7%. A localização proximal do tumor associou-se com preservação de membro (p=-0,001), margens inadequadas (p=0,006) e subtipo bifásico (p=0,047). CONCLUSÕES: Os dados confirmam a hipótese de tratar-se de tumor agressivo, com altos índices de recidiva local e à distância. Os resultados do tratamento são comparáveis a outros centros especializados. Tratamento fora destes centros deve ser desencorajado.
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Selting KA, Powers BE, Thompson LJ, Mittleman E, Tyler JW, Lafferty MH, Withrow SJ. Outcome of dogs with high-grade soft tissue sarcomas treated with and without adjuvant doxorubicin chemotherapy: 39 cases (1996-2004). J Am Vet Med Assoc 2005; 227:1442-8. [PMID: 16279389 DOI: 10.2460/javma.2005.227.1442] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the effect of adjuvant doxorubicin chemotherapy on outcome in dogs with high-grade (grade 3) soft tissue sarcomas (HGSTSs). DESIGN Retrospective case series. ANIMALS 39 dogs. PROCEDURES Medical records of dogs with HGSTSs were reviewed. Dogs treated with surgery alone or receiving single-agent doxorubicin chemotherapy postoperatively were included in the study. Owners and referring veterinarians were contacted for follow-up information. Slides from histologic sections were reviewed to confirm the diagnosis of HGSTSs. Cases in which follow-up examination was not performed and radiation therapy or chemotherapy other than doxorubicin was administered were excluded. RESULTS 39 dogs met inclusion criteria. Twenty-one dogs received adjuvant doxorubicin. Tumor-, patient-, and treatment-related variables were not significantly associated with measured outcomes including local, metastatic, and overall disease-free intervals as well as survival time. Overall median disease-free interval was 724 days with a median survival time of 856 days for all dogs. CONCLUSIONS AND CLINICAL RELEVANCE Adjuvant doxorubicin-based chemotherapy did not benefit this population of dogs with HGSTSs. Outcome for visceral HGSTSs was similar to that of nonvisceral HGSTSs in these cases.
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Affiliation(s)
- Kim A Selting
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, MO 65211, USA
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Bonvalot S, Laplanche A, Lejeune F, Stoeckle E, Le Péchoux C, Vanel D, Terrier P, Lumbroso J, Ricard M, Antoni G, Cavalcanti A, Robert C, Lassau N, Blay JY, Le Cesne A. Limb salvage with isolated perfusion for soft tissue sarcoma: could less TNF-α be better? Ann Oncol 2005; 16:1061-8. [PMID: 15930042 DOI: 10.1093/annonc/mdi229] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The optimal dose of TNF-alpha delivered by isolated limb perfusion (ILP) in patients with locally advanced soft tissue sarcoma is still unknown. PATIENTS AND METHODS Randomised phase II trial comparing hyperthermic ILP (38-40 degrees ) with melphalan and one of the four assigned doses of TNF-alpha: 0.5 mg, 1 mg, 2 mg, and 3/4 mg upper/lower limb. The main end point was objective tumour response on MRI. Secondary end points were histological response, rate of amputation and toxicity. Resection of the remnant tumour was performed 2-3 months after ILP. The sample size was calculated assuming a linear increase of 10% in the objective response rates between each dose level group. RESULTS One hundred patients (25 per arm) were included. Thirteen per cent of patients had a systemic leakage with a cardiac toxicity in six patients correlated with high doses of TNF-alpha. Objective tumour responses were: 68%, 56%, 72% and 64% in the 0.5 mg, 1 mg, 2 mg and 3 or 4 mg arms, respectively (NS). Sixteen per cent of patients were not operated, 71% had a conservative surgery and 13% were amputated with no difference between the groups. With a median follow-up of 24 months, the 2 year overall and disease-free survival rates (95% CI) were 82% (73% to 89%) and 49% (39% to 59%), respectively. CONCLUSION At the range of TNF-alpha doses tested, there was no dose effect detected for the objective tumour response, but systemic toxicity was significantly correlated with higher TNF-alpha doses. Efficacy and safety of low-dose TNF-alpha could greatly facilitate ILP procedures in the near future.
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Affiliation(s)
- S Bonvalot
- Department of Surgery, Institut Gustave Roussy, Villejuif, France.
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Lans TE, Grünhagen DJ, de Wilt JHW, van Geel AN, Eggermont AMM. Isolated Limb Perfusions With Tumor Necrosis Factor and Melphalan for Locally Recurrent Soft Tissue Sarcoma in Previously Irradiated Limbs. Ann Surg Oncol 2005; 12:406-11. [PMID: 15915375 DOI: 10.1245/aso.2005.03.093] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2004] [Accepted: 12/19/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recurrent extremity soft tissue sarcoma (STS) in a previously operated and irradiated area can usually be managed only by amputation. Tumor necrosis factor (TNF)-alpha-based isolated limb perfusion (ILP) is an established alternative to achieve limb salvage but is assumed to require sufficient vasculature. Because radiotherapy is known to destroy vasculature, we wanted to evaluate retrospectively whether the outcome of ILP in patients with radiotherapy for their primary tumor nonetheless showed a benefit from TNF treatment. METHODS We consulted a prospective database of TNF-based ILPs at the Erasmus MC-Daniel den Hoed Cancer Center in Rotterdam. Out of 342 TNF-based ILPs between 1991 and 2003, 30 ILPs were performed in 26 patients with recurrent STS in the irradiated field after prior surgery and radiotherapy. Eleven patients (42%) had multiple tumors (n = 2-20). All patients were candidates for amputation. RESULTS We observed 6 complete responses (20%), 15 partial responses (50%), no change in 8 patients (27%), and progressive disease in 1 patient (3%). The median duration of response was 16 months (range, 3-56 months) at a median follow-up of 22 months (range, 3-67 months). The local recurrence rate was 45% in patients with multiple tumors and 27% in patients with single tumors. Ten patients (35%) died of systemic metastases. Limb salvage was achieved in 17 patients (65%). Regional toxicity was limited and systemic toxicity minimal. CONCLUSIONS TNF-based ILP can avoid amputations in most patients with recurrent extremity STS in a prior operated and irradiated field.
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Affiliation(s)
- T E Lans
- Department of Surgical Oncology, Erasmus MC-Daniel den Hoed Cancer Center, PO Box 5201, 3008 AE Rotterdam, The Netherlands
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46
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Eilber FC, Brennan MF, Riedel E, Alektiar KM, Antonescu CR, Singer S. Prognostic factors for survival in patients with locally recurrent extremity soft tissue sarcomas. Ann Surg Oncol 2005; 12:228-36. [PMID: 15827815 DOI: 10.1245/aso.2005.03.045] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2004] [Accepted: 11/19/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND Factors prognostic for survival in patients with locally recurrent extremity soft tissue sarcomas (STS) are poorly defined, thus making it difficult to identify high-risk patients who may benefit from adjuvant therapy. METHODS A total of 1421 patients underwent surgical treatment for primary extremity STS at a single institution between 1982 and 2002. Of these, 179 (13%) patients underwent complete surgical resection of an isolated local recurrence and were the subjects of this study. Clinicopathologic factors from both the primary tumor and the local recurrence were analyzed. RESULTS The median interval to initial local recurrence was 16 months: 65% developed a local recurrence by 2 years and 90% by 4 years. Only four patients who presented with a low-grade primary tumor progressed to a high-grade local recurrence. Independent prognostic factors for disease-specific survival after local recurrence were a high histological grade (hazard ratio, 5.1; P = .0004), a large local recurrence tumor size (hazard ratio, 1.5; P = .0001), and a short local recurrence-free interval (hazard ratio, 1.6; P = .0001). Patients who developed a local recurrence >5 cm in < or =16 months (n = 44; 0 low grade) had a 4-year disease-specific survival of 18%, compared with 81% for patients who developed a local recurrence < or =5 cm in >16 months (n = 46; 11 low grade). CONCLUSIONS Histological grade, local recurrence size, and local recurrence-free interval are independently predictive of survival in patients with locally recurrent extremity STS. A large local recurrence that develops in a short interval indicates a biologically aggressive tumor with a high tumor-specific mortality. Patients who develop such recurrences are ideal subjects for systemic neoadjuvant therapy trials.
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Affiliation(s)
- Fritz C Eilber
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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47
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Ghert MA, Abudu A, Driver N, Davis AM, Griffin AM, Pearce D, White L, O'Sullivan B, Catton CN, Bell RS, Wunder JS. The Indications for and the Prognostic Significance of Amputation as the Primary Surgical Procedure for Localized Soft Tissue Sarcoma of the Extremity. Ann Surg Oncol 2004; 12:10-7. [PMID: 15827772 DOI: 10.1007/s10434-004-1171-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Accepted: 08/19/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND The indications for primary amputation of a localized soft tissue sarcoma (STS) of the extremity are not well defined in the literature. However, it has been suggested that patients who require an amputation to treat an STS are at increased risk for developing metastases. We categorized the main indications for primary amputation in our patient population and compared their oncological outcome with the outcome of patients who underwent limb-sparing surgery. METHODS 413 consecutive patients treated surgically at a single center for primary, nonmetastatic, deep, intermediate-, or high-grade STS of the extremity were reviewed. Indications for primary amputation were identified. Demographics and outcomes were compared between the amputation and limb-salvage groups. Multivariate Cox model analysis was used to identify independent risk factors for systemic relapse. RESULTS Twenty-five (6%) of 413 patients with STS underwent primary amputation: they were older (P = .05), had larger tumors (P = .001), and had a significantly greater risk of developing metastatic disease than patients who underwent limb-sparing procedures (P = .008). However, multivariate analysis demonstrated that the only independent predictors of systemic relapse were tumor size (P = .0001) and tumor grade (P = .0001). Primary amputation was not an independent risk factor for metastatic disease. CONCLUSIONS The decision to perform a primary amputation for an STS of the extremity is based on the location and local extent of the tumor, and the expected function of the extremity after tumor resection. The higher risk of metastases for patients who require primary amputation is accounted for by independent risk factors associated with their tumors--predominantly large tumor size.
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Affiliation(s)
- Michelle A Ghert
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, 600 University Avenue, Suite 476E, Toronto, Ontario, M5G 1X5, Canada
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Kim JY, Youssef A, Subramanian V, Rogers BA, Pollock RE, Robb GL, Chang DW. Upper Extremity Reconstruction Following Resection of Soft Tissue Sarcomas: A Functional Outcomes Analysis. Ann Surg Oncol 2004; 11:921-7. [PMID: 15466352 DOI: 10.1245/aso.2004.06.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Treatment for soft tissue sarcoma of the upper extremity has evolved to include limb salvage techniques. We reviewed our experience with limb salvage therapy for upper extremity sarcomas with an emphasis on functional outcomes following the reconstructive surgery. METHODS A retrospective analysis was performed of 81 consecutive patients with soft tissue sarcoma of the upper extremity who had limb salvage therapy with reconstruction by a plastic surgeon. Univariate and multivariate regression analyses of relevant outcome variables were performed. Enneking functional scores were obtained from 43 patients. RESULTS The study included 16 microvascular reconstructions and 67 non-microvascular reconstructions for a total of 83 reconstructions in 81 patients. The mean defect size was 129 cm(2) (standard deviation: 106 cm(2)). The mean total functional score was 23.1 (range, 9 to 30). Any reconstruction-related complication and preoperative chemotherapy use were associated with a 7.3 point (P = .03) and 4.7 point (P = .01) decrease in total functional score, respectively. Kaplan-Meier product-limit analysis showed 82% 5-year overall survival and 67% 5-year disease-free survival rates. CONCLUSIONS For soft tissue sarcoma of the upper extremity, limb salvage with good functional outcome is possible with a judicious approach to reconstruction.
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Affiliation(s)
- John Y Kim
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 443, Houston, TX 77030, USA
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Kim JY, Subramanian V, Yousef A, Rogers BA, Robb GL, Chang DW. Upper Extremity Limb Salvage with Microvascular Reconstruction in Patients with Advanced Sarcoma. Plast Reconstr Surg 2004; 114:400-8; discussion 409-10. [PMID: 15277806 DOI: 10.1097/01.prs.0000131987.40578.7b] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Limb salvage is a viable alternative to amputation in many cases of advanced sarcoma. The authors examined their experience with microvascular reconstruction of upper extremity defects after sarcoma resection, focusing on oncologic and functional outcomes. A retrospective analysis yielded 17 patients who underwent 18 free flap procedures and met the inclusion criteria. Most patients (71 percent, n = 12) had recurrent sarcoma at presentation to the authors' institution. Malignant fibrous histiocytoma was the most common pathologic subtype (n = 6). High-grade tumors were present in 94 percent of patients (n = 16). The free flap survival rate was 100 percent. The rectus abdominis flap was the most common free flap used (39 percent; n = 7). Local recurrence occurred in nine flaps (50 percent), and five patients ultimately required amputations. Six patients (35 percent) had distant recurrence. The mean Enneking score for limb function was 73 percent of the maximum (21.9 of 30). The 5-year disease-specific survival rate was 61.3 percent. In select patients with advanced upper extremity sarcoma undergoing limb salvage, microvascular flap reconstruction can provide reliable, safe coverage with reasonable preservation of function.
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Affiliation(s)
- John Y Kim
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, 77030, USA
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Abstract
Soft-tissue sarcomas are a group of rare malignant tumours, many of which arise in the limbs. Most are treated with a combination of wide local excision and radiotherapy, but a small number--including proximal, large, high-grade, or recurrent tumours, or those involving major neurovascular structures--necessitate major amputation including forequarter or hindquarter amputation. These uncommon operations should remain in the surgical armamentarium for carefully selected patients. Those being considered for amputation should be referred to a tertiary sarcoma unit for examination of all other options, such as limb-salvage surgery, tumour downstaging with chemotherapy or radiotherapy (perhaps with subsequent limb-salvage surgery), or novel techniques such as isolated limb perfusion. Only after careful assessment should amputation be carried out. Outcomes after major amputation are highly variable, but such procedures can confer useful palliation to patients with distressing symptoms (pain, bleeding, fungation), long-term disease-free survival with reasonable function in carefully selected patients, and cure in some.
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Affiliation(s)
- Matthew A Clark
- Department of Surgery, Middlemore Hospital, Auckland, New Zealand
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