Major upper-limb amputations for malignant tumors

Reconstruction of oncologic upper extremity defects with fibula free flaps has high union rates and excellent functional outcomes

BACKGROUND

Limb salvage has better functional outcomes than amputation in the upper extremity. This can however be challenging after bony tumor resections.

METHODS

This is a retrospective case series of patients who underwent humerus, ulna, or radius reconstruction with a fibula free flap. Data were collected on demographics, oncologic history, surgical details, and complications. Functional outcome measures included the patient's ability to perform activities of daily living (ADL), presence of pain, and musculoskeletal tumor society (MSTS) score.

RESULTS

Over a 25-year period, 38 reconstructions were performed. The flap success rate was 97.5%. Bony union was obtained in 19 of 19 (100%) forearm reconstructions and in 15 of 19 (79%) humerus reconstructions (p = 0.10). All 19 forearm reconstruction patients and 18/19 humerus reconstruction patients were able to perform ADLs with no pain or only occasional pain. The MSTS scores were not significantly different between the humerus and forearm cohorts (27.1 vs. 27.3, p = 0.68). Functional outcomes were significantly better in limbs that achieved union (p < 0.001). Recipient and donor site complications occurred in 10 (26.3%) and 5 (13%) patients, respectively.

CONCLUSIONS

Oncologic upper-extremity reconstruction with fibula free flaps has excellent functional outcomes. Bone union is a predictor of superior limb function.

Vertical Rectus Abdominis Myocutaneous Flap for Reconstruction of Forequarter Amputation Defect after Shoulder Soft Tissue Sarcoma Resection: Technical Consideration

Forequarter amputations in advanced local malignancy or trauma cases often leave a large defect that is challenging to reconstruct. Options for defect closure are varied. A vertical rectus abdominis myocutaneous (VRAM) flap could be an alternative to close a significantly large defect, which is relatively easier than the more technically demanding free flap. This case presents a 64-year-old man with a soft tissue sarcoma in the left shoulder that was treated by forequarter amputation and subsequent defect closure using a VRAM flap. The VRAM flap was initially used to reconstruct the chest and abdominal walls. There have been no reported uses for the shoulder defect. The repair site defect was viable even with a less aesthetic donor site, and all of the defects were closed without any signs of infection. The VRAM flap is a good option for a large defect closure at the shoulder region, particularly after forequarter amputation.

Recurrent malignant peripheral nerve sheath tumor presenting as an asymptomatic intravenous thrombus extending to the heart: a case report

Background

Malignant peripheral nerve sheath tumor (MPNST) is a rare soft tissue sarcoma mainly treated via surgical resection. Herein, we report a case of MPNST wherein a massive tumor thrombus extended to the major veins and heart.

Case presentation

A 39-year-old female with a history of neurofibromatosis type 1 developed MPNST from the right radial nerve. In addition to adjuvant chemotherapy, she underwent wide tumor resection and concomitant radial nerve resection, followed by postoperative radiotherapy. Histological evaluation revealed marked venous invasion. The 2-year follow-up CT revealed an asymptomatic recurrent tumor thrombus extending from the right subclavian vein to the heart. An urgent life-saving operation was performed to ligate the base of the right subclavian vein and remove the entire intravenous thrombus that extended to the right ventricle. The remaining tumor in the right subclavian vein increased in size 3 months after thrombectomy. After confirming the absence of any metastatic lesions, the patient underwent extended forequarter amputation to achieve surgical remission. One year later, a new metastasis to the right diaphragm was safely resected. The patient remains alive without any evidence of disease 2 years after the extended forequarter amputation.

Conclusions

In cases of a previous history of microscopic venous invasion, recurrence can occur as a massive tumor thrombus that extends to the great vessels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02473-2.

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.

Malignant Tumors of the Hand

Primary malignant tumors in the hand are rare as compared to benign lesions; however, it is essential for orthopeadic surgeons to be familiar with their clinical presentation. The approach to working up a mass in the hand must be methodical and thorough, and clinicians must maintain high index of suspicion when evaluating these lesions. Successful identification and treatment of malignant tumors of the hand may include referral to a sarcoma center for staging, workup, and multidisciplinary treatment. Surgical treatment of malignant tumors in the hand is uniquely complicated by the increased number of critical structures that may be in close proximity to the tumor. It is therefore imperative to understand the principles of diagnosis, staging, biopsy, resection, and amputation before treating malignant tumors of the hand.

Residual rotation of forearm amputation: cadaveric study

Background

The purpose of this study was to investigate residual rotation of patients with forearm amputation and the contribution of involved muscle to residual rotation.

Methods

Testing was performed using five fresh-frozen cadaveric specimens prepared by isolating muscles involved in forearm rotation. Amputation was implemented at 25 cm (wrist disarticulation), 18 cm, or 10 cm from the tip of olecranon. Supination and pronation in the amputation stump were simulated with traction of involved muscle (supinator, biceps brachii, pronator teres, pronator quadratus) using an electric actuator. The degree of rotation was examined at 30°, 60°, 90°, and 120° in flexion of elbow.

Results

Average rotation of 25 cm forearm stump was 148° (SD: 23.1). The rotation was decreased to 117.5° (SD: 26.6) at 18 cm forearm stump. It was further decreased to 63° (SD 31.5) at 10 cm forearm stump. Tendency of disorganized rotation was observed in close proximity of the amputation site to the elbow. Full residual pronation was achieved with traction of each pronator teres and pronator quadratus. Although traction of supinator could implement residual supination, the contribution of biceps brachii ranged from 4 to 88% according to the degree of flexion.

Conclusions

Close proximity of the amputation site to the elbow decreased the residual rotation significantly compared to residual rotation of wrist disarticulation. The preservation of pronosupination was 80% at 18 cm forearm stump. Although the pronator teres and the pronator quadratus could make a full residual pronation separately, the supinator was essential to a residual supination.

Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol

BACKGROUND

We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation.

METHODS

Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain.

RESULTS

Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively.

CONCLUSIONS

Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.

Amputation for Extremity Sarcoma: Contemporary Indications and Outcomes

INTRODUCTION

Amputation for localized extremity sarcoma (ES), once the primary therapy, is now rarely performed. We reviewed our experience to determine why patients with sarcoma still undergo immediate or delayed amputation, identify differences based on amputation timing, and evaluate outcomes.

METHODS

Records of patients with primary, nonmetastatic ES who underwent amputation at our institution from 2001 to 2011 were reviewed. Univariate analysis was performed, and survival outcomes were calculated.

RESULTS

We categorized 54 patients into three cohorts: primary amputation (A1, n = 18, 33%), secondary amputation after prior limb-sparing surgery (A2, n = 22, 41%), and hand and foot sarcomas (HF, n = 14, 26%). Median age at amputation was 54 years (range 18-88 years). Common indications for amputation (> 40%) were loss of function, bone involvement, multiple compartment involvement, and large tumor size (A1); proximal location, joint involvement, neurovascular compromise, multiple compartment involvement, multifocal or fungating tumor, loss of function, and large tumor size (A2); and joint involvement and prior unplanned surgery (HF). There was no difference in disease-specific survival (DSS) (p = 0.19) or metastasis-free survival (MFS) (p = 0.31) between early (A1) and delayed (A2) amputation. Compared with cohorts A1/A2, HF patients had longer overall survival (OS) (p = 0.04).

CONCLUSIONS

Indications for amputation for extremity sarcoma vary between those who undergo primary amputation, delayed amputation, and amputation for hand or foot sarcoma. Amputations chosen judiciously are associated with excellent disease control and survival. For patients who ultimately need amputation, timing (early vs. delayed) does not affect survival.

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.

Vascular control for a forequarter amputation of a massive fungating humeral osteosarcoma

Forequarter amputation is a radical operation performed for treatment of malignant neoplasms of the shoulder girdle not amenable to limb salvage. Traditional approaches involve bone and soft tissue resection, followed by ligation of the axillary vessels. We describe a technique to minimize blood loss whereby control of the subclavian vessels is performed before amputation of a large tumor associated with extensive venous congestion. A 34-year-old man presented with proximal humeral osteosarcoma. Surgery involved claviculectomy to facilitate vascular control of the subclavian vessels, followed by guillotine amputation at the proximal upper arm level and completion of the amputation as conventionally described.

Forequarter amputation for recurrent breast cancer

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Forequarter amputation is an aggressive treatment for recurrent breast cancer.

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Some patients with regional metastatic disease do benefit from forequarter amputation.

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Patients with unrelenting cancer pain do gain relief from forequarter amputation.

Introduction

Localized excision combined with radiation and chemotherapy represents the current standard of care for recurrent breast cancer. However, in certain conditions a forequarter amputation may be employed for these patients.

Presentation of case

We present a patient with recurrent breast cancer who had a complicated treatment history including multiple courses of chemotherapy, radiation, and local surgical excision. With diminishing treatment options, she opted for a forequarter amputation in an attempt to limit the spread of cancer.

Discussion

In our patient the forequarter amputation was utilized as a last resort to slow disease progression after she had failed multiple rounds of chemotherapy and received maximal radiation. Unfortunately, while she had symptomatic relief in the short-term, she had cutaneous recurrence of metastatic adenocarcinoma within 2 months of the procedure. In comparing this case with other reported forequarter amputations, patients with non-metastatic disease showed a mean survival of approximately two years. Furthermore, among patients who had significant pain prior to surgery, all patients reported pain relief, indicating a significant palliative benefit. This seems to indicate that our patient’s unfortunate outcome was anomalous compared to that of most patients undergoing forequarter amputation for recurrent breast cancer.

Conclusion

Forequarter amputation can be judiciously used for patients with recurrent or metastatic breast cancer. Patients with recurrent disease without evidence of distant metastases may be considered for curative amputation, while others may receive palliative benefit; disappointingly our patient achieved neither of these outcomes. In the long term, these patients may still have significant psychological problems.

Upper extremity considerations for oncologic surgery

It was estimated that more than 3000 people would be diagnosed with a primary bone or joint malignancy and more than 11,000 people would be diagnosed with a soft tissue sarcoma in 2013. Although primary bone and soft tissue tumors of the upper extremity are infrequent, it is imperative that the clinician be familiar with a systematic approach to the diagnosis and treatment of these conditions to prevent inadvertently compromising patient outcome. With advances in chemotherapy, radiotherapy, tumor imaging, and surgical reconstructive options, limb salvage surgery is estimated to be feasible in 95% of extremity bone or soft tissue sarcomas.

Interscapulothoracic (forequarter) amputation for malignant tumors involving the upper extremity: surgical technique and case series

BACKGROUND

Forequarter amputation (FQA) is reserved for large, multifocal, or recurrent tumors affecting the shoulder and upper extremity. Although it is performed less frequently with the advancement of limb salvage surgery, FQA remains an important treatment in select patients. The purpose of this study is to illustrate the surgical technique in a case series of 4 patients.

METHODS

Between 2010 and 2012, 4 patients (mean age, 61 years; range, 36-78 years) presented with malignant disease of the upper extremity that was not amenable to or had failed limb salvage. All patients had FQA by the illustrated anterior clavicular osteotomy technique. Patient data were retrospectively reviewed from preoperative workup until last follow-up or death.

RESULTS

All patients had tumors that involved major neurovascular structures of the upper extremity and shoulder girdle. One presented with neuroendocrine carcinoma and has achieved local control after FQA. Three presented with high-grade sarcoma. One of these had recurrence after prior limb salvage and neoadjuvant radiation and unfortunately succumbed to metastatic disease 6 months after FQA. An additional sarcoma patient who presented after shoulder arthroscopy for a "labral cyst" with recurrent and fulminant synovial sarcoma succumbed to her disease. The remaining sarcoma patient has had no recurrence and minimal phantom pain at last follow-up.

DISCUSSION

Obtaining vascular control early in the procedure is crucial to minimize blood loss. When it is indicated, FQA is a relatively safe and reliable procedure for dealing with otherwise challenging tumors of the shoulder girdle and upper extremity.

LEVEL OF EVIDENCE

Level IV, case series, treatment study.

Amputation: a ten-year survey

Background

Limb loss occurs due to different causes and has been increased in many countries. It has without exception, great economic, psychological and social impacts.

Objectives

This study assesses the demographics of amputees in one city of Iran.

Patients and Methods

This retrospective study was undertaken on all of the amputees between April 2002 and December 2011. Patients’ demographics including age, sex, the amputated limb, etiology of limb loss and level of amputation were recorded.

Results

We had 216 patients in the study. The average number of amputations was 21.6 per year and varied from 14 to 32. The mean age of amputation was 39.26± 12.6 years. Of the patients, 172 were male (79.62%) and 44 female (20.37%); 119 of the amputations (55.09 %) were major and 97 minor (44.9 %). The most common cause of amputation was trauma and the most common was the toe. In trauma patients the mean age was 38.12± 10.25 years and 98 (83.7%) were male.

Conclusions

In contrast to similar studies in developed countries, trauma was found to be the major cause of all types of amputations. Results of this study may be used in prevention planning.

A survey on causes of amputation in a 9-year period in Iran

BACKGROUND

Limb loss occurs as a result of different causes and has been increasing in many countries. This study determines the demography of amputees in one of the relatively large cities of Iran.

METHODS

This retrospective study was undertaken on all of the amputees between 2003 and 2011. Patients' demographics including age, sex, the limb that had undergone amputation, etiology of limb loss and side and level of amputation were recorded. Also, the level of amputation was recorded as minor (below wrist or ankle) or major (above wrist or ankle).

RESULTS

In total, 624 patients were enrolled in the study. The number of amputees was from 53 to 118/year. Of the patients, 508 were male (81.4 %) and 118 were female (18.6 %). The men with amputation were younger on average than women; 61.9 % of the amputations (386) were major and 38.1 % were minor (238). Overall, the most common cause of amputation was trauma and the most common level was transmetatarsal. The most common level for major amputations was below knee.

CONCLUSION

In contrast to similar studies in developed countries, trauma was found to be the major cause of all types of amputations and in all age groups, which emphasizes the need for preventive measures in the country.