Outcome of treatment for pediatric sarcoma of the foot: a retrospective review over a 20-year period

Benefits Associated With Early Diagnosis and Treatment of Soft Tissue Sarcomas of the Foot and Ankle

Soft tissue sarcomas arising in the foot and ankle are often misdiagnosed, resulting in excision without adequate preoperative staging or surgical margins. The goal of the present study was to review a case series of soft tissue sarcomas of the foot and ankle with attention directed at unplanned excisions of sarcomas. An unplanned excision means that a patient either underwent an inadequate preoperative workup or the preoperative workup indicated a benign entity, resulting in surgical resection. We retrospectively analyzed the medical records of 10 patients with sarcomas of the foot and ankle treated at our institution. All soft tissue sarcomas were excised with the widest margin possible without any major bone or neurovascular resection to allow for preservation of the foot. All patients were followed up for a minimum of 8 months to assess pain, function, and complications. The patients were followed up for an average of 22.4 (range 8 to 44) months. Of the 10 patients, 6 had undergone preoperative magnetic resonance imaging without contrast and the sarcomas were read as benign or cystic masses. Two patients had undergone preoperative magnetic resonance imaging with contrast, and these scans were also misread. Despite having undergone previous unplanned surgery, none of these sarcomas had recurred after repeat resection with a wider margin at a mean follow-up of 22.4 (range 8 to 44) months. At the last follow-up point, 8 patients were alive without evidence of disease. Minor complications included lymph edema in 1, stress fracture in 1, and wound infection in 1 that resolved. Preoperative MRI with contrast is recommended before resecting any soft tissue masses of the foot and ankle. In the event of an unplanned excision of a soft tissue sarcoma, the patient should be referred to an orthopedic oncologist for definitive surgery to optimize the oncologic and functional results. In the present retrospective analysis, previous intervention did not seem to affect the prognosis, including local recurrence, distant metastasis, disease-free interval, and functional outcomes.

Rhabdomyosarcoma of the extremities: a focus on tumors arising in the hand and foot

BACKGROUND

Extremities are peculiar sites of origin for rhabdomyosarcomas (RMS) and are usually associated with an unfavorable outcome.

METHODS

The authors reviewed the clinical data on 60 patients <21 years old with limb RMS treated at the Pediatric Oncology Unit of the Istituto Nazionale Tumori of Milan, in Italy, over a 30-year period. Twelve patients had tumors arising in the hand and foot.

RESULTS

Complete tumor resection was achieved in 21 patients (but in only 1 case of hand/foot RMS); all patients received chemotherapy and 43 also had radiotherapy. The alveolar subtype was identified in 62% of cases. Half of the hand/foot cases had metastatic disease at onset. Overall survival at 5 years was 33% among the hand/foot cases and 56% for the others. Most of the relapsing cases had distant metastases.

CONCLUSIONS

A particularly poor survival was observed for RMS of the hand/foot due its marked tendency to spread. Surgical resection is particularly difficult in such cases and a multimodality treatment approach seems crucial to improving their outcome.

Soft-tissue sarcomas of the extremities in patients of pediatric age

PURPOSE

The extremity site is a peculiar location for soft-tissue sarcomas (STS) of children and adolescents. Here we report the experience of the Pediatric Oncology Unit of the Istituto Nazionale Tumori of Milan, Italy, concerning 204 patients with STS of the limbs treated between 1977 and 2006.

METHODS

The study series included 52 patients with rhabdomyosarcoma (RMS)(65% of which were of the alveolar subtype), nine with extraosseous Ewing sarcoma and 143 with non-rhabdomyosarcoma soft-tissue sarcomas (NRSTS), 38% of which were synovial sarcoma. Patients were treated with a multimodality approach including surgery, chemotherapy, and radiotherapy.

RESULTS

For the RMS patients, the 5-year event-free survival (EFS) rate was 37.1%, with distant metastases being the main cause of treatment failure. The outcome was particularly poor for patients with large invasive tumors, hand/foot involvement and/or nodal or distant metastases, and for patients who were not given radiotherapy. For the extraosseous Ewing sarcoma cases, 5-year EFS was 74%. For the NRSTS cases, the 5-year EFS was 72.6%: tumor size and local invasiveness, tumor grade, malignant peripheral nerve sheath tumor (MPNST) histology, and distant metastases were the main prognostic factors.

DISCUSSION

While the limbs are the most common sites of NRSTS and are often characterized by a more favorable prognosis than for axial tumors, the clinical features of extremity RMS often differ from those of RMS of other sites, with a higher incidence of unfavorable prognostic factors (e.g., alveolar subtype) and consequently unsatisfactory treatment results. The treatment of these patients is complex and necessarily multidisciplinary, and it demands not only adequate experience of treating children and adolescents in clinical trials, but also particular skills in the field of orthopedic surgery.

Rhabdomyosarcoma arising in the hand or foot: a clinicopathologic analysis

Rhabdomyosarcomas (RMS) arising at different anatomic sites have distinct clinicopathologic features that affect prognosis and outcome. RMS arising in the extremities generally have a worse prognosis. Case reports and anecdotal experience suggests the possibility that RMS of the hand or foot (RMSHF) may behave even more aggressively than RMS elsewhere in the extremities. This study describes clinicopathologic features and outcome of RMSHF. Charts and pathologic material from RMSHF cases from institutional files over a 32-year interval were reviewed. Additional cases from published reports and series over a 42-year interval were identified by a MEDLINE search. Pertinent clinicopathologic features for each case were compiled. Survival analysis and other data from these patients were compared with previously reported statistics in the literature for RMS at other anatomic sites, including elsewhere in the extremities. Six patients from the institutional files and 46 from published reports were identified. A number of adverse prognostic indicators were observed in the majority of these patients including alveolar morphology (86%) and distant metastasis at presentation (63%). Despite the aggressive nature of these tumors, the majority were smaller than 5 cm (61%). A propensity was observed for metastases to unusual sites such as breast, ovary, testis, pancreas, and kidney. The median survival was 19 months, and the 5-year survival was 27%. While these may reflect a constellation of findings related to site, it is also possible that alveolar histology is the main influence. RMSHF can present as a very small primary tumor with clinically evident or occult metastatic disease. Whether this reflects the location, the predominantly alveolar histologic type, or a molecular genetic subtype will require further analysis. Patients presenting with RMSHF should be thoroughly evaluated for occult metastases at the time of diagnosis and followed closely throughout treatment for subsequent involvement of unusual sites.

Distal lower extremity sarcomas: frequency of occurrence and patient survival rate

BACKGROUND

Primary sarcomas in the distal leg, tibia, fibula, ankle, and foot are uncommon and are believed to be less malignant than those that arise in other sites, but only limited information is available to support this contention.

METHODS

Using a computerized system containing extensive information regarding over 14,000 patients, mostly with tumors treated by our center over a 25-year period, 175 sarcomatous lesions with MSTS stage I, II, and III were located in the distal lower extremity. These were compared with 2367 lesions of similar diagnoses in other body parts. The principal studies included diagnostic distribution and outcome (recorded as death as a result of disease). Data were compared for diagnosis, gender, age, Musculoskeletal Tumor Society (MSTS) stage, anatomic site, and treatment methods and evaluated statistically by chi-square methods.

RESULTS

The most frequent distal lower limb tumors were synovial cell sarcoma, osteosarcoma, and Ewing's tumor and the percentage distribution of the various tumors for that site as compared with the rest of the body was quite different. Of even more importance was the remarkable difference in outcome with the death rate for the lower limb tumors set at 10%, while the same tumors at other sites had a death rate of 27% (p <.000002). Furthermore, gender, stage, age, and the type of operative procedure showed highly significant differences between the tumors of the lower leg and those of the remainder of the body.

CONCLUSIONS

On the basis of these data, it is evident that far fewer sarcomas occur in the lower leg, tibia, fibula, ankle, and foot than in other body sites and that their diagnostic distribution is different. Of perhaps greater interest is the fact that the rate of metastasis and death is markedly reduced for this site as compared with others. The authors speculate on the causes of this remarkable alteration in numbers and outcome.

Soft tissue sarcomas in children

In childhood, soft tissue sarcomas comprise a complex group of malignancies of varied histologic subtypes, the prognoses of which depend on the histology, age, site, extent of involvement and a variety of other factors. This paper discusses the varieties of tumors classified as soft tissue sarcomas in childhood and the multimodal approach taken to cure these tumors, with particular attention to the details of difficult surgical problems.