Extremity preservation by combined modality therapy in sarcomas of the hand and foot: an analysis of local control, disease free survival and functional result

Reirradiation in Conservative Salvage of Recurrent Soft-tissue Sarcoma: An Analysis of Treatment Efficacy and Toxicities

OBJECTIVE

Compared with radical resection alone, perioperative radiation therapy (RT) combined with neurovascular preserving surgery is the standard for the management of virgin soft-tissue sarcomas. Yet, the optimal management of a local recurrence remains unclear. We report outcomes of patients with locally recurrent soft-tissue sarcoma treated with resection and reirradiation at the University of Florida.

MATERIALS AND METHODS

We reviewed the records of patients treated with primary conservative surgery and radiation for soft-tissue sarcoma followed by salvage resection and reirradiation for a local recurrence at our institution.

RESULTS

We analyzed 23 patients treated between 1976 and 2014 (median follow-up, 46 mo). Tumor sites included: proximal extremity, 11 patients; trunk, 6; distal extremity, 5; and head and neck, 1. All patients had conservative gross total resection of their recurrent tumor, without amputation. For reirradiation, 16 patients received external-beam RT alone, 6 received external-beam RT and brachytherapy, and 1 received brachytherapy alone. Two patients received chemotherapy. After retreatment, the 5-year overall survival, cause-specific survival, local control, and distant control rates were 39%, 42%, 46%, and 60%, respectively. Ten patients experienced local recurrences, 1 experienced regional recurrence, and 9 developed distant metastases. Retreatment-related complications ranged from delayed wound healing to limb amputation; 8 patients required amputation. Only 3 patients remained disease-free at last follow-up. No statistically significant associations were found between treatment factors (eg, RT dose) and local control.

CONCLUSIONS

Achieving local control of recurrent soft-tissue sarcoma is challenging. Treatment with reoperation and reirradiation can lead to debilitating complications affecting function and quality of life.

Imaging Features of Primary Tumors of the Hand

Musculoskeletal tumors of the hand are a rare entity and are divided into skeletal and soft tissue tumors. Either category comprises benign and malignant or even intermediate tumors. Basic radiology allows an optimal resolution of bone and related soft tissue areas, ultrasound and more sophisticated radiologic tools such as scintigraphy, CT and MRI allow a more accurate evaluation of tumor extent. Enchondroma is the most common benign tumor affecting bone, whereas chondrosarcoma is the most commonly represented malignant neoplasm localized to hand bones. In the soft tissues, ganglions are the most common benign tumors and epithelioid sarcoma is the most frequently represented malignant tumor targeting hand soft tissues. The knowledge regarding diagnostic and therapeutic management of these tumors is often deriving from small case series, retrospective studies or even case reports. Evidences from prospective studies or controlled trials are limited and for this lack of clear and supported evidences, data from the medical literature on the topic are controversial, in terms of demographics, clinical presentation, diagnosis, prognosis and therapy. The correct recognition of the specific subtype and extension of the tumor through first line and second line radiology is essential for the surgeon, in order to effectively direct the therapeutic decisions.

Synovial sarcoma of the hand-wrist: a case report and review of the literature

Background

Synovial sarcomas are infrequent malignant tumors occurring mostly in adolescents and young adults. The occurrence of synovial sarcoma in the hand-wrist area is rare (4 to 8.5% of all synovial sarcomas in different studies).

Case presentation

This report documents an uncommon case of synovial sarcoma occurring in the hand-wrist of a 69-year-old Caucasian woman. She was subsequently treated with surgical excision and radiotherapy without recurrence after follow up.

Conclusions

This paper aims to characterize the demographic, pathologic, and clinical features with a literature review. The present literature review confirms that hand-wrist synovial sarcomas are more frequent among males and subjects 10 to 40 years old. Most cases in this location are usually not larger than 5 cm in size. The five-year survival rate is higher than that reported in a previous review on hand synovial sarcomas, and this suggests an improved survival in recent decades.

Patient-reported functional outcomes in a cohort of hand and foot sarcoma survivors treated with limb sparing surgery and radiation therapy

BACKGROUND AND OBJECTIVES

Describe patient-reported functional outcomes for hand and foot sarcoma survivors treated with limb-sparing surgery and radiation therapy (LSS + RT).

METHODS

Fifty-four patients with hand/wrist and foot/ankle sarcomas treated with LSS + RT from 1991 to 2015 were identified. Survivors ≥18 years old without subsequent amputation completed self-assessed functional surveys: Toronto upper extremity salvage score (TESS-UE) and Michigan hand outcomes (MHQ) surveys for hand; TESS lower extremity (TESS-LE) and Foot and Ankle Outcomes (FAOS) surveys for foot. Scoring scales: 0-100, MHQ and TESS; -26 to 56 and 25-59, FAOS core and shoe comfort, respectively. Higher scores denote superior function.

RESULTS

Five-year local tumor control was 88%. Fourteen of 24 hand (58%) and 14/18 foot (78%) survivors completed surveys. Mean TESS-UE and MHQ scores were 89.4 and 72.8, respectively. Mean TESS-LE, core FAOS, and shoe comfort scores were 92.4, 46.19, and 53.1, respectively. No factors correlated with outcomes. TESS-UE and MHQ scores strongly correlated (r = .87). TESS-LE and FAOS scores were associated with a poor correlation (r = .02 and r = .69).

CONCLUSIONS

The largest patient-reported functional outcomes analysis for hand and foot sarcoma survivors treated with LSS + RT demonstrates excellent local tumor control and acceptable functional outcomes. Further exploration of optimal functional assessment tools is needed given the potential scope differences.

Diagnoses, treatment, and oncologic outcomes in patients with calcaneal malignances: Case series, systematic literature review, and pooled cohort analysis

BACKGROUND AND OBJECTIVES

Malignant tumors of the calcaneus are rare but pose a treatment challenge.

AIMS

(1) describe the demographics of calcaneal malignancies in a large cohort; (2) describe survival after amputation versus limb-salvage surgery for high-grade tumors.

METHODS

Study group: a "pooled" cohort of patients with primary calcaneal malignancies treated at two cancer centers (1984-2015) and systematic literature review. Kaplan-Meier analyses described survival across treatment and diagnostic groups; proportional hazards modeling assessed mortality after amputation versus limb salvage.

RESULTS

A total of 131 patients (11 treated at our centers and 120 patients from 53 published studies) with a median 36-month follow-up were included. Diagnoses included Ewing sarcoma (41%), osteosarcoma (30%), and chondrosarcoma (17%); 5-year survival rates were 43%, 73% (70%, high grade only), and 84% (60%, high grade only), respectively. Treatment involved amputation in 52%, limb salvage in 27%, and no surgery in 21%. There was no difference in mortality following limb salvage surgery (vs. amputation) for high-grade tumors (HR 0.38; 95% CI 0.14-1.05), after adjusting for Ewing sarcoma diagnosis (HR 5.15; 95% CI 1.55-17.14), metastatic disease at diagnosis (HR 3.88; 95% CI 1.29-11.64), and age (per-year HR 1.04; 95% CI 1.02-1.07).

CONCLUSIONS

Limb salvage is oncologically-feasible for calcaneal malignancies.

What Factors Influence the Outcome of Surgically Treated Soft Tissue Sarcomas of the Hand and Wrist?

BACKGROUND

Soft tissue sarcomas (STS) of the hand are exceedingly rare. The aim of this study was to review our institution's experience with STS of the hand to identify factors affecting outcomes and survivorship.

METHODS

We retrospectively reviewed the records of 46 hand STS treated with definitive surgery at our institution between 1992 and 2013. Pertinent demographics as well as information regarding the surgical procedure, and disease status at latest follow-up were reviewed. Mean age at diagnosis was 38 years with a mean follow-up of 5 years.

RESULTS

The most common tumor subtypes were epithelioid (n = 10) and synovial sarcoma (n = 8). Sixty-one percent were superficial in location. Thirty-three patients had had a nononcologic resection prior to definitive surgical treatment at our institution. Ultimately, negative margins were obtained in all cases. Local recurrence was observed in 5 patients and distant metastases in 14 patients. Tumor sizes ≥2 cm, American Joint Committee on Cancer (AJCC) grade, and depth of the tumor were found to adversely affect the outcome in terms of disease-free and overall survival. Reexcision of an inadvertently excised tumor at an outside institution did not adversely affect the outcome. The 10-year overall and disease-free survival was 72% and 63%.

CONCLUSIONS

Local recurrence after a wide excision was observed infrequently; however, distant disease was relatively common. Tumors with a size ≥2 cm were associated with a worse disease-free and overall survival, highlighting the aggressive nature of these tumors.

Soft tissue sarcoma - A review of presentation, management and outcomes in 110 patients

Soft tissue sarcomas are a rare group of mesenchymal tumours the treatment of which poses oncological and reconstructive challenges. Limb-salvage surgery aims to balance adequate excision margins for disease control and preservation of important structures to retain function. Reported here is the review of the Hull Plastic surgery sarcoma service over a twelve year period.

METHOD

We performed a review of the Hull sarcoma database over a twelve year period between 1997 and 2009. Demographic data, tumour grade, operative details complications and outcomes were recorded.

RESULTS

The database contained a total of 435 patients with a diagnosis of sarcoma. 110 were treated at the Plastic Surgery department over a period of 12 years between 1997 and 2009. The patients treated in our department consisted of 67 males and 43 females (median age 70 years). The most common histological type was leiomyosarcoma (n = 23). Distribution of anatomical sites affected were head and neck (n = 15), upper limb (n = 17), lower limb (n = 56), trunk (n = 22). Large tumours (greater than 8 cm) n = 30, deep tumours n = 48, and high grade (Trojani 3) n = 33. Patients were treated with surgical excision and postoperative radiotherapy in the high grade groups (2 and 3). A range of reconstructive procedures were required from skin grafting, functional muscle transfer and free flap reconstruction. Nine patients developed regional recurrence, six patients had grade 3 tumours. Three were not resectable. Fourteen patients developed distant metastases, seven had grade 3 tumours, six underwent chemotherapy, two were treated palliatively. There were twenty deaths in this group, of which sixteen were sarcoma related. Deaths in the high risk groups was seven (high grade), nine (deep tumours) and eight (tumour size >8 cm). There were six survivors from eleven in the group with all three of these risk factors.

CONCLUSION

This study summarises the management of sarcoma form one unit over a twelve year period and lends further evidence to the fact that the principles of limb-salvage surgery are applicable to a wide range of tumour-types and grades, to all patient age groups and anatomical sites with good functional results and that local and free flap reconstruction provides wound cover robust enough to withstand courses of radiotherapy. Early recurrence of high-grade disease and the development of metastasis carry a worse prognosis, especially if adjuvant therapy cannot be given.

LEVEL OF EVIDENCE

4.

Ewing sarcoma of the first metacarpal with a 9-year follow-up: case report

Ewing sarcoma is a primary bone tumor that rarely occurs in the hand. We present a case involving the thumb metacarpal with long-term follow-up. Carpometacarpal and metacarpophalangeal arthrodeses with autograft are relatively simple procedures that stabilized the thumb and preserved satisfactory function.

Ewing sarcoma of the proximal phalanx: case report

We report a case of primary Ewing sarcoma of the proximal phalanx of the right middle finger in an 18-year-old boy. He was treated with neoadjuvant chemotherapy, followed by ray amputation. To restore maximum function, the index ray was transferred to the base of the third metacarpal bone and fixed with a plate. The function of his right hand after the operation was excellent and the cosmetic appearance acceptable. There was no evidence of local recurrence or metastasis after 20 months follow up.

Ewing's sarcoma of the finger: report of two cases and literature review

Ewing's sarcoma of the finger is extremely rare. Pain and swelling of the affected finger are the most frequent presenting features. We report two cases of Ewing's sarcoma located at ring finger and the thumb in two children aged 14 and 10 years. The first patient died of generalised metastases despite surgery, chemotherapy and radiation therapy. The second had no localised recurrence or metastases after surgery and chemotherapy at last follow-up of 4.5 years after tumour resection. The tumour's surgical accessibility, chemotherapy, and radiation therapy improve the prognosis of this tumour.

Functional outcome in limb-salvage surgery for soft tissue tumours of the foot and ankle

Purpose. This paper describes the functional and oncologic outcome of 30 cases (in 29 patients) treated with limb-salvage surgery for localized soft tissue sarcoma (STS) or fibromatosis of the foot and ankle.Subjects. Patients were eligible for the study if they had a STS or fibromatosis in the distal one-third of the tibia or the foot such that ablative surgery would require a below-knee amputation; had no metastatic disease at presentation; and had a minimum of 2 years of follow-up.Methods. Function was prospectively evaluated using the modified Enneking functional rating scale (MSTS) at 3, 6, 12 months and at most recent follow-up. Premorbid work status and change following surgery, lower leg oedema, and the use of orthotics and ambulatory aids were consecutively assessed. Tumour characteristics were recorded and patients were followed for systemic and local recurrence.Results. Thirty-six consecutive cases were managed by a multi-disciplinary sarcoma team. Six patients underwent below-knee amputation due to extensive local disease, while 30 cases were treated with limb-salvage surgery. Of the patients treated with limb salvage, there were 19 high-grade sarcomas, five low-grade sarcomas and six cases of fibromatosis. Microscopically negative margins were achieved in 26 of 30 cases. Ten cases required bone excision, and eight patients needed free vascularized tissue flaps. Twenty-five patients received adjuvant radiotherapy. Seven patients had post-operative complications. At mean follow-up of 52 months (range 24-109 months), four patients had developed systemic recurrence. There was one local recurrence in a patient with fibromatosis, while another patient with fibromatosis developed recurrence a considerable distance from the surgical and radiation field. Mean scores on the MSTS were 27.5 (range 11-35), 29.9 (range 13-35), 31.4 (range 17-35) and 31.0 (range 13-35) at 3, 6, 12 months and at most recent follow-up, respectively. Eighty-five per cent of the patients scored good to excellent at their last visit. Twelve patients reported persistent pain with two continuing to require occasional narcotics. Six had persistent mild oedema. Four required shoe modifications and three continue to use a cane. Six patients were unable to return to their premorbid employment with the majority of these previously employed in jobs requiring physical labour or long periods of either standing or walking.Discussion. Thirty of 36 patients (83%) presenting with foot and ankle STS or fibromatosis were candidates for limb preservation. With excellent local control and good functional outcome demonstrated in this study, limb salvage should be a primary goal in the management of selected patients with STS and fibromatosis of the foot and ankle.

Soft tissue sarcoma of the hand or foot: conservative surgery and radiotherapy

Purpose. Conservative treatment in the form of limited surgery and post-operative radiotherapy is controversial in hand and foot sarcomas, both due to poor radiation tolerance of the palm and sole, and due to technical difficulties in achieving adequate margins.This paper describes the local control and survival of 41 patients with soft tissue sarcoma of the hand or foot treated with conservative surgery and radiotherapy. The acute and late toxicity of megavoltage radiotherapy to the hand and foot are described. The technical issues and details of treatment delivery are discussed. The factors influencing local control after radiotherapy are analysed.

Subjects . Eighteen patients had sarcomas of the hand and 23 of the foot. All patients received post-operative radiotherapy, the majority receiving a dose of 60 Gy in 2-Gy daily fractions using a two-phase treatment.

Results . The acute and late toxicity of treatment were within acceptable limits. The actuarial 5-year overall survival of the whole patient group was 67.6% and the local relapse-free survival was 44%.The local control was similar in tumours of hand and foot, and in patients treated at first presentation or relapse.

Discussion. Post-operative radiotherapy to the hand or foot appears to be a well tolerated treatment resulting in long-term local control in a significant proportion of patients. The increased frequency of recurrence within the high-dose volume suggests the need for the use of higher total doses of radiotherapy.

Treatment of epithelioid sarcoma at the royal marsden hospital

Purpose: The aim of this study was to assess treatment and outcome with respect to clinical and pathological features.

Patients and methods: Thirty-nine patients were identified (range 7–66 years, mean 23). Initial treatment comprised local excision in 11 patients and wide excision in 14. Post-operative external beam radiotherapy was prescribed in 22 patients with a total dose of 60 Gy, delivered in two phases.

Results: The cause-specific survival for the entire group was 79, 63, 56 and 45% at 1, 3, 5 and 10 years, respectively. A distal limb location was associated with a better prognosis than proximal limb location (P = 0.04).

Conclusions: Our data favour treatment with wide functional excision followed by radical dose radiotherapy in attempt to minimize risk of local recurrence, especially when primary tumours are bigger than 3 cm. Our data also suggest the same treatment for local recurrence, when technically possible, to avoid amputation.

Ewing's Sarcoma of the Upper Extremity: Presenting Symptoms, Diagnostic Delay and Outcome

Purpose:To look at the presenting features, Enneking stage, size of primary tumour, method of treatment and patient and doctor delays in upper extremity Ewing's sarcoma to observe the effects on local recurrence, metastasis and survival.

Patients and methods:Nineteen patients with upper extremity Ewing's sarcoma were identified using the Scottish Bone Tumour Registry over the past 40 years.

Results:With increasing tumour Enneking stage at presentation there was a significantly higher mortality (P=0.02). Patients with a higher Enneking stage also had an increased trend towards local recurrence (P=0.08). Stage did not influence the occurrence of metastasis. Patients with larger tumours tended to have a higher mortality (50 vs. 27% dead at 5 years). All patients presented clinically with pain and all but two complained of some sort of swelling. There was a trend towards a higher Enneking Stage in patients presenting with a longer duration of symptoms (P=0.1). No difference in survival was noted between patients undergoing surgery and chemotherapy and patients undergoing radiotherapy and chemotherapy. Disease-free survival was 100% at both 5 and 10 years for Enneking stage IIA, 56% at 5 and 10 years for stage IIB and 0% at 5 years for stage III.

Discussion:This study re-emphasises the potential importance of a diagnostic delay on outcome. Longer symptom duration is associated with a higher Enneking stage at presentation. In turn a higher presenting stage results in a higher mortality. Pain and swelling are prominent clinical findings at first presentation in upper extremity Ewing's.

The management of soft tissue sarcoma

SUMMARY

Soft tissue sarcomas are a rare group of mesenchymal tumours that display cardinal signs, which can raise suspicion to their diagnosis. Management in a sarcoma treatment centre by its multidisciplinary team has improved outcome. Good local disease control with limb salvage and adjuvant radiotherapy has considerably reduced the morbidity of previous limb amputation. By the early involvement of a plastic surgeon, tissue reconstruction is optimised and wound complications reduced. This article looks at the contemporary management of soft tissue sarcoma and, in particular, its relevance to the plastic surgeon today.

Management of locally recurrent soft-tissue sarcoma after prior surgery and radiation therapy

PURPOSE

The aim of this study was to evaluate outcome and treatment toxicity after wide local re-excision (WLE), with or without additional radiation therapy, for patients with isolated first local recurrence of soft-tissue sarcoma arising within a previously irradiated field.

METHODS

A retrospective review was performed of 62 consecutive patients. All patients underwent prior resection and external beam radiation. For recurrent disease, 25 patients were treated with WLE alone, and 37 patients were treated with WLE and additional radiation (45- 64 Gy). In 33 patients, the radiation was delivered via an afterloaded brachytherapy, single-plane implant.

RESULTS

The 5-year disease specific and distant metastasis-free survival rates were 65% and 73%, respectively. Local control (LC) at 5 years was 51%, and on multivariate analysis, a positive surgical resection margin (p< 0.001) was associated with a lower rate of LC. Reirradiation was not associated with improved LC; however complications requiring outpatient or surgical management were more common in patients who had undergone reirradiation (80% vs. 17%, p < 0.001). Amputation was also more common in the subgroup of patients who underwent extremity reirradiation (35% with radiation vs. 11% without, p = 0.05), although only one amputation was performed to resolve a treatment complication.

CONCLUSION

Conservative surgery alone results in LC in a minority of patients who have failed locally after previous excision and external beam radiation. Although selection biases and small patient numbers confound the analysis, local treatment intensification with additional radiation does not clearly improve outcome after surgical excision alone, and is associated with an increase in complications.

Intraoperative electron radiotherapy for extremity sarcomas does not increase acute or late morbidity

Intraoperative electron radiotherapy is used to treat surgical sites that potentially harbor occult tumor immediately after limb-sparing surgical resection of extremity soft tissue sarcomas. It is unknown whether single-fraction, high-dose intraoperative electron radiotherapy at the time of surgery increases wound morbidity when combined with preoperative or postoperative external beam radiotherapy. In a retrospective study, we evaluated whether intraoperative electron radiotherapy increased 90-day and late (> 90 days) wound complication rates by comparing patients who had adult extremity soft tissue sarcomas treated by limb-sparing surgery and preoperative (n = 14) or postoperative (n = 13) external beam radiotherapy. The median followup was 36 months. Seven (26%) patients had wound complications occurring within 90 days postoperatively and completion of radiotherapy. Late wound complication rates were similar. Two patients in each of the external beam radiotherapy groups required late subtotal limb amputations for prolonged wound complications. Our findings suggest intraoperative electron radiotherapy during limb-sparing surgery allows radiation dose escalation without increased 90-day or late-wound complication rates when combined with preoperative or postoperative external beam radiotherapy for patients with extremity soft tissue sarcomas.

LEVEL OF EVIDENCE

Prognostic Study, Level II (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Adjuvant Radiotherapy in the Management of Soft Tissue Sarcoma Involving the Distal Extremities

OBJECTIVE

Treating soft tissue sarcoma (STS) of the distal extremity is challenging in terms of achieving local control and avoiding complications. It is now accepted that a limb conserving approach provides equivalent survival when compared with radical amputation.

METHODS

Twenty-three patients with STS involving the hand-wrist or foot-ankle complex received adjuvant radiotherapy (RT) for limb conservation and were evaluated to determine if local control, survival, and functional ability were achieved. The median patient age was 64 and median time of follow-up was 11 years. The location of the sarcoma included the hand (n = 12) or foot (n = 11). Seven patients received preoperative RT (median dose, 50.40 Gy) and 16 patients received postoperative RT (median dose, 64.80 Gy). Patients treated preoperatively and 9 treated postoperatively received hyperfractionated RT at 1.2 Gy twice-daily. Seven patients treated postoperatively received conventional daily-fractionated treatment.

RESULTS

Twenty of 23 patients received RT at first presentation; 3 were treated for locally recurrent disease. The 5- and 10-year rates of local control were 91%. The 10-year rates of cause-specific and absolute survival were 96% and 91%, respectively. The 5- and 10-year rates of distant metastases-free survival were 87%. The ultimate limb-conservation rate was 91%. No patient required an amputation because of local recurrence or treatment complications. Function of the hand or foot was maintained for all of the 21 patients for whom limb-conserving treatment was achieved.

CONCLUSIONS

Combined modality therapy with limb-conserving surgery and adjuvant RT achieves excellent local control (91%) and potential overall survival (91%) rates with excellent functional outcome.

Reconstruction of the hand and upper extremity after tumor resection

This article reviews the surgical options available for reconstruction of the upper extremity following tumor resection. In order to achieve maximum function and limb salvage a multidisciplinary approach to patient care is emphasized. With proper preoperative planning, salvage of limb form and function can be accomplished in over 95% of cases. Successful reconstruction is measured by preservation of patient health, limb function, limb sensation and cosmesis and stable wound coverage. Important adjuncts to reconstruction include adequate postoperative splinting and aggressive rehabilitation to maximize long-term upper extremity function.

Tumeur d'Ewing du pouce : présentation d'un cas clinique et revue de la littérature

The authors report a case of an Ewing sarcoma of the thumb. It is a rare localisation of this disease and it should not be unknown. Based on the literature, the appropriate treatment is discussed.

Prognostic factors in Ewing's sarcoma of the foot

The outcome of treatment and prognostic factors were reviewed in 36 patients who had Ewing's sarcoma of the foot. The tumor was most common in the calcaneus (19 patients) and metatarsals (15 patients). Age, levels of lactate dehydrogenase, degree of anemia, tumor volume, type of surgery, and radiotherapy were not related to prognosis. Females with pain for less than 6 months, fever, high levels of erythrocyte sedimentation rate, and high levels of alkaline phosphatase showed a tendency for a poorer prognosis. The only observed prognostic factors are tumor site and treatment. Patients treated with four-drug neoadjuvant chemotherapy had the best survival. Four patients with metastatic disease at diagnosis died. Fourteen of 32 patients (44%) with localized Ewing's sarcoma were continuously disease-free at an average followup of 7 years.

Primitive neuroectodermal tumor of the thumb metacarpal bone: a case report and literature review

A 27-year-old otherwise healthy patient was diagnosed with a primitive neuroectodermal tumor of the thumb metacarpal bone of the left hand. Based on a common chromosomal translocation this tumor shows a close relationship to Ewing's sarcoma. Its occurrence in the extremities is uncommon and involvement of the hand is extremely rare. The treatment consisted of neo- and adjuvant chemotherapy and marginal resection of the affected thumb metacarpal bone including periosseous soft tissue and reconstruction of the thumb by an intercalated segmental index pollicization.

Extremity soft-tissue sarcomas selectively treated with surgery alone

PURPOSE

This study determined local control (LC), freedom from distant recurrence (FFDR), overall survival (OS), and potential prognostic factors in 34 adult patients with primary extremity or limb girdle soft-tissue sarcoma selectively managed with limb-conservation surgery alone.

METHODS AND MATERIALS

The medical records of 34 patients who underwent surgery alone for localized soft-tissue sarcoma of the extremity were reviewed. Median duration of follow-up in survivors was 55 months (range, 24-143). There were 13 (38%) females. Eighteen (53%) of the tumors were low-grade, 15 (44%) were superficial, 15 (44%) were small (5 cm or less), and 16 (47%) involved the distal extremity.

RESULTS

Actuarial 5-year LC was 80%, FFDR was 86%, and OS was 82%. All recurrences (local and distant) were in patients with high-grade tumors; their 5-year LC was 60%, FFDR was 71%, and OS was 69%. In 2 patients, metastatic disease developed either concurrent with or after their local recurrence. Univariate analysis revealed better OS, FFDR, and LC for patients with low-grade tumors (p < 0.05). Female patients had significantly better FFDR and OS (p < 0.05).

CONCLUSION

It is appropriate to consider withholding irradiation for selected patients with low-grade tumors resected with negative margins if, in the event of a local failure, a function-preserving surgical salvage is anticipated. For patients with high-grade sarcomas, the control of local and distant disease was not acceptable with limb-conservation surgery alone.

Functional outcome in extremity soft tissue sarcoma

The studies reporting functional outcome for patients undergoing limb preservation surgery for extremity soft tissue sarcoma (STS) have evaluated mainly impairments, that is, deficits at an anatomic structure level, such as joint range of motion and strength. Disability, activities of daily living, self-care, and mobility have been less frequently evaluated. Review of the literature suggests that approximately 50% of patients treated for STS have significant impairments, whereas the frequency of disability is less. Synthesis of the results is difficult because of the heterogeneity of patient samples, treatment, and the outcomes used to evaluate function. Future studies require the use of standardized definitions and reliable and valid functional outcome measures. Improved patient outcomes can be achieved only by understanding the determinants of these outcomes and by introducing interventions to improve patient functional outcome.

Functional outcome after soft-tissue reconstruction for limb salvage after sarcoma surgery

Limb salvage has been achieved for patients with sarcoma by means of compartmental resection, soft-tissue reconstruction, and adjuvant therapy without increased rates of local recurrence, metastasis, or mortality. Despite the prevalence of limb salvage procedures in the treatment of these tumors, relatively little information has been published regarding late functional results in these reconstructed extremities. This study reports on the functional outcome for soft-tissue reconstruction for limb salvage in patients with sarcoma. Over the past 6 years, 28 patients were treated for sarcomas of the extremity in which soft-tissue reconstruction was needed for complete limb salvage. The mean age of these patients was 48 years (range, 14 to 83 years); there were 14 male and 14 female patients. Of the 28 sarcomas, 23 cases involved the lower extremity and 5 cases were in the upper extremity. Reconstruction was performed primarily in 12 patients; 16 reconstructions were performed secondarily because of wound complications after initial extirpation. Adjuvant radiation therapy was administered either preoperatively or postoperatively in all cases. Of the 33 reconstructive procedures performed in these 28 patients, 16 involved free flaps and 17 involved local flaps. All patients achieved initial limb salvage after the reconstructive procedure(s). Mean follow-up was 38 months. Twenty patients were available for the evaluation portion of the study. Two patients had delayed amputations: one for recurrent disease and another for osteoradionecrosis. Two patients died before beginning the examination process: one patient from the sarcoma and another patient from colon cancer. Twenty of the remaining 24 patients agreed to participate and were examined using the Enneking outcome measurement scale. Patients were examined for range of motion, deformity, stability, pain level, strength, functional activity, and emotional acceptance and assigned a numerical score for each category. Based on this, an overall rating of excellent, good, fair, or poor was assigned. Nine patients (45 percent) achieved an overall rating of excellent, five patients (25 percent) achieved a rating of good, and six patients (30 percent) achieved a fair score. None had received a rating of poor. There were no differences in the results obtained comparing upper versus lower extremity, immediate versus delayed reconstruction, or reconstructions performed with a free flap versus a pedicled flap. This study supports the continued use of soft-tissue reconstruction for limb salvage in sarcoma surgery with good to excellent late functional results obtained in the majority of patients.

Limb salvage surgery and adjuvant radiotherapy for soft tissue sarcomas of the forearm and hand

Twenty-five consecutive patients with soft tissue sarcoma of the forearm and hand were assessed for limb-salvage surgery and were entered into a prospective study evaluating oncologic details and functional outcome. Seventeen patients had received incomplete primary excision elsewhere and presented with local recurrence or residual disease. Three had pulmonary metastases at the time of presentation. Twenty-three patients were candidates for limb-salvage surgery and 20 received adjuvant radiotherapy. The mean follow-up period was 37 months. There was local recurrence in three patients who had initially received marginal excision of the primary sarcoma, and three patients died of systemic disease. Limb function was assessed prospectively using both patient-based and clinician-based functional scoring systems and revealed good to excellent results in all but three patients. Eighty-eight percent of those who survived and did not require amputation were able to return to occupational and activities of daily living with no or minimal functional limitation. This study demonstrates that limb-salvage surgery, with adjuvant radiotherapy when necessary, is an effective alternative to amputation in the majority of patients with sarcoma of the forearm and hand. Radiation toxicity is rarely a problem.

Radiotherapy in soft tissue sarcoma of the extremities

The local treatment of soft tissue sarcoma is evolving. Limb-sparing compartmentectomy offers local control but at the expense of function and a high amputation rate. The functional outcome is improved with combined wide excision and radiotherapy, at the same time achieving a similar local control rate. Future directions should include attempts to reduce toxicity and maximise the functional result. As the limb function is ultimately related to the aggressiveness of the local treatment, the optimum surgical margin, radiation volume and dose, require further investigation. The pursuit of local control should not be compromised in the quest for reducing morbidity, as the relationship between local control and survival remains unclear.

Soft tissue sarcomas

This synthesis of the literature on radiotherapy for sarcomas originating in the body's soft, supportive tissues, ie, muscle, connective tissue, and fatty tissue is based on 71 scientific articles, including 4 randomized studies, 5 prospective studies, and 26 retrospective studies. These studies involve 3,444 patients. Over 90% of patients with soft tissue sarcomas in the arms and legs can be treated in a way that preserves the extremities. Subcutaneous and intramuscular sarcomas can be treated surgically with little functional loss or risk for local recurrence without adjuvant radiotherapy. To avoid amputation, surgery is often combined with radiotherapy for treatment of local relapse. Adequate surgical margins are usually difficult to achieve for head/neck tumors and retroperitoneal tumors, and therefore surgery is often combined with radiotherapy to reduce the risk for local relapse. Pre- and postoperative radiotherapy are similar. A disadvantage of preoperative radiotherapy is that it reduces the opportunity for exact diagnosis and determining morphobiologic sarcoma parameters. To further improve treatment results for advanced sarcomas, it is necessary to introduce other fractionation schedules, mainly hyperfractionation. This places greater demands on radiotherapy, mainly for staff resources. Combining radiotherapy and local intraarterial chemotherapy involves greater risks for complications and has not shown better treatment results than pre- or postoperative radiotherapy alone, and it is not recommended as standard treatment for soft tissue sarcomas. Intraoperative treatment methods should be targeted for further study and development.

Sarcomas of the hand and foot: analysis of local control and functional result with combined modality therapy in extremity preservation

PURPOSE

The records of 28 patients with sarcomas of the hand and foot treated at the National Cancer Institute (NCI) between 1977 and 1992 were reviewed to assess local control and functional results.

METHODS AND MATERIALS

Histologic types included 15 cases of the Ewing's sarcoma family of tumors, 7 cases of alveolar rhabdomyosarcoma, and 6 cases of nonrhabdomyosarcoma soft tissue sarcomas. Median age of all patients was 18 years (range 4-61), with a median potential follow-up of 114 months following diagnosis. Surgery varied from incisional biopsies for Ewing's Sarcoma and rhabdomyosarcoma lesions to complete excision when possible for nonrhabdomyosarcoma soft tissue sarcoma lesions. Amputation was not primarily performed, except in two patients who underwent ray resections of hand lesions (patients 13 and 24). Radiotherapy generally consisted of 50 Gy/25 fractions (fx)/5 weeks for Ewing's Sarcoma, 54 Gy/30 fx/6 weeks for rhabdomyosarcoma, and 63 Gy/35 fx/7 weeks for nonrhabdomyosarcoma soft tissue sarcomas. Chemotherapy was administered on various NCI protocols.

RESULTS

Actuarial local control for Ewing's Sarcoma was 84% at 5 and 10 years. All but one survivor are capable of hand/foot function for routine activities without orthotic requirements. Five of six patients (83%) who died of metastatic disease had functional distal extremities. Actuarial local control for rhabdomyosarcomas was 100%, with equivalent function. No patient developed a second malignancy in the treatment field.

CONCLUSIONS

Although equivalent local control may be achieved in these lesions with either amputation or radiotherapy, a prudent management course would be to defer amputation for management of local recurrences. Many patients with these lesions fail in distant sites only and die without local failure. For these patients and for those who remain long-term survivors, we believe a functional hand and foot provides a better quality of life than a prosthesis.

Case report 802: Ewing's tumor of the proximal phalanx of the third finger with radiographic progression documented over a 6-year-period

In summary, a case of Ewing's tumor of the proximal phalanx of the long finger of the right hand was presented. This case is unusual because of its location as well as the unusually long clinical course before the correct diagnosis was made. The major point to be stressed is that Ewing's tumor may initially present with a "benign" appearance mimicking a bone cyst [17] or angioma [12]. Timely follow-up of so-called benign lesions, particularly when recurrent swelling occurs, would help in avoiding prolonged delays in diagnosis.

Computer-aided treatment design of a distal upper extremity soft tissue tumor with electron beam radiotherapy

We present here a novel approach for the planning and treatment of a distal upper extremity soft tissue tumor. Utilizing computed tomography (CT) based electron dose calculations, a customized compensating wax bolus was designed in order to deliver sufficient dose coverage to the tumor volume while sparing the draining lymphatics of the patient's hand and digits. A clinical case is presented as well as the design and construction of the compensator. Outcome and clinical implications are discussed.

Functional outcome in patients treated with surgery and irradiation for soft tissue tumours

One hundred five consecutive patients underwent surgical resection and adjuvant irradiation in treatment of soft tissue sarcoma or aggressive fibromatosis. All patients were entered in a prospective study evaluating functional outcome and 88 patients were examined at 12 months following surgery. Outcome was characterized using the Enneking system as well as documenting employment/recreational status and limb edema. Sixty-eight of 88 patients had functional scores of 21 or better (out of a possible total of 35). Forty-four patients were serially evaluated at 12 and 24 months and there was no difference in their outcome at the 2 time points. Univariate analysis demonstrated that large tumour size, postoperative complications, and neural sacrifice were associated with poor functional outcome.

Conservative surgery and radiation therapy for soft tissue sarcoma of the wrist, hand, ankle, and foot

Seventy-eight patients with soft tissue sarcoma (STS) arising in the distal extremities--wrist, hand, finger, ankle, foot, and toe--who were treated with conservation surgery and radiation therapy were studied retrospectively with respect to survival, local recurrence, functional limb preservation, complications, and distant metastasis. After a median follow-up of 7.9 years, actuarial 5-year and 10-year survival rates were 80% and 69%, respectively, and disease-free rates were 61% and 51% at the same times. Actuarial local control rates were 80% and 74% at 5 and 10 years, respectively. Fifteen patients (19%) had local recurrence, but 12 of these were salvaged. Ultimately, 53 patients (68%) retained a normal or fairly normal extremity, six (8%) needed amputation for complications, and 13 (17%) needed amputation to control recurrent disease. The functional outcome was significantly better for patients with upper extremity lesions than for those with lower extremity tumors; even for the latter, this treatment strategy was preferable to amputation. The incidence of hematogenous metastases from distal extremity sarcomas depends on the size of the primary tumor. It was concluded that conservation surgery and radiation therapy (XRT) is an acceptable treatment strategy for STS arising in distal extremities; it yielded a high rate of disease control and functional limb preservation.

Ewing's sarcoma of the hand: localization and treatment

Ewing's sarcoma of the hand is rare. Only 20 cases of Ewing's sarcoma of the hand have been reported in the literature. Although Ewing's sarcoma of the hand is rare and highly malignant, modern combinations of treatment are possibly curative due to the tumors surgical accessibility and apparent restricted involvement of only tubular bone. This case study illustrates currently accepted combination therapy consisting of chemotherapy, radiation therapy, and surgical tumor reduction. In spite of the advances of adjuvant therapy, surgical removal of the tumor still remains the most effective treatment.

Ewing's sarcoma of the foot

Ewing's sarcoma is a rare, malignant neoplasm that is most common in children and adolescents. It is common in both the axial and appendicular skeleton but has been rarely reported in the foot. Historically, treatment has consisted of chemotherapy and radiation therapy. The roll of surgery in the management of these lesions have recently been "rediscovered" and depends on the anatomic location. The purpose of this paper is to discuss five consecutive cases of Ewing's Sarcoma of the forefoot treated with below-the-knee amputation for local tumor control. Four of the five patients also underwent some systemic chemotherapy. After comparing the various forms of therapy for this tumor, the benefits of below-the-knee amputation make it an excellent primary treatment for Ewing's sarcoma of the foot.

Intensive combined modality therapy of small round cell and undifferentiated sarcomas in children and young adults: local control and patterns of failure

Seventy-five patients (ages 4-35 years) with the following small round cell tumors and undifferentiated sarcoma were treated at the National Cancer Institute: Ewing's sarcoma (n = 32), peripheral neuroepithelioma (n = 14), rhabdomyosarcoma (n = 24), undifferentiated sarcoma (n = 5). Most patients had poor prognostic features including 36 (48%) with metastatic disease, and 42 (56%) with central (truncal) tumors (22 in the pelvis). Treatment included 5 cycles of intensive induction chemotherapy with vincristine, cyclophosphamide and adriamycin, plus aggressive local radiation therapy using simulation and computerized treatment planning for all patients. Thereafter, complete clinical responses were consolidated with intensive chemotherapy, total body irradiation and autologous bone marrow transplantation. There were three local only failures, 10 local plus distant failures, 36 distant only failures, 3 treatment-related deaths, and one intercurrent death. Overall actuarial survival and event-free survival at 4 years are 49 and 29%, respectively. Actuarial freedom from local progression was seen in 74% of patients at 4 years, quite remarkable considering the bulk and location of most of these tumors. Without aggressive surgery, many of these high risk patients had satisfactory outcomes, but better systemic treatments are still needed.

Extremity preservation by combined modality treatment of sarcomas of the hand and wrist

Soft tissue sarcomas are uncommon malignancies, less than 10% of which arise on the distal upper extremities. Consequently, experience with treatments which preserve both the limb and its function is lacking for tumors in this region. Sixteen patients with sarcomas arising in the hand and wrist and one with an aggressive desmoid tumor were treated by combined modality therapy at the Massachusetts General Hospital. Two patients had wide resections for multiple recurrent lesions, 5 had excisional biopsies, and 9 had incomplete excisions to preserve anatomic structures of the hand. One patient refused an amputation and had no surgery. Sarcoma patients were given postoperative radiation with a dose range of 50.2 to 69 Gy (median 68 Gy). The desmoid tumor received 44 Gy. A shrinking field technique with customized castings and cerrobend blocks was used to assure precision and minimize treatment volumes. Chemotherapy was reserved for metastatic disease. Local control was achieved in 14 patients who received combined modality treatment (87%), with a follow-up 1-12 years (median 33 months). Two of the three patients with local failures subsequently obtained a local control after salvage surgery and radiation. Four patients developed metastases, one with epitrochlear lymph node metastases was salvaged by amputation, the others died with lung disease 17, 37, and 111 months after treatment. Functional integrity of the limb was primarily dependent on the extent of surgical resection required. Among 12 patients with local and distant control, one patient (who had multiple wide resections of an extensive desmoid tumor preceding irradiation) lost over 50% use of her limb, but no patients required amputation for edema or pain control. Ten of the 12 patients with local and distant control had less than a 25% decrement in limb function and had no pain or edema associated with normal use of their hand. We conclude that for selected patients with sarcomas of the distal upper extremity, combined modality therapy consisting of conservative resection and careful radiation therapy is a viable alternative to amputation.

Influence of WR 2721 on radiation response of canine soft tissue sarcomas

Seventy-three dogs with soft tissue sarcomas were randomized to 2 dose response assays to receive irradiation alone or with the radioprotector WR-2721. Nausea and vomiting were the major side effects of WR-2721 administration although one death occurred because of cardiac and respiratory failure which may have been caused by the WR-2721. There was no change in blood counts or serum chemistry values. The TCD50/lyr was 52 Gy delivered in 10 fractions for both groups. However, there was an indication of tumor protection at lower doses because at all comparable dose levels the percentage tumor control was lower in dogs given WR-2721. There was no decrease in acute skin reactions of dogs treated with WR-2721 and little, if any, protection against fibrosis, soft tissue necrosis or bone necrosis. The lack of protection of normal tissues may have been caused by fractionation. The agent may be more useful combined with large single doses such as given in intraoperative radiotherapy.

Redefined role of radiation in combined treatment of Ewing's sarcoma

Eighty-six patients with Ewing's sarcoma were analyzed as to the role of radiation therapy. Fifty-eight patients (P group) had removal of the involved part of the bone after preoperative chemotherapy, and 28 (NP group) had local treatment either at the same time or before chemotherapy. Thirty-six of 58 P-group patients (61%) and 13 of the 28 NP-group patients (48%) are alive. Five of 48 patients in P-group, who had postoperative radiation, had local recurrence, as did 6 of 11 without postoperative radiation, a statistically significant difference (p = 0.001).

Soft tissue sarcomas in childhood

The authors discuss the epidemiology, pathology, clinical presentation, and treatment of rhabdomyosarcoma as well as some of the less common sarcomas of childhood and adolescence. Special focus is placed on making careful histopathologic distinction between entities and on clearly recognizing distinct clinical syndromes.