[Soft tissue sarcoma of the upper extremities. Analysis of factors relevant for prognosis in 160 patients]

Early Complications of Planned Resection Versus Unplanned Excision of Sarcomas in the Distal Upper Extremity

Purpose

Unplanned excisions are defined as excisions of malignant tumors performed without preoperative cross-sectional imaging or diagnostic biopsy, frequently resulting in residual disease and re-excision secondary to positive surgical margins. The purpose of this study was to compare the relative morbidity of planned versus unplanned upper-extremity sarcoma excisions.

Methods

A single tertiary referral hospital pathology database was queried from January 2015 through 2022 for primary upper-extremity sarcomas (forearm, wrist, hand, and finger). Demographics, tumor features, survival characteristics, and outcomes were retrospectively reviewed.

Results

Forty-two upper-extremity sarcoma patients were identified, two-thirds of whom had unplanned excisions. Those with unplanned excisions were more likely to be female (relative risk [RR]: 1.9; P = .002), undergo initial excision at a nonsarcoma center (RR: 14.0; P < .001), have masses distal to the forearm (RR: 1.6; P = .02), and have smaller masses (4.8 vs 7.4 cm, P = .03). 71.4% of tumors were high grade, and 60.7% less than 5 cm in size.Unplanned excisions had positive margins in 96.4% of cases and were more likely to undergo re-excision (odds ratio [OR]: 20.0; P = .001), more total resections (2.7 vs 1.4, P = .009), sacrifice of neurovascular structures (OR: 6.1; P = .04), adjuvant radiation therapy (OR: 4.5; P = .05), adjuvant systemic therapy (OR: 10.9; P = .03), or experience a complication (OR: 17.6; P = .002) at an average of 38.0 months of follow-up.Nearly half of all unplanned excision patients developed a local recurrence or metastatic disease. Six patients required an amputation versus one in the planned cohort (P = .17), and 26.5% of patients died at an average of 32.5 months from presentation.

Conclusions

Distal upper-extremity sarcoma excisions are frequently unplanned, with high rates of morbidity compared with planned excisions. Surgeons should have a low threshold for cross-sectional imaging and core needle biopsy of atypical lesions, irrespective of size, with referral to a sarcoma center.

Type of study/level of evidence

Prognostic IV.

Limb Amputations in Cancer: Modern Perspectives, Outcomes, and Alternatives

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.

Defect Coverage after Forequarter Amputation—A Systematic Review Assessing Different Surgical Approaches

Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion of osseous structures into these has several advantages. This article therefore systematically reviews reconstructive options after FQA, using osteomusculocutaneous fillet flaps, with emphasis on personalized surgical technique and outcome. Additionally, we report on a case with an alternative surgical technique, which included targeted muscle reinnervation (TMR) of the flap. Our literature search was conducted in the PubMed and Cochrane databases. Studies that were identified were thoroughly scrutinized with regard to relevance, resulting in the inclusion of four studies (10 cases). FQA was predominantly a consequence of local malignancy. For vascular supply, the brachial artery was predominantly anastomosed to the subclavian artery and the brachial or cephalic vein to the subclavian or external jugular vein. Furthermore, we report on a case of a large osteosarcoma of the humerus. Extended FQA required the use of the forearm for defect coverage and shoulder contour reconstruction. Moreover, we performed TMR. Follow-up showed a satisfactory result and no phantom limb pain. In case of the need for free flap reconstruction after FQA, this review demonstrates the safety and advantage of osteomusculocutaneous fillet flaps. If the inclusion of the elbow joint into the flap is not possible, we recommend the use of the forearm, as described. Additionally, we advocate for the additional implementation of TMR, as it can be performed quickly and is likely to reduce phantom limb and neuroma pain.

Forequarter amputation post transarterial chemoembolization and radiation in synovial sarcoma: A case report

INTRODUCTION AND IMPORTANCE

Forequarter amputation or interscapulathoracalis amputation is a major amputation procedure that involves the entire upper extremity, scapula, and a whole or part of the clavicula. Forequarter amputation is commonly used to control bleeding in malignant tumor cases in which no treatment is available for the extremities.

CASE PRESENTATION

We report a case of forequarter amputation in a 25-year-old patient with synovial sarcoma. Transarterial chemoembolization (TACE) and radiation synovial sarcoma were performed in the patient to reduce bleeding. This technique may also be used for treating synovial sarcoma with massive bleeding.

CLINICAL DISCUSSION

Despite forequarter amputation indications in malignant tumor cases and recurrent cancer cases, the effectiveness of this technique remains unclear. The patient was readmitted with a recurrent mass three months after surgery.

CONCLUSION

In this study, TACE and radiotherapy are effective in controlling bleeding preoperatively and intraoperatively in patients with synovial sarcoma.

Epithelioid Sarcoma in a Young Child: A Case Report and Literature Review

Epithelioid sarcoma is a rare, high-grade malignant soft tissue tumor that is often misdiagnosed. Classified as a mesenchymal malignancy, it exhibits both mesenchymal and epithelial markers. Occurrence in children under age 10 is extremely rare. This report describes the clinical course and management of a 5-year-old girl who presented with epithelioid sarcoma in the distal extremity. The lesion was initially misdiagnosed and treated for over a year as a common wart.

Reconstrucción de pared torácica con material de fijación en pacientes con lesiones tumorales. Serie de casos

Introducción. El manejo quirúrgico de las lesiones de la pared costal con resección y reconstrucción con material protésico ha venido en aumento, debido al avance en las técnicas quirúrgicas y en la experiencia del cirujano, así como en la innovación y las características de los materiales protésicos, que permiten realizar resecciones amplias de la pared garantizando una mayor estabilidad esquelética, una menor alteración de la mecánica respiratoria y mejores los resultados estéticos. Métodos. Se presenta la experiencia en la clínica CardioVID, Medellín, Colombia, entre los años 2015 y 2019, mediante una revisión retrospectiva de 8 casos sometidos a resección de lesiones benignas de la pared torácica y reconstrucción con material protésico. Resultados. Se encontró una adecuada evolución de los pacientes, con un buen resultado estético y funcional, con adecuado control de la enfermedad, sin reportes de complicaciones ni de recidiva en el seguimiento. Discusión. Una técnica adecuada permite la reconstrucción de estos defectos con complicaciones mínimas y bajas tasas de extracción de prótesis, finalizando con excelentes resultados funcionales y cosméticos. Con nuestra experiencia podemos concluir que la elección adecuada de los pacientes candidatos a manejo quirúrgico, una buena técnica quirúrgica y un personal con experiencia son cruciales para lograr buenos resultados en cuanto a función pulmonar y estética. Además de lograr una sobrevida bajo los parámetros establecidos posterior a lograr una resección R0.

Diagnostic and prognostic role of mean platelet volume and mean platelet volume/platelet ratio in the most common soft tissue sarcomas

Objectives

This study aims to investigate the diagnostic and prognostic role of mean platelet volume (MPV) and MPV/platelet (PLT) ratio in the most common soft tissue sarcomas.

Patients and methods

We retrospectively investigated 131 patients (76 males, 55 females; mean age: 51.8±17.1; range, 18 to 87 years) with soft-tissue sarcomas between January 2011 and January 2019. Demographic features, MPV, PLT counts, mortality, and recurrence records of the patients were obtained from archives. A total of 165 healthy volunteers (101 males, 64 females; mean age 52.9±4.1; range, 18 to 60 years) who applied to the outpatient clinic in 2019 and had routine blood control without any additional disease formed the control group.

Results

A total of 55 patients were diagnosed with liposarcoma and 76 with pleomorphic sarcoma. Of the tumors, 77.1% were located in the lower limbs. Lesions were mostly localized on the thigh 48.8% (n=64). Recurrence occurred in 28.2% of the patients. A total of 25 (19.1%) patients were exitus. The mean follow-up period of the patients was 34.4±19.1 (range, 9 to 112) months. The mean PLT value of the patient group was significantly higher than the control group. The median MPV and MPV/PLT ratio were statistically significantly lower in the patient group than in the control group. The MPV and MPV/PLT ratio were not associated with mortality and recurrence.

Conclusion

As a result, MPV and MPV/PLT ratio can be used as a diagnostic support parameter in soft tissue sarcomas, but have no prognostic value.

Multidisciplinary treatment of soft tissue sarcomas: An update

Standard treatment for soft tissue sarcoma, based on complete surgical resection with or without adjuvant radiotherapy and chemotherapy, has not substantially changed during the last several decades. Nevertheless, recent advances have contributed to considerable improvement in the management of these patients; for example, new magnetic resonance imaging sequences such as diffusion-weighted imaging and magnetic resonance imaging radiomics can better assess tumor extension and even estimate its grade. Detection of circulating genetic material (liquid biopsy) and next-generation sequencing are powerful techniques for genetic analysis, which will increase our understanding of the underlying molecular mechanisms and may reveal potential therapeutic targets. The role of chemotherapy in non-metastatic disease is still controversial, and there is a need to identify patients who really benefit from this treatment. Novel chemotherapeutic regimens have entered clinical praxis and can change the outcome of patients with metastatic disease. Advances in radiotherapy have helped decrease local adverse effects and sustain good local control of the disease. The following report provides an updated view of the diagnosis, treatment, and future perspectives on the management of patients with soft tissue sarcomas.

Reconstruction of Brachial Artery with Great Saphenous Vein Graft in A Case of Residual Soft Tissue Sarcoma Arm

Soft tissue sarcomas of the upper extremities are very rare tumors. Due to the complex anatomy of the arm, the management of the soft tissue sarcoma becomes very challenging for the operating surgeons. Nonetheless, a large portion of the patients can be treated in a limb-sparing manner ,if surgical expertises are present .We report a case of 30 years old lady with soft tissue sarcoma of right arm operated in an another hospital, came to our institute with pain in the operated site and positive histological margins. The patient had feeble radial and ulnar artery pulses. We had done a MR angiography of that limb and it showed no flow from mid arm level in the brachial artery, but presence of collaterals around elbow joint. We had removed the residual tumor and also excised 14 cm of right brachial artery. On opening the brachial artery, tumor thrombus was seen along the whole length of the excised segment. The defect was reconstructed with reverse great saphenous vein graft taken from left leg. Post-operative period was uneventful. Doppler ultrasonography done at 6 and 12 months later showed good flow in the grafted segment with minimal narrowing of the anastomosis sites.

Soft tissue tumours of the elbow: current concepts

Soft tissue tumours of the elbow are mostly benign. Malignant tumours in this area, although uncommon, often present unique clinical and histopathological characteristics that are helpful for diagnosis.Management of soft tissue tumours around the elbow may be challenging because of their rarity and the proximity to neurovascular structures. Careful staging, histological diagnosis and treatment are essential to optimize clinical outcome. A missed or delayed diagnosis or an improperly executed biopsy may have devastating consequences for the patient.This article reviews the most common benign and malignant soft tissue tumours of the elbow and discusses the clinicopathological findings, imaging features and current therapeutic concepts. Cite this article: EFORT Open Rev 2019;4:668-677. DOI: 10.1302/2058-5241.4.190002.

Forequarter amputation: a safe rescue procedure in a curative and palliative setting in high-grade malignoma of the shoulder girdle

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.

Soft Tissue Sarcomas of the Arm - Oncosurgical and Reconstructive Principles within a Multimodal, Interdisciplinary Setting

Soft tissue sarcomas of the upper extremity represent a severe threat for the patient and a difficult task for the treatment team. Due to the complex anatomy of the arm, most sarcomas involve valuable functional structures. Nonetheless, a large portion of the patients can be treated in a limb-sparing manner, and surgery is the mainstay of local tumor control. This review gives an overview of the disease entities and their epidemiology, on necessary patient work-up, staging, and imaging modalities, as well as the importance of interdisciplinary decision-making. The surgical therapies and principles of tumor excision are outlined, as well as reconstructive options. Furthermore, adjuvant treatments are discussed with a special focus on the various application techniques for radiation therapy. In spite of established treatment algorithms, each case is an individual challenge and individually tailored therapy is required. This aspect is illustrated by presenting three comprehensive cases demonstrating useful strategies. A summary of the relevant literature is given.

Thoracic Wall Reconstruction after Tumor Resection

Introduction

Surgical treatment of malignant thoracic wall tumors represents a formidable challenge. In particular, locally advanced tumors that have already infiltrated critical anatomic structures are associated with a high surgical morbidity and can result in full-thickness defects of the thoracic wall. Plastic surgery can reduce this surgical morbidity by reconstructing the thoracic wall through various tissue transfer techniques. Sufficient soft-tissue reconstruction of the thoracic wall improves quality of life and mitigates functional impairment after extensive resection. The aim of this article is to illustrate the various plastic surgery treatment options in the multimodal therapy of patients with malignant thoracic wall tumors.

Materials and methods

This article is based on a review of the current literature and the evaluation of a patient database.

Results

Several plastic surgical treatment options can be implemented in the curative and palliative therapy of patients with malignant solid tumors of the chest wall. Large soft-tissue defects after tumor resection can be covered by local, pedicled, or free flaps. In cases of large full-thickness defects, flaps can be combined with polypropylene mesh to improve chest wall stability and to maintain pulmonary function. The success of modern medicine has resulted in an increasing number of patients with prolonged survival suffering from locally advanced tumors that can be painful, malodorous, or prone to bleeding. Resection of these tumors followed by thoracic wall reconstruction with viable tissue can substantially enhance the quality of life of these patients.

Discussion

In curative treatment regimens, chest wall reconstruction enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. In palliative disease treatment, plastic surgical techniques of thoracic wall reconstruction provide palliation of tumor-associated morbidity and can therefore improve patients’ quality of life.

Primary flap reconstruction of tissue defects after sarcoma surgery enables curative treatment with acceptable functional results: a 7-year review

Background

Sarcomas, a heterogeneous group of tumors, are challenging to treat and require multidisciplinary cooperation and planning. We analyzed the efficacy of flap reconstruction in patients with bone and soft tissue sarcoma.

Methods

Patient charts and operative records were retrospectively reviewed from January 2006 through October 2013 to identify sarcoma patient characteristics, postoperative complications, revisions, recurrences, and survival. Pedicled and/or free flap reconstruction was performed in 109 patients. Flap selection was based on defect size, and exposure of anatomically critical structures or major orthopedic implants.

Results

Of 109 patients, 71 (65.1 %) were men, and mean age was 56.4 years. Tumors most frequently located in a lower extremity (38.7 %). Primary sarcomas comprised 79.2 % and recurrences occurred in 18.9 %. Wide resection was performed for 65.7 %, and there were 10 planned amputations combined with flap reconstruction. A total of 111 tumors received 128 flaps: 76 pedicled flaps, 42 free flaps, and 5 combined (10 total) pedicled + free-flaps. The success rate was 94 % for the pedicled flap group, 97 % for the free-flap group, and 100 % for the pedicle + free-flap group. Of 35 patients, 5 developed deep prosthetic infections. Only one amputation due to disease progression was performed. Satisfactory functional outcome was achieved in 69 %. Survival rate during a mean (standard deviation) 3(2) year follow-up was 83.5 %.

Conclusions

Primary flap reconstruction after sarcoma surgery satisfies oncologic goals. Large tumors in difficult areas can be removed and complete tumor resection achieved. Our findings indicate a high survival rate after sarcoma surgery utilizing flap reconstruction and a low recurrence rate.

Plastic surgery for the oncological patient

The therapy of oncological patients has seen tremendous progress in the last decades. For most entities, it has been possible to improve the survival as well as the quality of life of the affected patients. To supply optimal cancer care, a multidisciplinary approach is vital. Together with oncologists, radiotherapists and other physicians, plastic surgeons can contribute to providing such care in all stages of treatment. From biopsies to the resection of advanced tumors, the coverage of the resulting defects and even palliative care, plastic surgery techniques can help to improve survival and quality of life as well as mitigate negative effects of radiation or the problems arising from exulcerating tumors in a palliative setting. This article aims to present the mentioned possibilities by illustrating selected cases and reviewing the literature. Especially in oncological patients, restoring their quality of life with the highest patient safety possible is of utmost importance.

Concomitant upper extremity soft tissue sarcoma limb-sparing resection and functional reconstruction: assessment of outcomes and costs of surgery

BACKGROUND

The purpose of this study is to investigate functional outcomes and cost impacts of immediate functional reconstruction performed in conjunction with limb-sparing resection of upper extremity soft tissue sarcomas.

METHODS

Patients undergoing simultaneous limb-sparing upper extremity soft tissue sarcoma resection and functional reconstruction between December 1998 and March 2004 were retrospectively identified, their medical records reviewed, and costs of surgery analyzed. Functional outcomes and patient satisfaction were assessed via patient surveys and the Toronto Extremity Salvage Score (TESS).

RESULTS

Thirteen patients met the inclusion criteria. Average follow-up was 43.3 months. Reconstructions included rotational innervated muscle flaps (n = 6), free innervated myocutaneous flaps (n = 1), and tendon transfers or grafts (n = 6). Overall survival was 85 % (n = 11) and disease-free survival was 77 % (n = 10). Average total cost of surgery was $26,655. Patients undergoing reconstruction for hand and forearm sarcomas had significantly higher total costs of surgery than those undergoing reconstruction for elbow and upper arm sarcomas. Survey response rate was 91 % (n = 10). Average TESS score was 76. Of the patients who worked preoperatively, 88 % returned to work postoperatively, and all patients who returned to work currently use their affected limb at work.

CONCLUSIONS

Patients undergoing immediate functional reconstruction for upper extremity soft tissue sarcoma resection achieved very good to excellent functional outcomes with quick recovery times and a high return-to-work rate following immediate functional reconstruction, thereby minimizing surgical cost impacts. Immediate functional reconstruction in the same surgical setting is thus a viable strategy following upper extremity soft tissue sarcoma resection.

Importance of tumor size in soft tissue sarcomas: a proposal for a nomogram based on a score system to staging soft tissue sarcomas in the postoperative setting

In order to adequately stage patients with extremity soft tissue sarcomas (ESTS), it is mandatory to include all adverse prognostic factors and create an integral staging system. We were able to evaluate a nomogram based on a score (STSSS), to improve ESTS staging. We retrospectively evaluated 596 patients with ESTS in stages I-III, of the American Joint Committee on Cancer (AJCC), who had a complete resection. We analyzed the influence of clinicopathological factors on metastasis, recurrence, and disease-specific survival. The STSSS was based on histologic grade (HG), profundity, tumor size (TS), and surgical margins; we also compared STSSS versus AJCC systems in their ability to stage ESTS. The mean TS was 11.8 cm, with 50%>10 cm. Large TS and high HG were independent but adverse prognostic factors for metastasis. In addition, large TS, high grade, and R1 resection were independent adverse prognostic factors for decreased survival. There was a progressive decline in survival as TS increased, although AJCC staging did not correlate well between stages (IA vs. IB p=0.233, IA vs. IIA p=0.123, IA vs. IIB p=0.075, IB vs. IIA p=0.472, IB vs. IIB p=0.211). STSSS showed differences between these categories for 5-year survival (I vs. II p=0.003, II vs. III p=0.002, III vs. IV p<0.001). Surgical margins, HG, and TS are important determinants for metastases and survival. We also found a strong correlation between survival and prognosis with the use of STSSS in the immediate postoperative setting.

Managing soft tissue sarcomas in a developing country: are prognostic factors similar to those of developed world?

BACKGROUND

Managing soft tissue sarcomas (STS) in a developing country with limited financial resources and a poor health referral system is a challenge. Presenting late, these extremity STS are prone to recurrence despite apparently complete resection. This study aimed to explore and compare the impact of clinico-pathological factors on recurrence and survival in Pakistan with the corresponding figures quoted from the developed world.

METHODS

An institutional review was performed on all patients with primary STS of the extremities operated on between 1994 and 2008. The prognostic influence of clinical, pathologic, and treatment variables on local recurrence free survival (LRFS), metastasis free survival (MFS) and overall survival (OS) were analyzed by univariate and multivariate Cox regression analysis and Kaplan Meier survival curves.

RESULTS

A total of 84 patients with a mean age of 41.8 ± 21.9 years were included in the study. The local recurrence rate was 14.3% after a median of 6 (mean 7.4) months. Metastases occurred in 7 patients (8.3%) and 65 patients were alive without evidence of disease after a mean follow-up of 52.6 ± 39.8 months. Tumor size > 5 cm, grade 3 tumors and margin < 10 mm significantly increased local recurrence rates. A margin ≥ 10 mm and age < 45 years significantly enhanced cumulative survival. Significant multivariate risk factors for metastases were margin < 10 mm and tumor grade G3.

CONCLUSIONS

Despite a poor health referral system in our country, our results are no different from those reported from the developed world. Surgical margins and tumor grade prognostically influenced LRFS, MFS and OS.