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Abdel Al S, Abou Chaar MK, Zmaily M, Asha W, Haddad H, Al-Najjar H. "Whoops" fixation of proximal humerus pathological fracture ended with forequarter amputation - Case report. Int J Surg Case Rep 2020; 75:53-60. [PMID: 32919330 PMCID: PMC7490996 DOI: 10.1016/j.ijscr.2020.08.052] [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] [Received: 05/25/2020] [Revised: 08/26/2020] [Accepted: 08/26/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Even with the advancement of limb salvage surgery techniques, forequarter amputation (FQA) is still used in orthopedic oncology. Even though it might pose catastrophic sequelae on the patient's lifestyle, debilitating one's ability to perform regular tasks, FQA is still considered as a treatment of last resort for huge fungating tumors of the upper extremity. CASE PRESENTATION We present a case of an 18-year-old male patient, who was diagnosed in Libya with left proximal humerus fracture after a trivial trauma and underwent open reduction and internal fixation using k-wires as it was thought to be a simple fracture. Soon after, pain and swelling progressed severely and an open biopsy confirmed a diagnosis of osteosarcoma and imaging suggested metastatic disease to the lungs for which he was started on chemoradiotherapy. He was referred to our cancer center to continue his management and due to the aggressive nature of the tumor, the patient underwent palliative forequarter amputation followed by multiple lines of chemotherapy and radiotherapy, all of which failed to halt the progression of the disease. The patient was lost to follow up due to his decision to go back to Libya. CONCLUSION "Whoops" surgeries are fixated upon repairing fractures without looking for the alarming signs on radiographs to exclude pathological entity. As in our case, the procedure done escalated the osteosarcoma into such a massive fungating tumor due to the violation of the osteosarcoma pseudo capsule, in which the only available option is to do a palliative forequarter amputation.
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Affiliation(s)
- Samer Abdel Al
- Department of Orthopedic Oncology, King Hussein Cancer Center, Amman, Jordan.
| | | | - Mais Zmaily
- Department of Radiology, King Hussein Cancer Center, Amman, Jordan.
| | - Wafa Asha
- Department of Radiation Oncology, King Hussein Cancer Center, Amman, Jordan.
| | - Hussam Haddad
- Department of Pathology and Laboratory Medicine, King Hussein Cancer Center, Amman, Jordan.
| | - Hani Al-Najjar
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan.
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de Mestral C, Hsu AT, Talarico R, Lee DS, Hussain MA, Salata K, Al-Omran M, Tanuseputro P. End-of-life care following leg amputation in patients with peripheral artery disease or diabetes. Br J Surg 2019; 107:64-72. [DOI: 10.1002/bjs.11367] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/10/2019] [Accepted: 08/22/2019] [Indexed: 02/02/2023]
Abstract
Abstract
Background
The aim was to characterize end-of-life care in patients who have had a leg amputated for peripheral artery disease (PAD) or diabetes.
Methods
This was a population-based retrospective cohort study of patients with PAD or diabetes who died in Ontario, Canada, between 2011 and 2017. Those who had a leg amputation within 3 years of death were compared with a control cohort of deceased patients with PAD or diabetes, but without leg amputation. The patients were identified from linked health records within the single-payer healthcare system. Place and cause of death, as well as health services and costs within 90 days of death, were compared between the amputee and control cohorts. Among amputees, multivariable regression models were used to characterize the association between receipt of home palliative care and in-hospital death, as well as time spent in hospital at the end of life.
Results
Compared with 213 300 controls, 3113 amputees were less likely to die at home (15·5 versus 24·9 per cent; P < 0·001) and spent a greater number of their last 90 days of life in hospital (median 19 versus 8 days; P < 0·001). Amputees also had higher end-of-life healthcare costs across all sectors. However, receipt of palliative care was less frequent among amputees than controls (inpatient: 13·4 versus 16·8 per cent, P < 0·001; home: 14·5 versus 23·8 per cent, P < 0·001). Among amputees, receipt of home palliative care was associated with a lower likelihood of in-hospital death (odds ratio 0·49, 95 per cent c.i. 0·40 to 0·60) and fewer days in hospital (rate ratio 0·84, 0·76 to 0·93).
Conclusion
Palliative care is underused after amputation in patients with PAD or diabetes, and could contribute to reducing in-hospital death and time spent in hospital at the end of life.
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Affiliation(s)
- C de Mestral
- Li Ka Shing Knowledge Institute of St Michaels Hospital, Toronto, Ontario, Canada
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Diabetes Action Canada, Toronto, Ontario, Canada
| | - A T Hsu
- ICES, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | | | - D S Lee
- ICES, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - M A Hussain
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - K Salata
- Li Ka Shing Knowledge Institute of St Michaels Hospital, Toronto, Ontario, Canada
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - M Al-Omran
- Li Ka Shing Knowledge Institute of St Michaels Hospital, Toronto, Ontario, Canada
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
- Diabetes Action Canada, Toronto, Ontario, Canada
- Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - P Tanuseputro
- ICES, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
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Gil S, Fernandez-Pineda I, Rao B, Neel MD, Baker JN, Wu H, Wu J, Anghelescu DL. Role of Amputation in Improving Mobility, Pain Outcomes, and Emotional and Psychological Well-Being in Children With Metastatic Osteosarcoma. Am J Hosp Palliat Care 2018; 36:105-110. [PMID: 30058346 DOI: 10.1177/1049909118791119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND: Few studies have analyzed the benefit of limb amputations in children with metastatic osteosarcoma and limited life span. OBJECTIVE: We studied outcomes of limb amputations in children with metastatic osteosarcoma. DESIGN: We performed a retrospective review of patients who underwent limb amputations (January 1995-June 2015) and died within 1 year of surgery. SETTING/PARTICIPANTS: We studied 12 patients with osteosarcoma at a single institution. MEASUREMENTS: Data on mobility, pain, and emotional and psychological well-being were retrieved from medical records from 1 month before surgery to 6 months after surgery. RESULTS: Of the 12 patients (7 females and 5 males; median age at surgery 13 years [range, 7-20 years]) meeting study criteria, 3 patients and 9 patients had primary osteosarcoma in upper and lower limbs, respectively. Mobility improved postamputation in 8 bedridden/wheelchair-bound patients. Postamputation, emotional, and psychological well-being improved for 9 patients, 3 patients had persistent psychological and/or emotional symptoms, and no patient experienced signs of regret. Daily mean pain scores were significantly lower at 1 week (median 3 [range, 0-6]; P = .03) and 3 months (median 0 [range, 0-8]; P = .02) postsurgery than at 1 week presurgery (median 5.5 [range, 0-10]). Morphine consumption (mg/kg/d) showed a trend toward higher values at 1 week (median 0.2 [range, 0-7.6]; P = .6) and 3 months (median 0.2 [range, 0-0.5]; P = .3) postsurgery than at 1 week presurgery (median 0.1 [range, 0-0.5]). CONCLUSIONS: Patients undergoing limb amputations had reduced pain and improved mobility and emotional and psychological well-being. Amputations are likely to benefit children with limited life expectancy.
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Affiliation(s)
- Sebastian Gil
- 1 Department of Surgery, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Bhaskar Rao
- 1 Department of Surgery, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Michael D Neel
- 1 Department of Surgery, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Justin N Baker
- 2 Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Huiyun Wu
- 3 Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jianrong Wu
- 3 Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Doralina L Anghelescu
- 4 Division of Anesthesiology, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
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Smith HG, Thomas JM, Smith MJ, Hayes AJ, Strauss DC. Major Amputations for Extremity Soft-Tissue Sarcoma. Ann Surg Oncol 2017; 25:387-393. [DOI: 10.1245/s10434-017-5895-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Indexed: 12/31/2022]
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Abstract
Patients in advanced stages of illness trajectories with local and widespread musculoskeletal incurable malignancies, either treatment naive or having recurrence are referred to the palliative care clinic to relieve various disease-related symptoms and to improve the quality of life. Palliative care is a specialized medicine that offers treatment to the disease-specific symptoms, places emphasis on the psychosocial and spiritual aspects of life and help the patients and their family to cope with advance stage cancer in a stronger and reasonable way. The overall outcome of musculoskeletal malignancies has improved with the advent of multidisciplinary management. Even then these tumors do relapse and leads to organ failures and disease-specific deaths in children and young adults in productive age group thus requiring an integrated approach to improve the supportive/palliative care needs in end-stage disease. In this article, we would like to discuss the spectrum of presentation of advanced musculoskeletal malignancies, skeletal metastasis, and their management.
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Affiliation(s)
- Ashish Gulia
- Department of Surgical Oncology, Orthopedic Oncology (Bone and Soft Tissue Services), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Suman Byregowda
- Department of Surgical Oncology, Orthopedic Oncology (Bone and Soft Tissue Services), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Pankaj Kumar Panda
- Department of Surgical Oncology, Orthopedic Oncology (Bone and Soft Tissue Services), Tata Memorial Hospital, Mumbai, Maharashtra, India
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Elsner U, Henrichs M, Gosheger G, Dieckmann R, Nottrott M, Hardes J, Streitbürger A. Forequarter amputation: a safe rescue procedure in a curative and palliative setting in high-grade malignoma of the shoulder girdle. World J Surg Oncol 2016; 14:216. [PMID: 27526689 PMCID: PMC4986170 DOI: 10.1186/s12957-016-0973-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/04/2016] [Indexed: 12/15/2022] Open
Abstract
Background Forequarter amputation (FQA) is a surgical treatment of tumors in the upper extremity and shoulder girdle that infiltrate the neurovascular bundles. In both curative and palliative settings, FQA can serve as an effective oncological treatment. Methods This study presents the FQA-related data of 30 patients (mean age 50 years) treated between 2000 and 2012. Their medical condition was high-grade bone or soft tissue sarcoma in 26 and high-grade carcinoma in four cases. Results Mean operation time was 119 min. One major and five minor complications occurred in the postoperative period. Resection margins were wide in 91 % of patients. Local recurrence was observed in four patients after 19 months on average. Patients treated with curative intention had a 5-year survival chance of 39 %. Average survival after palliative amputation was 11 months. Conclusions FQA provides an opportunity for adequate oncological margins in large tumors, while offering relief from tumor-induced distress in palliative situations.
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Affiliation(s)
- Ulrich Elsner
- Department of Orthopedics and Tumororthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
| | - Marcel Henrichs
- Department of Orthopedics and Tumororthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Georg Gosheger
- Department of Orthopedics and Tumororthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Ralf Dieckmann
- Department of Orthopedics and Tumororthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Markus Nottrott
- Department of Orthopedics and Tumororthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Jendrik Hardes
- Department of Orthopedics and Tumororthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Arne Streitbürger
- Department of Orthopedics and Tumororthopedics, University Hospital of Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
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Freitas RRD, Crivellaro ALS, Mello GJP, Neto MA, Filho GDF, Silva LVD. HEMIPELVECTOMY: ERASTO GAERTNER HOSPITAL'S EXPERIENCES WITH 32 CASES IN 10 YEARS. Rev Bras Ortop 2015; 45:413-9. [PMID: 27022573 PMCID: PMC4799085 DOI: 10.1016/s2255-4971(15)30390-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective: To show the experience of the Erasto Gaertner Hospital with hemipelvectomy surgery over a 10-year period. Methods: This was a retrospective study on 32 patients who underwent hemipelvectomy at Erasto Gaertner Hospital between 1998 and 2008, assessing clinical and surgical characteristics. Results: Among the 32 patients, 15 were female and 17 were male. The mean age was 37.94 years. Eight cases showed involvement of the neurovascular bundle: three were located in the iliac and extended to the thigh, two were in the acetabulum and extended to the thigh and three were in the acetabulum and pubis. Twenty-three cases presented a neurovascular bundle free from neoplasia: 11 were restricted to the iliac, six were in the acetabular region, two were in the pubic ramus and four extended to the whole hemipelvis bone. One case involved the iliac-femoral vessels: one in the pubic ramus. Seven cases of chondrosarcoma and four cases of Ewing's sarcoma represented the majority. Eight cases underwent external hemipelvectomy and 24 underwent internal hemipelvectomy (11 were type I; four were type II; two were type II + III; three were type III and four were type IV). Of these 24 cases, 13 did not have any reconstruction, 10 had a fibular graft and one had an iliacfemoral vein and artery prosthesis. Twenty-six surgeries were curative and six were palliative. There were 14 deaths. Survival of two and five years was seen in 11 and 10 cases, respectively. For six cases, less than two years had passed since the operation. Three cases were lost during follow-up. Conclusion: This study shows the experiences of an oncology reference service specializing in highly complex surgical treatment.
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Affiliation(s)
| | | | | | - Múrio Armani Neto
- Orthopedists in the Oncological Orthopedics Service, Erasto Gaertner Hospital, Curitiba, PR
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8
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Tsai CH, Tzeng HE, Juang WK, Chu PG, Fann P, Fong YC, Hsu HC, Yen Y. Curative use of forequarter amputation for recurrent breast cancer over an axillary area: a case report and literature review. World J Surg Oncol 2014; 12:346. [PMID: 25407045 PMCID: PMC4246546 DOI: 10.1186/1477-7819-12-346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 08/16/2014] [Indexed: 11/28/2022] Open
Abstract
Axillary recurrence of breast cancer that involves the brachial neurovascular bundle is uncommon. However, for many patients with such recurrence, forequarter amputation can play a palliative role in relieving excruciating pain and paralysis of the upper limb. Further, for those patients who do not have distant metastasis or other local-regional recurrence, forequarter amputation provides a chance for a cure. Only a few case reports of curative amputations for recurrent breast cancer are present in the literature. Here, we report a case of forequarter amputation for curative treatment of axillary recurrent breast cancer, together with a literature review. To date, we have followed the patient for three years after amputation, during which there has been no evidence of recurrence or metastasis. Although radical resection is feasible, it can be accompanied by surgical wound complications and psychosocial stress. Therefore, an organized multidisciplinary approach is needed to ensure the success of radical resection.
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Affiliation(s)
| | | | | | | | | | | | | | - Yun Yen
- Department of Molecular Pharmacology, City of Hope National Medical Center and Beckman Research Center, 1500 East Duarte Road, Duarte, CA 91010, USA.
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Ruggieri P, Mavrogenis AF, Mercuri M. Quality of life following limb-salvage surgery for bone sarcomas. Expert Rev Pharmacoecon Outcomes Res 2014; 11:59-73. [DOI: 10.1586/erp.10.91] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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10
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Behnke NK, Crosby SN, Stutz CM, Holt GE. Periscapular amputation as treatment for brachial plexopathy secondary to recurrent breast carcinoma: a case series and review of the literature. Eur J Surg Oncol 2013; 39:1325-31. [PMID: 24176674 DOI: 10.1016/j.ejso.2013.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 09/30/2013] [Accepted: 10/07/2013] [Indexed: 12/28/2022] Open
Abstract
AIMS Recurrent breast carcinoma with brachial plexus involvement is often misinterpreted as a radiation- or chemotherapy-induced brachial plexopathy. We review a case series of 4 patients at our institution within a 1-year period, and describe their diagnostic workup and treatment with a palliative periscapular amputation. Our aim is to describe this entity, indications and benefits of this procedure, when required for progressive disease, with the goal of raising a collective index of suspicion to aid in earlier diagnosis. METHODS Four patients with recurrent axillary breast cancer and symptoms consistent with a brachial plexopathy were prospectively collected over a 1-year period. A Pubmed search was conducted; pertinent articles were reviewed and reported. RESULTS Patients presented with intractable pain and flaccid paralysis of the ipsilateral limb. All had been previously treated with surgical resection, axillary lymph node dissection, chemotherapy, and radiation therapy. Average time from breast surgery to presentation was 78.75 months (range 11-216 months.) Workup included MRI and biopsy to confirm recurrence. Periscapular amputation was performed for each patient, all of who experienced subjective pain relief postoperatively. Three of the 4 patients are still living; one patient died of disease. CONCLUSION Breast cancer survivors presenting with a brachial plexopathy should raise suspicion for recurrent disease. Close evaluation with MRI is the best first step in diagnosis. Although periscapular amputation is an aggressive surgical treatment, it is an acceptable option when disease has progressed to neurovascular involvement and a functionless limb.
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Affiliation(s)
- N K Behnke
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, 1215 21st Ave South, Nashville, TN 37232, USA
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11
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Palliative embolization for osteosarcoma. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:1351-6. [DOI: 10.1007/s00590-013-1312-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 08/28/2013] [Indexed: 11/25/2022]
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12
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Attar S, Steffner RJ, Avedian R, Hussain WM. Surgical intervention of nonvertebral osseous metastasis. Cancer Control 2012; 19:113-21. [PMID: 22487973 DOI: 10.1177/107327481201900205] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nonvertebral osseous metastases can result in pain and disability. The goals of surgical intervention are to reduce pain and to improve function if nonsurgical treatment fails. The indications for proceeding with surgical intervention depend on anatomic location, amount of local destruction, extent of skeletal and visceral disease and, most important, the patient's performance status and life expectancy. METHODS This article reviews the evaluation and treatment of metastatic nonvertebral osseous lesions from the perspective of the orthopedic surgeon, based mainly on an assessment of the surgical literature. RESULTS This article summarizes the approaches to preoperative evaluation, patient selection, and medical optimization. Guidelines for estimating osseous stability and fracture risk are discussed, and surgical implants and their relation to postoperative outcomes are examined. This review also describes less invasive ablative procedures currently available. CONCLUSIONS The surgical management of nonvertebral osseous metastases involves multidisciplinary collaboration. The surgical construct must be a stable, reliable, and durable intervention that is individually tailored and matched to a patient's prognosis and performance status.
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Affiliation(s)
- S Attar
- Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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13
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Mavrogenis AF, Rossi G, Altimari G, Calabrò T, Angelini A, Palmerini E, Rimondi E, Ruggieri P. Palliative embolisation for advanced bone sarcomas. Radiol Med 2012; 118:1344-59. [DOI: 10.1007/s11547-012-0868-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 12/04/2011] [Indexed: 01/26/2023]
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Ayvaz M, Yilgor C, Mermerkaya MU, Konan A, Sonmez E, Acaroglu RE. Simultaneous forequarter amputation and radical mastectomy for metastatic breast carcinoma in a male patient: a case report. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 81 Suppl 1:S6-S11. [PMID: 22319742 PMCID: PMC3267069 DOI: 10.4174/jkss.2011.81.suppl1.s6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 08/09/2011] [Accepted: 08/31/2011] [Indexed: 01/02/2023]
Abstract
Although the majority of forequarter amputations are performed for high-grade bone and soft tissue sarcomas or extensive osteomyelitis of the upper extremity, this radical operation may also be indicated for the curative treatment of recurrent breast cancer and for the palliation of locally advanced breast cancer. We report a male patient with metastatic breast adenocarcinoma who underwent simultaneous mastectomy and forequarter amputation for the management of both his primary and metastatic disease.
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Affiliation(s)
- Mehmet Ayvaz
- Department of Orthopedics and Traumatology, Hacettepe University, School of Medicine, Ankara, Turkey
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15
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Parsons CM, Pimiento JM, Cheong D, Marzban SS, Gonzalez RJ, Johnson D, Letson GD, Zager JS. The role of radical amputations for extremity tumors: a single institution experience and review of the literature. J Surg Oncol 2011; 105:149-55. [PMID: 21837679 DOI: 10.1002/jso.22067] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 07/24/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Major amputations are indicated for advanced tumors when limb-preservation techniques have been exhausted. Radical surgery can result in significant palliation and possible cure. METHODS We identified 40 patients who underwent forequarter (FQ) or hindquarter (HQ) amputations between May 2000 and January 2011. Patient demographics, tumor-related factors, and outcomes were reviewed. RESULTS There were 30 FQ and 10 HQ amputations. The most common diagnoses were sarcoma (55%) and squamous cell carcinoma (25%). Patients presented with primary tumors (35%), regional recurrence (57.5%), or unresectable limb metastatic disease (7.5%). Presenting symptoms included fungating wounds (35%), intractable pain (78%), and limb dysfunction (65%). Operations were performed with curative intent (10%), curative/palliative intent (70%), or palliation alone (20%). Wound complications occurred in 35%. Pain was improved in 78% of patients following surgery. Despite a 91% negative margin rate, 79% of patients recurred either locally or distantly. Median overall survival was 10.9, 13.2, and 3.4 months in the curative, curative/palliative, and palliative groups, respectively. CONCLUSIONS In the absence of conservative options, major amputations are indicated for the management of advanced tumors. These operations can be performed safely, resulting in effective palliation of debilitating symptoms. While recurrence rates remain high, some patients can achieve prolonged survival.
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Dimas V, Kargel J, Bauer J, Chang P. Forequarter amputation for malignant tumours of the upper extremity: Case report, techniques and indications. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2011; 15:83-5. [PMID: 19554191 DOI: 10.1177/229255030701500204] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Forequarter (interscapulothoracic) amputation is a major ablative surgical procedure that was originally described to manage traumatic injuries of the upper extremity. Currently, it is most commonly used in the treatment of malignant tumours of the arm. With the advent of limb-sparing techniques, primary forequarter amputation is performed less frequently, but remains a powerful surgical option in managing malignant tumours of the upper extremity; therefore, surgeons should be familiar with this procedure. A classic case report of forequarter amputation, with emphasis on indications and surgical techniques, is presented.
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Affiliation(s)
- Vanessa Dimas
- University of Texas Medical Branch, Galveston, Texas, USA
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17
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Kumar A, Naranje S, Gupta H, Khan SA, Yadav CS, Rastogi S, Gamanagatti S, Bakhshi S. A single incision surgical new anterior technique for forequarter amputation. Arch Orthop Trauma Surg 2011; 131:955-61. [PMID: 21203768 DOI: 10.1007/s00402-010-1244-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Conventionally described standard techniques of forequarter amputation may not be suitable for patients presenting with neglected or maltreated very large tumors of the proximal humerus. PATIENTS AND METHODS Eleven patients with unsalvageable malignant tumors of proximal humerus, who underwent forequarter amputation using a new technique between Jan 2008 to March 2010, were retrospectively analysed. This new single incision anterior approach involves supine positioning of patients, ligation of axillary vessels in the axilla followed by resection of muscles from lateral border and inferior angle of scapula, resection of lateral one-third of clavicle; resection of muscles from vertebral border and superior angle of scapula by applying superolateral traction without any incision over acromioclavicular axis or posterior scapular skin. RESULTS The average age was 16.27 year and minimum follow-up was 6 months (range 6-24 months). There were seven males and four females. Average duration of surgery was 62 min (range 55-90). Blood loss ranged from 400 to 750 ml. One patient had superficial infection and one patient with metastatic lesion died at 6 months follow-up. CONCLUSIONS This technique is safe, easy, less time consuming, involves small single incision in supine position, has better wound healing and can be used for both small and large tumors of proximal humerus with or without involvement of axillary vessels. Although there was no local recurrence for last 24 months but a long term follow-up is required to comment on its actual rate.
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Affiliation(s)
- Ashok Kumar
- Department of Orthopaedics, All India Institute of Medical Sciences, Delhi 110070, India.
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Ferguson PC, Deheshi BM, Chung P, Catton CN, O'Sullivan B, Gupta A, Griffin AM, Wunder JS. Soft tissue sarcoma presenting with metastatic disease: outcome with primary surgical resection. Cancer 2010; 117:372-9. [PMID: 20830769 DOI: 10.1002/cncr.25418] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Revised: 01/02/2010] [Accepted: 02/11/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objective of this study was to assess patient, tumor, and treatment factors that affected overall survival in a group of patients who underwent surgery for soft tissue sarcoma (STS) and presented with American Joint Commission on Cancer stage IV disease. METHODS A retrospective review was undertaken of a single institution's database from the years 1986 to 2006 in all patients who met the following inclusion criteria: 1) surgical management of the primary tumor was undertaken, and 2) metastatic disease was present at the time of initial presentation. In total, 112 patients were identified who met the inclusion criteria. RESULTS The 5-year survival rate for the entire group was 17%. In univariate analysis, the variables that were identified as statistically significant for predicting improved overall survival were resection of metastatic disease (P = .003), <4 pulmonary metastases (P = .05), and the presence of lymph node metastases versus pulmonary metastases (P = .0002). In multivariate analysis, only the presence of lymph node metastases versus pulmonary metastases retained statistical significance (P = .05). The 5-year survival rate for patients who had lymph nodes metastases at diagnosis was 59%, whereas it was only 8% for patients who presented with pulmonary metastases. CONCLUSIONS Patients who presented with metastatic STS had a very poor prognosis despite aggressive surgical management of their primary tumor. The current results indicated that, although patients with isolated lymph node metastases may be cured by surgical resection, patients with pulmonary metastases are unlikely to be cured even with aggressive surgical management and should be treated with palliation of symptoms as the main objective.
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Affiliation(s)
- Peter C Ferguson
- University Musculoskeletal Oncology Unit, Division of Orthopedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada.
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19
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Rickelt J, Hoekstra H, van Coevorden F, de Vreeze R, Verhoef C, van Geel AN. Forequarter amputation for malignancy. Br J Surg 2009; 96:792-8. [DOI: 10.1002/bjs.6555] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Forequarter amputation (FQA) is an important treatment for malignant disease of the shoulder girdle. The aim of this study was to elucidate its role in surgical oncology.
Methods
This retrospective study analysed 40 patients who had an FQA. In nine, the chest wall was resected. The most frequent diagnoses were soft-tissue sarcoma (28 patients) and recurrent breast cancer (five).
Results
Median follow-up was 16 (range 1–184) months. The 1-year, 2-year and 5-year overall survival for patients with malignant disease was 71, 59 and 38 per cent respectively. The median time to local recurrence (eight patients) was 4 (range 1–19) months. Thirty-two patients had curative FQA with a 1-year, 2-year and 5-year overall survival of 90, 75 and 48 per cent respectively, and a median overall survival of 51 months. The 5-year overall and disease-free survival for soft-tissue sarcoma was 41 and 26 per cent respectively. Eight patients had a palliative FQA with a median survival of 5 (range 1–12) months.
Conclusion
In locoregional disease such as sarcoma, FQA may offer the only possibility of cure. However, in patients with axillary metastasis, FQA has no impact on survival, although local control may improve the patient's quality of life.
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Affiliation(s)
- J Rickelt
- Department of Surgical Oncology, Erasmus Medical Centre/Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - H Hoekstra
- Department of Surgical Oncology, University Medical Centre Groningen/University of Groningen, Groningen, The Netherlands
| | - F van Coevorden
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Huis, Amsterdam, The Netherlands
| | - R de Vreeze
- Department of Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Huis, Amsterdam, The Netherlands
| | - C Verhoef
- Department of Surgical Oncology, Erasmus Medical Centre/Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
| | - A N van Geel
- Department of Surgical Oncology, Erasmus Medical Centre/Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands
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Abstract
Metastatic bone disease is a major contributor to the deterioration of the quality of life of patients with cancer; it causes pain, impending and actual pathological fractures, and loss of function and may also be associated with considerable metabolic alterations. Operative treatment may be required for an impending or existing fracture and intractable pain. The goals of surgery are to provide local tumor control and allow immediate weight-bearing and function. Radiation therapy is often indicated postoperatively. Detailed preoperative evaluation is required to assess the local extent of bone destruction and soft-tissue involvement, involvement of other skeletal sites, and the overall medical and oncological status.
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Affiliation(s)
- Jacob Bickels
- National Unit of Orthopedic Oncology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel.
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21
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Mack LA, Temple WJ. Extended Pelvic Resection for Sarcoma or Visceral Tumors Invading Musculoskeletal Pelvis. Surg Oncol Clin N Am 2005; 14:397-417. [PMID: 15817246 DOI: 10.1016/j.soc.2004.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Lloyd A Mack
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
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22
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Johnston EA, Namm JP, Reeves ME. Major extremity amputation for nodal metastasis from squamous cell carcinoma. J Surg Oncol 2005; 93:76-8; discussion 78-9. [PMID: 16353183 DOI: 10.1002/jso.20347] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The regional lymph node basin is usually the first site of spread in cutaneous squamous cell carcinoma (SCC). Regional metastases are usually treated with comprehensive nodal dissection, sometimes followed by radiation and/or chemotherapy. Occasionally, when disease recurs after these conventional therapies, major extremity amputation may be the only way to render patients free of disease. We present three cases for which major extremity amputation was necessary. One patient underwent forequarter amputation for nodal metastasis, which had invaded the brachial plexus. Another patient underwent hip disarticulation for femoral bony invasion from inguinal nodal metastasis. The third patient underwent a hemipelvectomy for nodal metastasis, which had eroded the femoral artery and pelvic bone. These cases show that major extremity amputation can be both palliative and curative in patients with SCC.
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Affiliation(s)
- Elizabeth A Johnston
- Department of Surgery, Loma Linda University and VA Medical Centers, Loma Linda, California 9235, USA
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23
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Abstract
The role of major amputations in the palliative care of cancer patients remains controversial. Major amputations result in loss of function, frequently require prolonged recovery, and are associated with major morbidity or mortality. Therefore, it may seem that major amputations should be rarely recommended for the palliation of cancer patients. Hence, we attempt to establish the indications,management, and outcomes of major amputations in the palliative management of cancer patients.
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Affiliation(s)
- I Benjamin Paz
- Department of General and Oncologic Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA 91010, USA.
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24
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Abstract
Despite an increasing trend towards early diagnosis of breast cancer,patients still present with locally advanced disease. Also, in some patients chemotherapy will fail, and local and regional recurrence will occur. This article outlines options for palliative care for such patients.
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Affiliation(s)
- David G Sheldon
- Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
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25
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Wittig JC, Bickels J, Kollender Y, Kellar-Graney KL, Meller I, Malawer MM. Palliative forequarter amputation for metastatic carcinoma to the shoulder girdle region: indications, preoperative evaluation, surgical technique, and results. J Surg Oncol 2001; 77:105-13; discussion 114. [PMID: 11398163 DOI: 10.1002/jso.1079] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Uncontrolled metastatic carcinoma of the shoulder girdle is a difficult oncologic problem. This study reviews our experience with palliative forequarter amputation with emphasis on patient selection criteria, preoperative radiologic assessment, surgical technique, epineural postoperative analgesia, and clinical outcome. METHODS Eight patients who underwent palliative forequarter amputation for metastatic carcinoma between 1980 and 1999 were analyzed retrospectively. Diagnoses included breast carcinoma (n = 3), squamous cell carcinoma (n = 2), hypernephroma (n = 2), and carcinoma of unknown origin (n = 1). All patients presented with severe, intractable pain and a useless extremity. Venography demonstrated obliteration of the axillary vein in each of the patients in whom this procedure was performed. Exploration of the brachial plexus confirmed tumor encasement and unresectability in all patients. Epineural catheters for bupivacaine infusion were placed for postoperative pain control. RESULTS All patients experienced dramatic pain relief and improved mobility and overall function. Life-threatening hemorrhage and sepsis were alleviated. There were no instances of phantom limb pain or adverse psychological reactions, and no complications related to epineural analgesia. CONCLUSIONS Palliative forequarter amputation is relatively safe and reliable and provides effective pain relief for selected patients with unresectable metastatic carcinoma to the axilla and bony shoulder girdle in whom radiotherapy and/or chemotherapy has not been effective. The triad of pain, motor loss, and an obliterated axillary vein is indicative of brachial plexus infiltration and unresectability.
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Affiliation(s)
- J C Wittig
- Department of Orthopedic Oncology, Washington Cancer Institute at the Washington Hospital Center, Washington, DC 20010, USA.
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26
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Tran NV, Evans GR, Kroll SS, Miller MJ, Reece GP, Ainsle N, Robb GL. Free filet extremity flap: indications and options for reconstruction. Plast Reconstr Surg 2000; 105:99-104. [PMID: 10626977 DOI: 10.1097/00006534-200001000-00017] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Radical and extended forequarter and hind limb amputations have been used for curative and palliative intents. Concerns regarding wound healing and closure, especially in irradiated fields, have occasionally limited the extent of ablation. This article reports an experience with coverage of these large defects by using the free filet extremity flap. A retrospective review was performed of 11 patients who had undergone immediate reconstruction with free filet extremity flaps between 1991 and 1998. There were nine men and two women with an average age of 43.9 years. All except three patients received preoperative radiotherapy. Resections included four hindquarter and seven forequarter amputations for palliation of intractable pain, tissue necrosis, and infections. Donor vessels included the brachial artery, its venae comitantes, cephalic and basilic veins, and common femoral and popliteal vessels. Immediate reconstruction was successful in all cases by the use of the amputated limb as the free filet flap. All wounds healed despite irradiation inclusive of defects up to 50 cm x 70 cm (3500 cm2). The average follow-up time was 5 months with a mean survival of 3.5 months. Four patients currently are alive, and one patient died within 30 days of surgery. The remaining six patients have died of their disease within 9 months of the palliative procedures. Pain, tissue necrosis, and infections were improved in all patients after hospital discharge. Extensive defects can be reconstructed and healed successfully, even in irradiated wounds, with the use of the free filet extremity flap. Appropriate advanced preoperative and intraoperative planning is essential. Although survival was unchanged, this technique allowed healed wounds with an improvement in the quality of life.
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Affiliation(s)
- N V Tran
- Department of Plastic Surgery, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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27
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Ham SJ, Schraffordt Koops H, Veth RP, van Horn JR, Eisma WH, Hoekstra HJ. External and internal hemipelvectomy for sarcomas of the pelvic girdle: consequences of limb-salvage treatment. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1997; 23:540-6. [PMID: 9484927 DOI: 10.1016/s0748-7983(97)93173-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The outcome of different limb-saving treatment modalities for pelvic girdle sarcoma is controversial. The oncological and functional results after 11 external and 10 internal hemipelvectomies and the consequences of limb-salvage treatment were studied in 21 consecutive patients with primary bone (19 patients) or soft tissue sarcoma (two patients) of the pelvic girdle. Following external hemipelvectomy, 10 patients (91%) died after a median follow-up of 1.6 years (range: 0.3-7.1). Isolated local recurrences occurred in three patients (27%), with concomitant distant failure in one (9%), while isolated distant failure occurred in six patients (55%). The rate of flap necrosis and wound infection following external hemipelvectomy were both 25%. Following internal hemipelvectomy, nine patients (90%) were alive without evidence of disease after a median follow-up of 6.6 years (range: 2.3-16.0). Concomitant local and distant failures were found in one patient (10%). Reconstruction-related complications necessitated revisional procedures in five of seven patients (72%), leading to external hemipelvectomy in one. Patients with a locally advanced pelvic girdle sarcoma who are unable to undergo an internal hemipelvectomy have a worse prognosis than patients who undergo an internal hemipelvectomy. An internal hemipelvectomy is not attended by an increased risk of local failure, but is by long-term local complications, requiring extensive surgical procedures.
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Affiliation(s)
- S J Ham
- Department of Surgical Oncology, Groningen University Hospital, The Netherlands
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28
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Volpe CM, Peterson S, Doerr RJ, Karakousis CP. Forequarter amputation with fasciocutaneous deltoid flap reconstruction for malignant tumors of the upper extremity. Ann Surg Oncol 1997; 4:298-302. [PMID: 9181228 DOI: 10.1007/bf02303578] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Malignant tumors of the upper extremity involving a considerable portion of the medial axillary wall may require forequarter amputation to achieve gross resection of tumor. These resections frequently leave a large defect, often requiring a split thickness skin graft or free flap to close the wound. To address this problem of wound closure, we have modified our technique and devised a reconstructive component as part of our forequarter amputation procedure. METHODS The medical records of seven patients who underwent forequarter amputation and fasciocutaneous deltoid flap reconstruction between 1982 and 1994 were reviewed. RESULTS All the amputation sites were completely closed with a fasciocutaneous deltoid flap without the use of additional skin grafts or free flaps. After a median follow-up of 12 months, there were no local recurrences. Three patients (43%) are alive and disease free 5, 12, and 19 months after their forequarter amputation. One patient is alive with disease after 14 months. The remaining three patients died of their disease. CONCLUSION The fasciocutaneous deltoid flap is technically easy to perform, provides wound coverage without the use of skin grafts, and is especially useful for tumors involving the media axillary wall and in patients with previous axillary radiation.
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Affiliation(s)
- C M Volpe
- Department of Surgery, State University of New York at Buffalo, School of Medicine, USA
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29
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Merimsky O, Kollender Y, Inbar M, Chaitchik S, Meller I. Palliative major amputation and quality of life in cancer patients. Acta Oncol 1997; 36:151-7. [PMID: 9140431 DOI: 10.3109/02841869709109223] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Limb sparing surgery has replaced the amputation surgery in the treatment of limb sarcomas. Recurrent or persistent disease constitutes a major problem. Local symptoms such as agonizing pain, fractures, tumor fungation, inability to walk and inability to maintain daily activities, further impair the patient's quality of life. In this clinical set-up palliative amputation should be considered. Eighteen patients with soft-tissue or bone sarcomas and 3 patients with metastatic carcinoma underwent palliative major amputation. Hemipelvectomy was performed in 3 patients, hip disarticulation in 10, knee disarticulation or below-knee amputation in 3 patients, shoulder disarticulation in one patient and forequarter amputation in 4 patients. Local control of the disease and pain and improvement of the performance status were observed in 19 evaluable patients. The mobility was restored in 15 patients with lower limb surgery. The median survival following the procedure was 9 months. There was only one case of immediate post-operative death. Severe phantom pain was not reported by any of the patients. Quality of life was reported to be improved by two-thirds of the patients. To conclude, we have, found palliative major amputation surgery worth performing in low-performance status cancer patients with locally advanced disease.
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Affiliation(s)
- O Merimsky
- Department of Oncology, Tel-Aviv Sourasky Medical Center, Israel
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30
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Abstract
The value of cancer treatment was assessed using a 'natural experiment' where patients who refused treatment served as no-treatment controls in a situation where withholding treatment to form a control group is unethical. Each cancer patient who refused treatment in Alberta, Canada between 1975 and 1988 was compared with five subjects who accepted treatment, matched on cancer site, age, number of cancers, and time period. Variables associated with treatment-refusal were included in Cox's proportional hazards model of survival, with death from cancer as the endpoint and deaths from other causes as censored observations. Treatment was refused at a rate of 7.5 per 1,000. One-third of patients who refused treatment had lung cancer and most had unstaged disease. Treatment refusal was associated with a difference in median survival of approximately nine months. Site-specific analyses showed a range of effects. Case fatality among the treated patients fell by approximately 10 percent during the 14-year study period. Even in advanced disease, treatment can result in improved survival. However, the results of this study must be interpreted with caution and cannot be generalized to all cancer patients.
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Affiliation(s)
- S A Huchcroft
- Division of Epidemiology and Preventive Oncology, Alberta Cancer Board, Calgary, Canada
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