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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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Huynh THN, Kuruvilla DR, Nester MD, Zervoudakis G, Letson GD, Joyce DM, Binitie OT, Lazarides AL. Limb Amputations in Cancer: Modern Perspectives, Outcomes, and Alternatives. Curr Oncol Rep 2023; 25:1457-1465. [PMID: 37999825 DOI: 10.1007/s11912-023-01475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW This review summarizes current findings regarding limb amputation within the context of cancer, especially in osteosarcomas and other bony malignancies. We seek to answer the question of how amputation is utilized in the contemporary management of cancer as well as explore current advances in limb-sparing techniques. RECENT FINDINGS The latest research on amputation has been sparse given its extensive history and application. However, new research has shown that rotationplasty, osseointegration, targeted muscle reinnervation (TMR), and regenerative peripheral nerve interfaces (RPNI) can provide patients with better functional outcomes than traditional amputation. While limb-sparing surgeries are the mainstay for managing musculoskeletal malignancies, limb amputation is useful as a palliative technique or as a primary treatment modality for more complex cancers. Currently, rotationplasty and osseointegration have been valuable limb-sparing techniques with osseointegration continuing to develop in recent years. TMR and RPNI have also been of interest in the modern management of patients requiring full or partial amputations, allowing for better control over myoelectric prostheses.
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Affiliation(s)
- Thien Huong N Huynh
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Davis R Kuruvilla
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Matthew D Nester
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | | | | | - David M Joyce
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Odion T Binitie
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
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Jawad AM, Duraku LS, Susini F, Chaudhry T, George S, Jester A, Power DM. Resect, rewire, and restore: Nerve transfer salvage of neurological deficits associated with soft tissue tumors in a retrospective cohort series at a tertiary reconstructive center. J Plast Reconstr Aesthet Surg 2023; 85:523-533. [PMID: 37280143 DOI: 10.1016/j.bjps.2023.04.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/28/2023] [Accepted: 04/07/2023] [Indexed: 06/08/2023]
Abstract
AIMS We aimed to explore the effectiveness of nerve transfer as an intervention to restore neurological deficits caused by extremity tumors through direct nerve involvement, neural compression, or as a consequence of oncological surgery. METHODS A retrospective cohort study of consecutive cases was conducted, including all patients who underwent nerve transfers to restore functional deficits in limbs following soft tissue tumor resection. The threshold for a successful nerve transfer was a BMRC motor grade of 4/5 and sensory grade of 3-3+/4 with protective sensation. RESULTS In total, 29 nerve transfers (25 motor and 4 sensory) were completed in 11 patients, aged 12-70 years at referral, over a 6-year period to 2020. This included 22 upper limb and 3 lower limb motor nerve transfers. The timing of delayed nerve transfer reconstructions was 1-15 months following primary oncological resection, with immediate simultaneous reconstructions performed in 4 cases. The threshold for success was achieved in 82% of upper limb and 33% of lower limb motor nerve transfers, while all sensory transfers were successful in restoring protective sensation. CONCLUSION Nerve transfer surgery, a well-established technique in restoring deficits following traumatic nerve injury, is further demonstrably relevant in extremity oncological reconstruction, especially as it can be performed remotely to the tumor location or resection site and introduces a healthy nerve or fascicle to rapidly reinnervate distal muscles without sacrificing major function. This study further illustrates the importance of early recognition and referral to specialist services where multi-disciplinary surgical resection and reconstructive planning can be conducted. LEVEL OF EVIDENCE IV Clinical Case Series.
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Affiliation(s)
- Ali M Jawad
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Liron S Duraku
- Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Francesca Susini
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Tahseen Chaudhry
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Samuel George
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Andrea Jester
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, United Kingdom
| | - Dominic M Power
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom.
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Geiger EJ, Liu W, Srivastava DK, Bernthal NM, Weil BR, Yasui Y, Ness KK, Krull KR, Goldsby RE, Oeffinger KC, Robison LL, Dieffenbach BV, Weldon CB, Gebhardt MC, Howell R, Murphy AJ, Leisenring WM, Armstrong GT, Chow EJ, Wustrack RL. What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report. Clin Orthop Relat Res 2023; 481:526-538. [PMID: 35583517 PMCID: PMC9928620 DOI: 10.1097/corr.0000000000002243] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/21/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although pediatric lower extremity sarcoma once was routinely treated with amputation, multiagent chemotherapy as well as the evolution of tumor resection and reconstruction techniques have enabled the wide adoption of limb salvage surgery (LSS). Even though infection and tumor recurrence are established risk factors for early amputation (< 5 years) after LSS, the frequency of and factors associated with late amputation (≥ 5 years from diagnosis) in children with sarcomas are not known. Additionally, the resulting psychosocial and physical outcomes of these patients compared with those treated with primary amputation or LSS that was not complicated by subsequent amputation are not well studied. Studying these outcomes is critical to enhancing the quality of life of patients with sarcomas. QUESTIONS/PURPOSES (1) How have treatments changed over time in patients with lower extremity sarcoma who are included in the Childhood Cancer Survivor Study (CCSS), and did primary treatment with amputation or LSS affect overall survival at 25 years among patients who had survived at least 5 years from diagnosis? (2) What is the cumulative incidence of amputation after LSS for patients diagnosed with pediatric lower extremity sarcomas 25 years after diagnosis? (3) What are the factors associated with time to late amputation (≥ 5 years after diagnosis) in patients initially treated with LSS for lower extremity sarcomas in the CCSS? (4) What are the comparative social, physical, and emotional health-related quality of life (HRQOL) outcomes among patients with sarcoma treated with primary amputation, LSS without amputation, or LSS complicated by late amputation, as assessed by CCSS follow-up questionnaires, the SF-36, and the Brief Symptom Inventory-18 at 20 years after cancer diagnosis? METHODS The CCSS is a long-term follow-up study that began in 1994 and is coordinated through St. Jude Children's Research Hospital. It is a retrospective study with longitudinal follow-up of more than 38,000 participants treated for childhood cancer when younger than 21 years at one of 31 collaborating institutions between 1970 and 1999 in the United States and Canada. Participants were eligible for enrollment in the CCSS after they had survived 5 years from diagnosis. Within the CCSS cohort, we included participants who had a diagnosis of lower extremity sarcoma treated with primary amputation (547 patients with a mean age at diagnosis of 13 ± 4 years) or primary LSS (510 patients with a mean age 14 ± 4 years). The LSS cohort was subdivided into LSS without amputation, defined as primary LSS without amputation at the time of latest follow-up; LSS with early amputation, defined as LSS complicated by amputation occurring less than 5 years from diagnosis; or LSS with late amputation, defined as primary LSS in study patients who subsequently underwent amputation 5 years or more from cancer diagnosis. The cumulative incidence of late amputation after primary LSS was estimated. Cox proportional hazards regression with time-varying covariates identified factors associated with late amputation. Modified Poisson regression models were used to compare psychosocial, physical, and HRQOL outcomes among patients treated with primary amputation, LSS without amputation, or LSS complicated by late amputation using validated surveys. RESULTS More study participants were treated with LSS than with primary amputation in more recent decades. The overall survival at 25 years in this population who survived 5 years from diagnosis was not different between those treated with primary amputation (87% [95% confidence interval [CI] 82% to 91%]) compared with LSS (88% [95% CI 85% to 91%]; p = 0.31). The cumulative incidence of amputation at 25 years after cancer diagnosis and primary LSS was 18% (95% CI 14% to 21%). With the numbers available, the cumulative incidence of late amputation was not different among study patients treated in the 1970s (27% [95% CI 15% to 38%]) versus the 1980s and 1990s (19% [95% CI 13% to 25%] and 15% [95% CI 10% to 19%], respectively; p = 0.15). After controlling for gender, medical and surgical treatment variables, cancer recurrence, and chronic health conditions, gender (hazard ratio [HR] 2.02 [95% CI 1.07 to 3.82]; p = 0.03) and history of prosthetic joint reconstruction (HR 2.58 [95% CI 1.37 to 4.84]; p = 0.003) were associated with an increased likelihood of late amputation. Study patients treated with a primary amputation (relative risk [RR] 2.04 [95% CI 1.15 to 3.64]) and LSS complicated by late amputation (relative risk [RR] 3.85 [95% CI 1.66 to 8.92]) were more likely to be unemployed or unable to attend school than patients treated with LSS without amputation to date. The CCSS cohort treated with primary amputation and those with LSS complicated by late amputation reported worse physical health scores than those without amputation to date, although mental and emotional health outcomes did not differ between the groups. CONCLUSION There is a substantial risk of late amputation after LSS, and both primary and late amputation status are associated with decreased physical HRQOL outcomes. Children treated for sarcoma who survive into adulthood after primary amputation and those who undergo late amputation after LSS may benefit from interventions focused on improving physical function and reaching educational and employment milestones. Efforts to improve the physical function of people who have undergone amputation either through prosthetic design or integration into the residuum should be supported. Understanding factors associated with late amputation in the setting of more modern surgical approaches and implants will help surgeons more effectively manage patient expectations and adjust practice to mitigate these risks over the life of the patient. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Erik J. Geiger
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Wei Liu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nicholas M. Bernthal
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Brent R. Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin R. Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Robert E. Goldsby
- Division of Oncology, Department of Pediatrics, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | - Kevin C. Oeffinger
- Department of Medicine and Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Bryan V. Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Christopher B. Weldon
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
- Department of Surgery and Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mark C. Gebhardt
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Rebecca Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J. Murphy
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wendy M. Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Eric J. Chow
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rosanna L. Wustrack
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA, USA
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Maes DJ, Alaqeel M, Parry M, Botchu R, Sumathi V, Jeys LM, Stevenson JD. Haemorrhagic soft-tissue sarcoma: Oncological outcomes and prognostic factors for survival. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:345-352. [PMID: 36031468 DOI: 10.1016/j.ejso.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/04/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Haemorrhagic soft-tissue sarcomas (HSTS) are characterised by aggressive local growth and highly metastatic behaviour. We aimed to describe oncological outcomes and prognostic factors. MATERIALS AND METHODS Retrospective review including 64 patients treated with palliation (n = 7), with limb salvage surgery (LSS) (n = 9), with neoadjuvant radiotherapy (RT) + LSS (n = 12), with LSS + adjuvant RT (n = 30) or amputation (n = 6). Kaplan-Meier survival analysis estimated overall survival (OS), metastasis-free survival (MFS) and local recurrence-free survival (LRFS). After uni- and multivariate analysis, prognostic factors affecting OS, MFS and LRFS were identified. RESULTS Median age was 67 years (IQR 23 years) with median follow-up of 11 months (IQR 28 months). All cases were high grade. Eight (13%) had pulmonary metastases at presentation and another 40 (63%) developed metastases after median 9 months (IQR 19 months). Median OS was 12 months (IQR 38 months), and estimated OS after two-years was 15.9% and 52.9% for patients with and without metastatic disease at presentation, respectively. Improved OS was associated with negative resection margins (p = 0.031), RT (p = 0.045), neoadjuvant RT (versus adjuvant RT, p = 0.044) and amputation (versus LSS, p < 0.001). MFS was 35.1% after two-years. LR occurred in 18 of 51 (35.3%) patients with surgically treated localised disease. LRFS was 63.4% after two-years and significantly affected by a negative margin (p = 0.042) and RT (p = 0.001). CONCLUSION Haemorrhagic soft-tissue sarcomas should be excised, either with amputation or LSS with a clear resection margin. If LSS is attempted, neoadjuvant RT reduces the risk of tumour spillage and early LR, enhances the feasibility of achieving clear resection margins, and offers superior overall survival compared to adjuvant RT.
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Affiliation(s)
- Danielle J Maes
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
| | - Motaz Alaqeel
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK; Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Michael Parry
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
| | - Rajesh Botchu
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
| | - Vaiyapuri Sumathi
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK.
| | - Lee M Jeys
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK; College of Health and Life Sciences, Aston University, Birmingham, B4 7ET, UK.
| | - Jonathan D Stevenson
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK; Aston Medical School, Aston University, Birmingham, B4 7ET, UK.
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Gong MF, Li WT, Bhogal S, Royes B, Heim T, Silvaggio M, Malek M, Dhupar R, Lee SJ, McGough RL, Weiss KR. Intraoperative Evaluation of Soft Tissue Sarcoma Surgical Margins with Indocyanine Green Fluorescence Imaging. Cancers (Basel) 2023; 15:cancers15030582. [PMID: 36765538 PMCID: PMC9913765 DOI: 10.3390/cancers15030582] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/19/2023] Open
Abstract
Soft tissue sarcomas (STS) are rare malignant tumors often associated with poor outcomes and high local recurrence rates. Current tools for intraoperative and definitive margin assessment include intraoperative frozen section and permanent pathology, respectively. Indocyanine green dye (ICG) is a historically safe fluorophore dye that has demonstrated efficacy for intraoperative margin assessment in the surgical management of both breast and gastrointestinal cancers. The utility of ICG in the surgical management of sarcoma surgery has primarily been studied in pre-clinical mouse models and warrants further investigation as a potential adjunct to achieving negative margins. This study is a prospective, non-randomized clinical study conducted on patients with confirmed or suspected STS. Patients younger than 18 years, with a prior adverse reaction to iodine or fluorescein, or with renal disease were excluded from the study. Intravenous ICG was infused approximately three hours prior to surgery at a dosage of 2.0-2.5 mg/kg, and following tumor resection, the excised tumor and tumor bed were imaged for fluorescence intensity. When scanning the tumor bed, a threshold of 77% calibrated to the region of maximum intensity in the resected tumor was defined as a positive ICG margin, according to published protocols from the breast cancer literature. ICG results were then compared with the surgeon's clinical impression of margin status and permanent pathology results. Out of 26 subjects recruited for the original study, 18 soft tissue sarcomas (STS) were included for analysis. Three subjects were excluded for having bone sarcomas, and five subjects were excluded due to final pathology, which was ultimately inconsistent with sarcoma. The average age of patients was 64.1 years old (range: 28-83), with an average ICG dose of 201.8 mg. In 56% (10/18) of patients, ICG margins were consistent with the permanent pathology margins, with 89% specificity. The use of ICG as an intraoperative adjunct to obtaining negative margins in soft tissue sarcoma surgery is promising. However, studies with larger sample sizes are warranted to further delineate the accuracy, optimal dosage, timing, and types of sarcoma in which this diagnostic tool may be most useful.
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Affiliation(s)
- Matthew F. Gong
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - William T. Li
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - Sumail Bhogal
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - Brittany Royes
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - Tanya Heim
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - Maria Silvaggio
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - Marcus Malek
- Department of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Rajeev Dhupar
- Department of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - Stella J. Lee
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - Richard L. McGough
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
| | - Kurt R. Weiss
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA
- Correspondence:
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Jawad MU, Pollock BH, Alvarez E, Carr-Ascher JR, Randall RL, Thorpe SW. Non-Private Health Insurance Predicts Advanced Stage at Presentation and Amputation in Lower Extremity High Grade Bone Sarcoma: A National Cancer Database Study : Amputation Predicts Survival: An Effect Most Pronounced in Pediatric and AYA Age Group. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11494-4. [PMID: 35314919 DOI: 10.1245/s10434-022-11494-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/03/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Advances in diagnostic and treatment modalities for high grade bone sarcomas (HGBS) of lower extremity (LE) have enabled limb salvage resections as a feasible first-line surgical option. However, amputations are still performed. Impact of amputation on survival and predictive factors for amputation and the stage at presentation for HGBS of LE remain unknown. METHODS National Cancer Database was used to extract 5781 cases of high-grade bone sarcoma of the LE from 2004 to 2017. Kaplan-Meier and Cox regression were used to determine the impact of amputation on survival. Chi square test and logistic regression were used to assess the correlation of predictive factors with amputation and stage at presentation. RESULTS Amputation [hazard ratio (HR) 1.516; 95% confidence interval (CI) 1.259-1.826; p < 0.001] and advanced stage (HR 0.248; 95% CI 0.176-0.351; p < 0.001) were independent predictors of poor overall survival. The impact of amputation on survival was most pronounced for pediatric and adolescents and young adults (AYA) age groups (18% decrease in 10-year survival). Amputation was more likely to be performed among those with nonprivate insurance (HR 1.736; 95% CI 1.191-2.531; p = 0.004), a finding that was mirrored for advanced stage at presentation (HR 0.611; 95% CI 0.414-0.902; p = 0.013). DISCUSSION Amputation is an independent predictor of poor outcomes among patients with HGBS of LE. The impact of amputation on survival is the highest for the pediatric and AYA age group. Nonprivate insurance is associated with increased likelihood of amputation and an advanced stage at presentation among patients with high-grade bone sarcoma of the LE. This is the largest study highlighting insurance-related disparities in this cohort.
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Affiliation(s)
- Muhammad Umar Jawad
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Brad H Pollock
- Department of Public Health Sciences, University of California, Davis, Davis, CA, USA
| | - Elysia Alvarez
- Department of Pediatrics, University of California, Davis, Davis, CA, USA
| | - Janai R Carr-Ascher
- Department of Internal Medicine, University of California, Davis, Davis, CA, USA
| | - R Lor Randall
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Steven W Thorpe
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA.
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Nigam A, Aminpour N, Zeymo A, Desale S, Villano AM, Unger KR, Aboulafia AJ, Al-Refaie WB. National evaluation of patterns and predictors of underuse of multimodal therapy for high-risk extremity soft tissue sarcoma. Surgery 2022; 171:1348-1357. [DOI: 10.1016/j.surg.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 12/01/2022]
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9
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Amputation for Extremity Sarcoma: Indications and Outcomes. Cancers (Basel) 2021; 13:cancers13205125. [PMID: 34680274 PMCID: PMC8533806 DOI: 10.3390/cancers13205125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/07/2021] [Accepted: 10/09/2021] [Indexed: 12/23/2022] Open
Abstract
Simple Summary Sarcomas are malignant tumors of soft tissues or bone. While limb salvage surgery (LSS) is the standard treatment, amputation is an option especially in local recurrence (LR) or complications after LSS. Two groups with primary amputations (n = 120) or secondary amputations after failed LSS due to LR or complications (n = 29) were compared. Five-year LR-free survival was 84% and 17 (16%) patients developed LR, of which 16 were in group I and only one in group II. Overall survival (OS) at five years was 44%, and the rate was identical in both groups. In those group II patients who had a secondary amputation after LSS due to contaminated margins or LR (n = 12) five-year OS was 33% compared to 48% in patients with complications (n = 17). This study indicates the worse oncological outcomes with respect to OS of sarcoma patients needing an amputation as compared to LSS. Patients with primary amputation or those who had a secondary amputation after failed LSS for whatever reason showed the same results. Abstract Background: Sarcomas are rare, malignant tumors of soft tissues or bone. Limb salvage surgery (LSS) is the standard treatment, but amputation is still an option, especially in local recurrence or complications after LSS. Methods: We retrospectively reviewed indications and oncological outcomes in patients who underwent an amputation. Two groups with either primary amputations (n = 120) or with secondary amputations after failed LSS with local recurrence or complications (n = 29) were compared with the main end points of LRFS and OS. Results: Five-year LRFS was 84% with 17 (16%) patients developing local recurrence, of which 16 (13%) occurred in group I. Forty-two (28%) patients developed metastatic disease and overall survival at five years was 44%. Overall survival (OS) was the same in both groups. In those group II patients who had a secondary amputation due to LR or insufficient margins after LSS (n = 12) the five-year OS was 33% compared to 48% in patients with amputation due to complications (n = 17) (n.s.). Conclusions: This study indicates the worse oncological outcomes with respect to OS of sarcoma patients requiring an amputation as compared to LSS. Patients with primary amputation or those who had a secondary amputation after failed LSS for whatever reason showed the same oncological results.
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Robb L, Buick T, Rust PA. A lump in the hand. BMJ 2021; 373:n1447. [PMID: 34162579 DOI: 10.1136/bmj.n1447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Lydia Robb
- Department of Plastic and Reconstructive Surgery, NHS Lothian, St John's Hospital Livingston, West Lothian, UK
| | - Tim Buick
- Department of Plastic and Reconstructive Surgery, NHS Lothian, St John's Hospital Livingston, West Lothian, UK
| | - Philippa A Rust
- Hooper Hand Unit, NHS Lothian, St John's Hospital Livingston, West Lothian, UK
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Abstract
METHODS A multicentre retrospective study was carried out at two tertiary sarcoma centres. A database search identified all patients with a CS treated between January 1995 and January 2018. There were 810 CSs of which 76 (9.4%) were located in the fingers, toes, metacarpals, and metatarsal bones. RESULTS The median age of the study population was 55 years (36 to 68) with a median follow-up of 52 months (22 to 87) months. Overall, 70% of the tumours were in the hand (n = 54) and 30% in the foot (n = 22). Predictors for LR were margin (p = 0.011), anatomical location (p = 0.017), and method of surgical management (p = 0.003). Anatomical location (p = 0.026), histological grade between 1 and 3 (p = 0.004) or 2 and 3 (p = 0.016), and surgical management (p = 0.001) were significant factors for LR-free survival. Disease-specific survival was affected by histological grade (p < 0.001), but not by LR (p = 0.397). CONCLUSION Intralesional curettage of a low-grade CS is associated with an increased risk of LR, but LR does not affect disease-specific survival. Therefore, for low-grade CSs of the hands and feet, surgical management should aim to preserve function. In grade 2 CS, our study did not show any decreased disease-specific survival after recurrence; however, we suggest a more aggressive surgical approach to these tumours to prevent local recurrence, especially in the metacarpal and metatarsal bones. In high-grade tumours, the incidence of progressive disease is high and, therefore, the treatment of the primary tumour should be aggressive where possible, and patients observed closely for the development of metastatic disease. Cite this article: Bone Joint J 2021;103-B(3):562-568.
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Affiliation(s)
- Gilber Kask
- Department of Orthopaedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Department of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Helsinki, Finland
| | - Minna K Laitinen
- Department of Orthopaedics and Traumatology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jonathan Stevenson
- Royal Orthopaedic Hospital, Birmingham, UK.,Aston University Medical School, Aston University, Birmingham, UK
| | | | - Lee M Jeys
- Royal Orthopaedic Hospital, Birmingham, UK.,Faculty of Health Science, Aston University, Birmingham, UK
| | - Michael C Parry
- Royal Orthopaedic Hospital, Birmingham, UK.,Aston University Medical School, Aston University, Birmingham, UK
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12
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Calvo NJ, Mann AJ, Lopez-Viego M, Genuit T. Limb Salvage Resection of Massive Dedifferentiated Thigh Liposarcoma in a Patient Lost to Follow-Up. Cureus 2021; 13:e13356. [PMID: 33754090 PMCID: PMC7971712 DOI: 10.7759/cureus.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Dedifferentiated liposarcoma (DDL) is a rare soft tissue tumor that represents a non-lipogenic progression of well-differentiated liposarcoma (WDL). Unlike WDL, DDL has the propensity for metastasis and is associated with an increased incidence of local recurrence. For DDL of the extremities that is resectable with acceptable functional outcomes, treatment includes primary surgical resection with negative margins. Although rare due to advances in reconstructive techniques, amputation for DDL of the extremities should be considered in which appropriate tumor resection cannot be performed without adequate preservation of limb function. We present the clinical progression of a patient with a large DDL of the right thigh who was initially lost to follow-up, but ultimately underwent delayed definitive therapy with the intent for limb salvage. This case illustrates the importance of assessing neurovascular, osseous, and soft tissue involvement to properly predict and preserve limb function while achieving adequate tumor resection.
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Affiliation(s)
- Nicholas J Calvo
- Surgery, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Adam J Mann
- Surgery, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Miguel Lopez-Viego
- Surgery, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA.,Surgery, Bethesda Hospital East, Baptist Health South Florida, Boynton Beach, USA
| | - Thomas Genuit
- Surgery, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
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Othman S, Bricker JT, Azoury SC, Elfanagely O, Weber KL, Kovach SJ. Allograft Alone vs. Allograft with Intramedullary Vascularized Fibular Graft for Lower Extremity Bone Cancer: A Systematic Review and Meta-Analysis. J Plast Reconstr Aesthet Surg 2020; 73:1221-1231. [DOI: 10.1016/j.bjps.2020.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/09/2020] [Indexed: 12/30/2022]
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Correa-González N, De La Calva C, Miranda I, Amaya JV, Angulo M, Baixauli-García F. Soft tissue sarcomas in the elbow region and influence of their anatomical features in their treatment. Experience in the Unit of Musculoskeletal Tumours. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020; 64:301-309. [PMID: 32561206 DOI: 10.1016/j.recot.2020.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 04/10/2020] [Accepted: 04/21/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND AIM Soft tissue sarcomas are exceptionally located in the elbow region. The aim of this work was to study the soft tissue sarcomas of the elbow region, their epidemiological and histopathological characteristics, anatomical features, the treatment performed, and the results obtained, in a unit of musculoskeletal tumours. METHODS Retrospective review of ten patients with a mean follow-up of 65.0 ± 11.9 (range 21-132) months with soft tissue sarcomas located in the elbow region operated in our centre between 2008 and 2016. RESULTS Mean age was 60.8 ± 6.7 years. Undifferentiated pleomorphic sarcoma was the most frequent histological diagnosis. Limb preservation surgery was performed in 90% of patients. Three patients were previously operated without following surgical oncology guidelines in another hospital, and this was statistically related to the need for more than one surgery to control the disease. R1 margin was obtained in 5 patients and R0 in another 5. Adjuvant radiotherapy was used in 7 cases. In 4 patients, subsequent surgery was performed for local or systemic control of the disease. Local recurrence occurred in 3 cases and in 5 there was distant disease. CONCLUSION The elbow region presents difficulty in achieving wide margins due to the proximity of neurovascular structures, adjuvant and / or neoadjuvant therapies could play an important role in performing limb preservation surgery. It would be advisable to refer these tumours to specialized units with multidisciplinary teams.
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Affiliation(s)
- N Correa-González
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - C De La Calva
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - I Miranda
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Arnau de Vilanova, Valencia, España.
| | - J V Amaya
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - M Angulo
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - F Baixauli-García
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario y Politécnico La Fe, Valencia, España
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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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Zeller J, Kiefer J, Braig D, Winninger O, Dovi-Akue D, Herget GW, Stark GB, Eisenhardt SU. Efficacy and Safety of Microsurgery in Interdisciplinary Treatment of Sarcoma Affecting the Bone. Front Oncol 2019; 9:1300. [PMID: 31850204 PMCID: PMC6901986 DOI: 10.3389/fonc.2019.01300] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/11/2019] [Indexed: 01/08/2023] Open
Abstract
Background: Sarcomas are tumors of mesenchymal origin with high variation in anatomical localization. Sarcomas affecting the bone often require an interdisciplinary resection and reconstruction approach. However, it is critical that microsurgical reconstruction strategies do not negatively impact tumor safety and overall survival, as limb salvage is only the secondary goal of tumor surgery. Here, we analyzed the efficacy and safety of microsurgery in interdisciplinary treatment of sarcoma affecting the bone. Patients and Methods: We performed a retrospective chart review of all patients treated for soft-tissue and bone sarcoma at the senior author's institution with a focus on bone affection and microsurgical reconstruction between 2000 and 2019. This particular subgroup was further investigated for tumor resection status, 5-year survival rate, length of hospital stay, as well as overall complication and amputation rates. Results: Between 2000 and 2019, 803 patients were operated for sarcoma resection and reconstruction by the Department of Plastic and Hand Surgery. Of these, 212 patients presented with sarcoma of the extremity affecting the bone. Within this subgroup, 40 patients required microsurgical reconstruction for limb salvage, which was possible in 38 cases. R0 resection was achieved in 93.8%. The 5-year survival was 96.7%, and the overall complication rate was 25%, of which 40% were microsurgery associated complications. Conclusion: Safe and function-preserving treatment of soft-tissue and bone sarcoma is challenging. Primary reconstruction with microsurgical techniques of sarcoma-related defects enables limb-sparing and adequate oncosurgical cancer treatment without increasing the risk for local recurrence or prolonged hospital stay. The treatment of sarcoma patients should be reserved to high-volume centers with experienced plastic surgeon embedded in a comprehensive treatment concept.
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Affiliation(s)
- Johannes Zeller
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Jurij Kiefer
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - David Braig
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany.,Plastic and Reconstructive Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Oscar Winninger
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - David Dovi-Akue
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Georg W Herget
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - G B Stark
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
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Readability, Suitability, and Complexity of Online Resources for Lower Extremity Reconstruction. Ann Plast Surg 2019; 82:2-6. [DOI: 10.1097/sap.0000000000001636] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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