Distal lower extremity sarcomas: frequency of occurrence and patient survival rate

[Surgical treatment of locally aggressive and malignant tumors of the proximal third of the fibula. Oncology results and functional evaluation]

INTRODUCTION

Proximal fibula malignant and locally aggressive benign bone tumors are uncommon and usually treat by surgery. Bloc resection of the knee can compromise knee stability due to of the resection of the posterolateral ligament complex.

MATERIAL AND METHODS

We analyzed 28 consecutive patients treated for a proximal fibula bone tumor between 1980 and 2006 (osteosarcoma: 9, giant cell tumor: 9, Ewing sarcoma: 8 and chondrosarcoma: 2). Sixty-one percent were male and the median age was 21 years (range: 8-60). The mean follow-up was 86 months. The posterolateral complex was reinserted at tibial metaphyseal level. Patients were evaluated functionally using the Musculoskeletal Tumor Society scale (MSTS).

RESULTS

Overall survival rate was 89%, local recurrence rate was 11%, and secondary amputation rate was 6% at 7 years of median follow-up. The average MSTS score was 93%. Five patients had neurological complications. No patient experienced subjective instability or vascular insufficiency.

CONCLUSIONS

Bloc resection of the proximal fibula for the treatment of aggressive or malignant primary bone tumors allowed us to obtain local tumor control, and overall survival rate for sarcomas of 89% at 7 years. The posterolateral ligament complex tibial reinsertion provided functional knee stability without major functional consequences in the medium term.

Trauma as pathogenesis of a plantar forefoot fibrolipoma: first case and review of the literature

Lipomas and their variants are benign soft-tissue tumors that occur at any age and most frequently on the upper back and neck, shoulder, and abdomen. The foot is a relatively uncommon site for soft-tissue neoplasia and the etiology is not usually related to trauma. We describe a case of a pedunculated fibrolipoma of the forefoot that originated from a cut wound at the Atlantic Ocean. A brief review of the literature is also given.

The pathologic response of resected synovial sarcomas to hyperthermic isolated limb perfusion with melphalan and TNF-α: a comparison with the whole group of resected soft tissue sarcomas

Background

Hyperthermic isolated limb perfusion with tumor necrosis factor-α and melphalan (TM-HILP) has been successfully used to treat limb soft tissue sarcomas (STSs) with high response rates. The data on the effectiveness of HILP-TM for the treatment of STSs are mainly based on various STS types. The aim of this study was to investigate the responses of synovial sarcomas (SS) to TM-HILP.

Methods

A total of 125 TM-HILP-treated tumors (STS^all), including 14 SSs, were included in the study. The tumors were subdivided into proximal and distal limb localizations. Tumor typing (using the WHO classification), resection status (using the UICC classification), and response to therapy were assessed using light microscopy. The SSs were tested for the SYT-SSX translocation using RT-PCR. The following tests were applied: a chi-squared test, a t test, and the Mann-Whitney U test.

Results

The SSs were localized distally more often than were the STS cohort (STS^−SS) (85.7% vs. 32.4%) and were smaller (5.8 cm vs. 10.7 cm). There were no differences in the responder/nonresponder ratios or the mean percentages of pathological regression between the SS and STS^−SS cohorts (74.0% vs. 76.0%). A general localization-dependent difference in the tumor responses to TM-HILP could not be detected in the STS^all cohort (distal, 72.0% vs. proximal, 78.0%); however, a UICC R0 status was more often observed in proximal tumors (distal, 50.0% vs. proximal, 71.4%). There was no association between the SYT-SSX type and SS responses to TM-HILP.

Conclusions

Because of the high response rates, TM-HILP is recommended for the treatment of SSs. The distal limb localization of TM-HILP-treated STSs was generally (STS^all cohort) associated with fewer R0 resections.

Do malignant bone tumors of the foot have a different biological behavior than sarcomas at other skeletal sites?

We analyze the delay in diagnosis and tumor size of malignant bone tumors of the foot in a retrospective study. We compared the oncological and surgical long-term results with identical tumor at other anatomical sites in order to analyze the biological behavior of sarcomas that are found in the foot. Thirty-two patients with a histologically proven malignant bone tumor (fifteen chondrosarcomas, nine osteosarcomas, and eight Ewing sarcomas) between the years 1969 and 2008 were included. The median follow-up was 11.9 years. The overall median time gap between the beginning of symptoms and diagnosis in the study group was 10 months. Ewing sarcoma presented with the longest delay in diagnosis (median of 18 months), followed by osteosarcoma (median of 15 months) and chondrosarcoma (median of 7.5 months). The delay in diagnosis of these tumors was significantly longer than that of equivalent tumors at other skeletal sites, but the 5- and 10-year survival rates and the occurrence of distant metastases were comparable. In contrast, the average size of foot tumors was 5- to 30-fold less than that of tumors analyzed at other skeletal sites. This study indicates that sarcomas of the foot demonstrate a distinct biological behavior compared to the same tumor types at other skeletal sites.

Reconstruction with pasteurized autograft for primary malignant bone tumor of distal tibia

OBJECTIVE

The aim of this study was to assess the specific protocol for the treatment of primary malignant bone tumors of distal tibiae in a group of patients for limb salvage, with wide "en bloc" intra-articular excision and reconstruction of the defect with recycled pasteurized autograft, which was stabilized using an internal fixator.

METHODS

Between 1994 and 2009, ten patients (three females and seven males) at a mean age of 26.5 years old were treated for malignant bone tumors of the distal tibiae with "en bloc" intra-articular excision and ankle arthrodesis using recycled pasteurized autograft. Nine cases were histopathologically diagnosed as high-grade osteosarcoma, and one case as invasive osteoblastoma. All bone tumors were staged according to Enneking's criteria with two stages IIA cases, and eight stages IIB cases.

RESULTS

At a mean follow-up of 81 months, the mean postoperative functional score was 74.3%. All the patients had bony union at the last follow-up. Six patients required secondary iliac crest cancellous bone grafting at the proximal end to achieve union. The mean time for graft union was 18.9 months, and the average union time of the proximal junctions was longer than that of the distal junctions. Superficial infection occurred in two patients (20.0%), which were resolved by changing dress. There was no deep infection or graft fracture during the entire procedure.

CONCLUSIONS

The use of pasteurized bone graft for primary malignant bone tumors of distal tibia indicated a satisfactory outcome, with regard to graft survival, complications, and functional results. A pasteurized auto-graft can be an easily accessible and economical alternative of high efficiency for the usual reconstruction modalities.

Foot sarcomas: Factors affecting oncological and functional outcomes

Oncological and functional prognostic factors for patients with foot sarcomas have yet to be clarified. This study was undertaken to identify the prognostic factors for oncological and functional outcomes and the significance of adjuvant radiotherapy in achieving local control in patients with foot sarcomas. We reviewed 31 consecutive patients with soft tissue (24), and bone (7) sarcomas arising in the foot and analyzed the impact of patient characteristics on the functional and oncological outcomes. There were seven cases with clear cell or epithelioid sarcomas. Two of the 31 cases experienced local recurrence despite the fact that only two cases received adjuvant radiotherapy. Sixteen out of 18 cases of soft tissue sarcomas with limb salvage surgery underwent reconstructive procedures for soft tissue defects. Amputation required as a surgical treatment (p=0.002) was a poor prognostic factor. Larger size (p=0.029) and bone reconstruction (p=0.018) were poor prognostic factors for local recurrence-free survival, and amputation (p=0.001) and bone reconstruction (p=0.008) for metastasis-free survival in patients with soft tissue sarcomas. No significant factors were derived in patients with bone sarcomas. Larger size (p=0.021), amputation (p=0.016) and bone reconstruction (p=0.03) were poor prognostic factors affecting function in patients with soft tissue sarcomas, and hindfoot site (p=0.028) and amputation (p=0.028) were poor prognostic factors affecting function in patients with bone sarcomas. Surgery with a negative operative margin and reconstructive procedures achieved good local control and function. Patients that had tumors with larger size, necessitating amputation or bone reconstruction, required novel multimodal treatment in order to improve their outcomes.

Similar survival but better function for patients after limb salvage versus amputation for distal tibia osteosarcoma

BACKGROUND

Amputation has been the standard surgical treatment for distal tibia osteosarcoma. Advances in surgery and chemotherapy have made limb salvage possible. However, it is unclear whether limb salvage offers any improvement in function without compromising survival.

QUESTIONS/PURPOSES

We therefore compared the survival, local recurrence, function, and complications of patients with distal tibia osteosarcoma treated with limb salvage or amputation.

METHODS

We retrospectively reviewed 42 patients with distal tibia osteosarcoma treated from 1985 to 2010. Nineteen patients had amputations and 23 had limb salvage and allograft reconstructions. We graded the histology using Broders classification, and staged patients using the Musculoskeletal Tumor Society (MSTS) and American Joint Committee on Cancer (AJCC) systems. The tumor grades tended to be higher in the group of patients who had amputations. We determined survival, local recurrence, MSTS function, and complications. The minimum followup was 8 months (median, 60 months; range, 8-288 months).

RESULTS

The survival of patients who had limb salvage was similar to that of patients who had amputations: 84% at 120 and 240 months versus 74%, respectively. The incidence of local recurrence was similar: three of 23 patients who had limb salvage versus no patients who had amputations. The mean MSTS functional score tended to be higher in patients who had limb salvage compared with those who had amputations: 76% (range, 30%-93%) versus 71% (range, 50%-87%), respectively. The incidence of complications was similar.

CONCLUSION

Patients treated with either limb salvage or amputation experience similar survival, local recurrence, and complications, but better function is achievable for patients treated with limb salvage versus amputation. Local recurrence and complications are more common in patients with limb salvage.

LEVEL OF EVIDENCE

Level III, retrospective comparative study. See the Guidelines for Authors for a complete description of levels of evidence.

Clinical management and surgical treatment of distal fibular tumours: a case series and review of the literature

PURPOSE

Study reports clinical and functional outcomes of surgical treatment in a case series of nine patients with distal fibular tumours.

METHODS

Nine patients with distal fibular tumours were observed between 2005 and 2010. A PubMed search was performed using the terms "fibula", "lower limb tumour [cancer]", "sarcoma", "Ewing", "peroneal", "fibular metastasis", and "limb-salvage surgery".

RESULTS

In all our patients, lesions were unilateral. All patients complained of pain; limping was present in 5 of 9 tumours. Patients were managed surgically, except one who underwent local radiotherapy. In six patients, a benign or tumor-like lesion was detected. Malignancies consisted of metastatic lung adenocarcinoma (two cases) or multifocal mesenchymal cancer (one case). Non-malignant lesions were treated by curettage and filling, followed by internal fixation when needed. In malignant or locally aggressive lesions, metadiaphyseal fibular resection was performed. The literature search retrieved either case reports or small case series, reflecting the rarity of distal fibular tumours. Surgical treatment was successful in all patients with benign lesions, whereas the rate of success was 40-100 % in case of malignancies.

CONCLUSIONS

Given the low incidence of distal fibular tumours, controversies exist about the optimal surgical management. Clinical observation and imaging should be reserved to asymptomatic benign lesions. In non-malignant tumours causing pain, limping, and pathological fractures; in malignancies, surgery is recommended. Finally, in patients with asymptomatic lesions of uncertain nature, biopsy and histological examination should be performed to plan appropriate management.

Composite biological reconstruction following total calcanectomy of primary calcaneal tumors

BACKGROUND

Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy or aggressive benign tumor increasingly possible. However, reconstructions of the calcaneus remain a major surgical challenge because of the rarity and specific anatomy of this condition.

METHODS

we retrospectively reviewed 4 patients who had primary calcaneal tumors and underwent total calcanectomy and reconstructions with use of composite of allograft and vascularized osteocutaneous fibular grafts between 2007 and 2010. The diagnoses included chondrosarcoma in 1, fibrosarcoma in 1, aggressive osteoblastoma in 1, and giant-cell tumor in 1. Wide resection margins were achieved in all patients. The mean age at the time of the operation was 32.1 years. Patients were examined clinically and radiographically and were assessed functionally with Musculoskeletal Tumor Society (MSTS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score.

RESULTS

The median duration of follow-up was 24.5 months. No local recurrence occurred in this series and all patients had no evidence of disease at the time of final follow-up. Limb salvage was achieved in all patients. Revision surgery was necessary in two patients because of complications (skin flap necrosis and infection). The average MSTS 93 score and AOFAS score were 91.7% and 87.5 at the final follow-up, respectively. All fibular flaps survived and bone unions achieved successfully. The overall mean time for bone union was 9.5 months. The mean time to full-weight bearing was 7 months.

CONCLUSIONS

Vascularized fibular flaps in combination with massive allografts provide an excellent option for biological reconstruction after total calcanectomy in tumor situation and have proven to be a successful limb salvage procedure, which result in earlier patient recovery and return of function.

LEVEL OF EVIDENCE

Therapeutic Level IV.

The adverse effect of an unplanned surgical excision of foot soft tissue sarcoma

Background

Malignant soft tissue tumors of the foot are extremely rare and thus can be prematurely excised without appropriate preoperative evaluation. The present study compares adverse effects between unplanned and planned surgical excisions.

Methods

We retrospectively reviewed the clinical records, radiographs, pathology reports and pathological specimens of 14 consecutive patients with soft tissue sarcoma of the foot among 592 with sarcomas between 1973 and 2009. We then compared the incidence and clinical outcomes after unplanned (UT; n = 5) and planned (PT; n = 9) surgical excisions of foot sarcomas.

Results

The most frequent diagnosis was synovial sarcoma (n = 4; 28.6%). The overall 5-year survival rates of the PT and UT groups were 65.6% and 60.0%, respectively, and the event-free 5-year survival rates were 63.5% and 40.0%, respectively. Event-free and overall survival rates did not significantly differ between the two groups. However, tumors were significantly larger in the PT group than in the UT group (p < 0.05).

Conclusions

Unplanned resection lead to a relatively worse prognosis and a likelihood of recurrence despite additional resections. We recommend that soft tumors of the foot should only be excised after appropriate preoperative evaluation regardless of the size of the tumor.

Osteosarcoma: A rare cause of painful enlargement of the hallux

Malignant osseous and soft-tissue tumors of the foot are rare. We report a case of osteosarcoma in the proximal phalanx of the hallux in a 45-year-old man. In patients with foot-related symptoms, a high index of suspicion for pedal osteosarcoma is required. Delayed or inappropriate diagnosis may compromise limb-sparing surgery and survivorship.

Prosthetic reconstruction for tumors of the distal tibia. Report of two cases

Prosthetic reconstruction in two patients with malignant bone tumors of the distal tibia was conducted. The diagnoses were metastatic bone tumor in one patient and low grade central osteosarcoma in another. The mean duration of follow-up was 5.5 years (3 and 8 years). Reconstruction was achieved using custom-made prosthesis (JMM, Japan Medical Materials), which replaced the distal tibia. In the patient with metastasis, local recurrence occurred 8 months after the primary surgery and the recurrent tumor was resected. Both patients were free from neoplastic disease at the latest follow-up. The average functional scores according to the system of the Musculoskeletal Tumor Society were 25 and 23. Custom-made prostheses allow an early return to functional weight-bearing without major complications. This technique provides a safe and effective method of stabilization for properly selected malignant tumors of the distal tibia.

Resection arthrodesis of the ankle for aggressive tumors of the distal tibia in children

BACKGROUND

There is no consensus on the ideal treatment for malignant tumors of the distal tibia. Many favor amputation.

METHODS

Thirteen children, at an average age of 12 years (8 to 16 y) sustained conservative surgical treatment for a tumor of the distal tibia. All patients had "en bloc" resection of the tumor with ankle arthrodesis achieved by nail or plate accompanied by autograft.

RESULTS

The results were assessed retrospectively with an average follow-up of 8.8 years. Nine patients were in complete remission. Two patients had died. Two patients were lost to follow-up. Two patients had a local recurrence, which required amputation. There were 4 infections, which responded well to therapy. Four patients required additional bone grafting because of nonunion. Three patients required osteotomy for malalignment. Bone healing was achieved for the 9 patients seen at last follow-up. All were able to walk with an average functional score of 24.7/30 (23 to 26) on the Musculoskeletal Tumor Society score.

CONCLUSIONS

Several reconstructive techniques are available: mega prosthesis of distal tibia and ankle, reconstruction by vascularized fibula or by autograft. All series reported significant rates of infections, cutaneous necrosis, and nonunion.

DISCUSSION

Conservative treatment with ankle arthrodesis is a possible alternative to amputation for the management of malignant tumors of the distal tibia in selected patients. Survival results and functional outcome were good despite initial complications.

LEVEL OF EVIDENCE

This is a retrospectively therapeutic study graded level 2 as level of evidence.

Limb salvage for soft-tissue sarcomas of the foot and ankle

We evaluated the oncological and functional outcome of 27 patients who had limb salvage for a soft-tissue sarcoma of the foot or ankle between 1992 and 2007, with a mean follow-up of 7.5 years (1.05 to 16.2). There were 12 men and 15 women, with a mean age at presentation of 47 years (12 to 84). Referrals came from other hospitals for 16 patients who had previous biopsy or unplanned excision, and 11 presented de novo. There were 18 tumours located in the foot and nine around the ankle. Synovial sarcoma was the most frequent histological diagnosis. Excision was performed in all cases, with 16 patients requiring plastic surgical reconstruction with 13 free and three local flaps. Adjuvant treatment was undertaken in 20 patients, 18 with radiotherapy and two by chemotherapy. Limb salvage was successful in 26 of the 27 patients. There have been two local recurrences and two mesenchymal metastases. Four patients have died of their sarcoma and two of other causes.

Function was evaluated with the Toronto Extremity Salvage Score and a mean overall score of 89.40 (52.1 to 100) was obtained. A questionnaire revealed that all surviving patients are able to wear normal shoes and none require a walking aid.

Limb salvage can achieve good oncological and functional results with additional treatment.

Endoprosthetic reconstruction of the distal tibia and ankle joint after resection of primary bone tumours

Endoprosthetic replacement of the distal tibia and ankle joint for a primary bone tumour is a rarely attempted and technically challenging procedure. We report the outcome of six patients treated between 1981 and 2007. There were four males and two females, with a mean age of 43.5 years (15 to 75), and a mean follow-up of 9.6 years (1 to 27). No patient developed a local recurrence or metastasis. Two of the six went on to have a below-knee amputation for persistent infection after a mean 16 months (1 to 31). The four patients who retained their endoprosthesis had a mean musculoskeletal tumour society score of 70% and a mean Toronto extremity salvage score of 71%. All were pain free and able to perform most activities of daily living in comfort. A custom-made endoprosthetic replacement of the distal tibia and ankle joint is a viable treatment option for carefully selected patients with a primary bone tumour. Patients should, however, be informed of the risk of infection and the potential need for amputation if this cannot be controlled.

Survival in Malignant Peripheral Nerve Sheath Tumours: A Comparison between Sporadic and Neurofibromatosis Type 1-Associated Tumours

We studied 123 patients with malignant peripheral nerve sheath tumours (MPNSTs) between 1979 and 2002. However, 90 occurred sporadically whereas 33 were associated with neurofibromatosis type 1 (NF1). Survival was calculated using Kaplan-Meier survival curves and we used Cox's proportional hazards model to identify independent prognostic factors. A 5-year survival for 110 nonmetastatic patients was 54%; (33% NF1 and 63% sporadic P = .015). Tumour stage and site were significant prognostic indicators after univariate analysis. After multivariate analysis, however, only NF1 (P = .007) and tumour volume more than 200 m (P = .015) remained independent predictors of poor outcome. We recommend that NF1 be taken into account during MPNST staging. As the survival rate in the NF group was dependant on tumour volume, routine screening of these patients with FDG PET and/or MRI may be warranted, thereby staging and controlling them at the earliest possible opportunity.

A diagnosis of marginal zone lymphoma following surgical correction of hallux abductovalgus: a case report

Marginal zone lymphoma is a neoplasm affecting the lymphatic system, including the bone marrow, thymus, spleen, and lymph nodes. This type of non-Hodgkin's lymphoma affects B cells and is estimated to comprise between 5% and 17% of all non-Hodgkin's diseases. The incidence of finding any neoplasm within the foot and ankle has been estimated to be only 2.0% to 3.5% of all patients. However, despite the low incidence of cancer found within the foot and ankle, the clinician must be mindful that the possibility does exist and should thus consider surgically excised soft tissue and bone for pathological evaluation. A case report of marginal zone lymphoma, incidentally diagnosed through hallux valgus surgery, is presented.

LEVEL OF CLINICAL EVIDENCE

4.

Fungating soft-tissue sarcomas. Treatment implications and prognostic importance of malignant ulceration

BACKGROUND

Several variables have been reported as being prognostic with regard to the outcomes of soft-tissue sarcomas. Although the tumors are subjectively ominous, no prior study has been performed to evaluate the treatment or prognosis of fungating soft-tissue sarcomas.

METHODS

We performed a retrospective review of all soft-tissue sarcomas treated at our institution between 1989 and 2004 that had been followed for a minimum of two years or until the death of the patient. Our study group consisted of twenty-four patients with a primary high-grade fungating tumor, and our control group consisted of 146 consecutive patients with a primary high-grade non-fungating tumor. The study cohorts were compared with regard to disease presentation, treatment, and oncologic outcomes.

RESULTS

There were no significant differences in tumor size, tumor depth, or histopathologic diagnoses between the cohorts, although the patients with a fungating tumor tended to be older (mean, sixty-five years compared with fifty-five years in the control group; p = 0.004) and have shorter postoperative follow-up (mean, thirty-eight months compared with sixty-five months in the control group; p = 0.03). The proportion of patients presenting with metastases was significantly greater in the group with a fungating tumor (33% compared with 9% in the control group; p = 0.003). Significantly more patients with a fungating tumor underwent amputation (35% compared with 12% in the control group; p = 0.01), while a greater proportion of control patients received radiation therapy (68% compared with 39% in the group with a fungating tumor; p = 0.02). There was no difference in the proportions of patients receiving chemotherapy or in the local recurrence rates between the two cohorts. The Kaplan-Meier five-year overall survival estimates were 20% in the group with a fungating tumor compared with 63% (p < 0.0001) in the control group. The Kaplan-Meier five-year disease-specific survival estimates for patients presenting with localized disease was 58% in the group with a fungating tumor and 74% in the control group (p = 0.05). Multivariate analysis demonstrated that disease stage, fungation, and a tumor size of > or = 10 cm were significant independent negative prognostic factors for disease-specific survival.

CONCLUSIONS

Malignant tumor ulceration is an independent predictor of a poor prognosis for patients with a high-grade soft-tissue sarcoma. Despite the discouraging overall prognosis, aggressive multidisciplinary treatment can lead to long-term survival in an important subgroup of patients with fungating lesions.

Local recurrence of disease after unplanned excisions of high-grade soft tissue sarcomas

Unplanned excisions of soft tissue sarcomas occur with alarming frequency and result in high rates of residual disease, potentially affecting patient prognosis. To determine if unplanned excisions and residual disease status at tumor bed excision increased local recurrence rates and predicted disease-specific patient survival, we retrospectively reviewed 203 consecutive patients with high-grade soft tissue sarcomas treated operatively and followed for at least 2 years (mean, 4.8 years) or until patient death. Among the 64 patients (32%) who had undergone previous unplanned excisions, six had gross residual disease and 40 of the remaining 58 (69%) had microscopic residual disease in the tumor bed. We observed subsequent local recurrence in nine of the 139 patients (6%) after planned excision compared with 22 patients (34%) after unplanned excision. More patients with unplanned excisions who underwent limb salvage procedures required flap coverage and/or skin grafting with their definitive resection (30% versus 5%). In the unplanned excision cohort, residual disease status at tumor bed excision predicted increased rates of local recurrence and decreased disease-specific survival. Unplanned excisions of high-grade soft tissue sarcomas resulted in increased rates of local recurrence but not disease-specific survival. Residual disease at reexcision predicted the likelihood of local recurrence.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Pretibial subcutaneous soft tissue lesions presenting to a paediatric orthopaedic clinic

Pretibial swellings in children usually represent erythema nodosum which exhibits characteristic skin changes. Three cases of pretibial subcutaneous lesions are presented which had no skin involvement or bony abnormalities on plain radiographs. At initial presentation, concerns of malignancy were raised but these lesions were ultimately diagnosed as granuloma annulare, fat necrosis and subcutaneous infection. In combination with clinical assessment and plain radiographs, MRI proved invaluable in reaching diagnosis and excluding neoplasia. Biopsy was only required in one case in this series after MRI. A tissue diagnosis, however, remains mandatory if there is any doubt over the nature of such lesions.

Soft tissue sarcomas of the foot and ankle: impact of unplanned excision, limb salvage, and multimodality therapy

BACKGROUND

Foot and ankle sarcomas have historically been treated with amputation because of the difficulty in achieving local disease control and maintaining a functional foot. Potential opportunities for limb salvage may be further compromised by unplanned excisions.

MATERIALS AND METHODS

We reviewed 52 consecutive patients with soft tissue sarcomas of the foot and ankle and analyzed the impact of planned versus unplanned initial excision, limb salvage, and multimodality therapy on treatment and outcomes.

RESULTS

Unplanned excisions had been performed in 29 (55.8%) patients. Limb salvage was performed in 38 patients, with 14 requiring free soft tissue transfers. At an average followup of 99 (range, 24 to 216) months, the 5-year overall survival estimate was 76.3%. Although not statistically significant, we noted clinically relevant potential differences in local recurrence-free, disease-free, and oncologic survival between the planned and unplanned excision groups. Seven patients (13.5%) had a local recurrence, five of these following an unplanned excision. Functional scores averaged 83.2% for all patients which were similar between planned versus unplanned and amputation versus limb salvage groups. Significantly more patients with unplanned excisions required free flaps for limb salvage (p = 0.017) and received adjuvant radiotherapy (p = 0.0004).

CONCLUSION

Unplanned surgery for soft tissue sarcomas of the foot and ankle often results in the need for more aggressive surgery and/or adjuvant radiotherapy and may impact oncologic outcomes, but does not necessarily portend worse functional outcomes. Multimodal therapy and judicious use of soft tissue flap reconstruction allows limb salvage in most patients with favorable outcomes.

Approach to the management of soft tissue tumors of the foot and ankle

To properly treat soft tissue tumors, the foot and ankle surgeon must start with an adequate fund of knowledge and follow a systematic approach. Some malignant soft tumors have a predilection for the foot and ankle, and they may mimic common musculoskeletal conditions, leading to a trap for the unwary clinician. This review will familiarize the practitioner with the common soft tissue tumors that occur in the foot and ankle along with their presentations. A systematic approach to the workup is outlined, which is designed to establish the diagnosis with a significant degree of certainty before the surgical treatment of the tumor is planned. A practical and reliable method of distinguishing benign tumors from those that are potentially malignant is presented. Finally, the techniques for surgical management of the common soft tissue tumors are summarized.

Synovial sarcoma: a case report

Synovial sarcoma most commonly affects adults in the third to fifth decades of life, and is the most common sarcoma of the foot. The tumors are encapsulated and frequently in contact with bone. Because there are often few anatomical barriers, malignant spread to surrounding nerves and vasculature is common. This article discusses the case of a young patient who presented to the foot and ankle clinic with soft tissue swelling in the right foot, and the imaging protocol for such a patient. A literature review of synovial sarcoma is also presented.

Reconstruction with pasteurized autograft for distal tibial tumor

INTRODUCTION

Primary malignant tumors of the distal tibia are rare. With advances in various treatment modalities, limb salvage for tumors of the distal tibia has been indicated for selected cases. This study examined whether the results of a pasteurized autologous bone graft are comparable to other reconstruction methods with regard to the graft survival and the functional outcome.

MATERIALS AND METHODS

Between 1992 and 2003, nine patients with malignant tumors of the distal tibia were subjected to the reconstruction with a recycled pasteurized autograft. The ultimate graft survival, union time, complications, and functional results were analyzed retrospectively.

RESULTS

One out of the nine autografts was removed after 15 months, due to non-union. Seven complications occurred in six patients, which included superficial infections (two cases), deep infections (one case), non-union (two cases), and fracture (two cases). None of the patients required a secondary below the knee amputation during the follow-up period. The average musculoskeletal tumor society (MSTS) functional score was 26/30 (86.7%).

CONCLUSIONS

The reconstruction with a pasteurized autograft is a simple and easily method for treating distal tibial malignancies. Moreover, vascularized fibula transfer might be considered a good ancillary procedure for resolving graft-related complications.

Clear cell sarcoma of soft tissues

Clear cell sarcoma (CCS) is a rare but highly malignant tumor of soft tissues often appearing as a small tender mass in the deep tissues of the distal extremities. We have studied 17 patients with such lesions treated since 1986 and have a high incidence of local recurrence and metastasis with a survival rate of only 47% despite surgery and for many of the patients, adjuvant therapy. The purpose of this article is to warn the readers of the dangers related to treating this seemingly benign lesion and urge them to perform wide surgery and utilize adjuvant therapy.

Treatment of proximal humeral chondrosarcoma with resection and allograft

Chondrosarcoma of the proximal humerus is an uncommon malignant bone tumor, and limited information is available about treatment. We retrospectively reviewed 31 patients treated by resection and replacement with allograft implants during the past 24 years. The patients were followed up for an average of more than 16 years. Despite some allograft complications, the overall success rate for the grafts was 77%, and patient survival was 96%. Only 1 patient died. Two patients required amputation for local recurrences, and the remainder did reasonably well despite some functional problems. On the basis of this study and by comparison data, we believe that proximal humeral chondrosarcomas are less malignant than chondrosarcomas in other sites. In comparing them against 26 metallic implants, we believe that resection and allograft implantation remains a generally successful treatment, although the improvement of the metallic devices over the years has made this technique more available and acceptable.

Fibular osteosarcomas: contaminated margins may not impact survival

The fibula is an expendable bone which when affected by primary malignancy may simplify treatment and improve outcome. This concept was questioned previously in a study showing a high rate of inadequate margins at surgical resection. We asked whether margin status and other dependent variables affect survival. We analyzed the charts of 36 patients with fibular osteosarcomas treated from 1919 to 2000. We estimated survival by the Kaplan-Meier method and the prognostic significance of dependent variables, especially marginal status, with univariate association using Cox proportional hazard regression. The survival of patients with fibular osteosarcomas was limited, with a median survival of 5 years 4 months after diagnosis. At 5 years, 16 patients died of their disease. Sixteen patients were still alive at 10 years followup. The margin status at surgery was not associated with survival. A higher tumor grade at diagnosis, surgical treatment with above-knee amputation, and occurrence of metastasis were associated with poorer long-term survival. The survival of patients with fibular osteosarcomas was not better than with osteosarcomas arising in other locations. A marginal resection surprisingly did not impact on overall survival, although we had a limited dataset and heterogeneous treatment protocols.

Limb salvage for osteosarcoma of the distal tibia with resection arthrodesis, autogenous fibular graft and Ilizarov external fixator

We report the results of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection arthrodesis, autogenous fibular graft and fixation by an Ilizarov external fixator.

In six patients with primary osteosarcoma of the distal tibia who refused amputation, treatment with wide en bloc resection and tibiotalar arthrodesis was undertaken. The defect was reconstructed using non-vascularised free autogenous fibular strut graft in three patients and a vascularised pedicular fibular graft in three, all supplemented with iliac cancellous graft at the graft-host junction. An Ilizarov external fixator was used for stabilisation of the reconstruction.

In five patients sound fusion occurred at a mean of 13.2 months (8 to 20) with no evidence of local recurrence or deep infection at final follow-up. The mean post-operative functional score was 70% (63% to 73%) according to the Musculoskeletal Tumour Society scoring system. All five patients showed graft hypertrophy.

Union of the graft was faster in cases reconstructed by vascularised fibular grafts. One patient who had a poor response to pre-operative chemotherapy developed local tumour recurrence at one year post-operatively and required subsequent amputation.

A particular solution in the treatment of primitive neoplasms of the distal third of the tibia. Presentation of a clinical case and review of the literature

Primitive malignant neoplasms affecting the distal third of the tibia are altogether rare, and their treatment is considerably controversial. The authors describe the diagnostic procedure and a particular surgical strategy of limb salvage in a case of malignant fibrous histiocytoma located at the distal third of the tibia, in particular pointing out the difficulties in restoring the continuity of the skeletal tissues and of the muscle, and with a review of the relevant literature.

Reconstruction of Musculoskeletal Defects Following Oncologic Resection in 76 Patients

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.

Advantage of limb salvage over amputation for proximal lower extremity tumors

Although function after lower extremity amputation and limb salvage has been compared, no study has assessed individual functional variables by surgical level. Our aim was to determine whether risks of long-term psychologic and physical limitations were associated with amputation or limb salvage at four levels: below-knee, above-knee, hip, and pelvis. We included 408 patients with sarcomas and postoperative followup of 2 years or greater who had completed a quality-of-life self-report questionnaire. The mean length of followup was 8.91 +/- 5.15 years (range, 2-27 years). Relative risk analysis was done on 12 dichotomous general health, psychologic, and physical function variables. At the below-knee level, outcomes were similar after both procedures. At the above-knee level, amputation was associated with increased risk of limp (RR = 1.6), walking aid use (RR = 2.1), anxiety (RR = 2.4), and inability to drive (RR = 3), and decreased risk of muscle weakness (RR = 0.57). At the hip and pelvic levels, outcomes were descriptively compared because of the small number of amputations. At these higher levels, limitations were more common after amputation. The difference in results between the below-knee and above-knee levels supports the importance of distinguishing surgical levels. Limb salvage offers a functional advantage at proximal tumor locations.

LEVEL OF EVIDENCE

Therapeutic study, Level III (retrospective, comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Bone invasion in extremity soft-tissue sarcoma

BACKGROUND

The purpose of the current study was to evaluate histologic bone invasion as a predictor of oncologic outcome in extremity soft-tissue sarcoma (STS) patients presenting to a specialty sarcoma center between 1986 and 2001.

METHODS

All patients who underwent surgery for extremity STS were identified from the prospective database at the study institution. Patient demographic features were compared using chi-square analyses or independent-sample Student t-tests. The disease outcomes were compared for those with and without bone invasion using Kaplan-Meier survival analysis and Cox modeling.

RESULTS

In a review of 874 patients with STS of the extremity, 48 patients (5.5%) had evidence of bone invasion. Patients with bone invasion presented with larger tumors that were more frequently deep in the extremity and more often had metastases at presentation. Patients with bone invasion had lower metastasis-free survival but bone invasion was not found to be an independent prognostic factor (P = .274) on Cox modeling. Bone invasion was found to be prognostic of overall survival on multivariate analysis (P < .0001).

CONCLUSIONS

In a small percentage of patients with STS, bone resection may be required to obtain an adequate surgical margin, thereby limiting the risk of local tumor recurrence. Histologic bone invasion portends a poorer prognosis in terms of overall survival.

Low-grade fibromyxoid sarcoma arising in the big toe

Low-grade fibromyxoid sarcoma (LGFMS) is a rare tumor. Reported herein is a case of LGFMS arising in the big toe. The patient was a 58-year-old man who underwent excision of the tumor. The tumor was well-demarcated. Histologically, there were proliferating spindle-shaped tumor cells arranged in a whorled growth pattern, and the stroma showed hyalinized collagen bundles and a myxoid matrix. Nuclear mitotic figures were conspicuous in part. A large rosette-like structure with hyalinized stroma was found, which is characteristic of LGFMS. The differential diagnosis included tumor occurrence in adults; tending to arise in distal extremities; and having bland fibromyxoid histological features, such as fibroma of tendon sheath, low-grade myxofibrosarcoma and acral myxoinflammatory fibroblastic sarcoma. It was not possible to detect the FUS/CREB3L2 and FUS/CREB3L1 fusion genes from the formalin-fixed and paraffin-embedded tissue, although the histological features of the present case were typical of LGFMS. LGFMS may become more common with time, and unique cases may accumulate.

Treatment of primary malignant bone tumours of the distal tibia

We treated 15 patients with primary malignant bone tumours of the distal tibia of which 14 were treated by limb salvage surgery. Reconstructions were done by allografts with or without microvascular fibula transfer, by bone transport, by fibula transfer alone or by endoprosthetic replacement. The most successful methods were bone transport and endoprosthetic replacement. However, serious complications with deep infections leading to secondary amputation occurred in four patients and in all reconstruction groups. After a mean follow up of 7 years, no local recurrence occurred, and all patients were alive and free of disease. After radical resection, bone transport in defects less than 15 cm is a viable option. In larger defects in children, allograft with vascularised fibula is an acceptable alternative, but amputation still has a role in this group. In adults, endoprosthetic replacement with proper soft tissue coverage is a viable option in cases with large bony defects.