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

Results of resection of forearm soft tissue sarcoma

PURPOSE

Soft tissue sarcomas (STS) of the forearm are rare. We aim to assess their oncological and functional outcomes.

METHODS

We retrospectively evaluated 34 patients who underwent surgical excision for forearm STS at our institution between 1993 and 2020. We analyzed postoperative Musculoskeletal Tumor Society rating scale (MSTS) and local recurrence-free survival (LRFS), metastasis-free survival, and overall survival (OS) rates. The significance of the following variables was determined: age, sex, histology, tumor size, Fédération Nationale des Centres de Lutte contre le Cancer grade, American Joint Committee on Cancer stage, surgical margin, unplanned excision, metastases upon initial presentation, receipt of chemotherapy, and radiotherapy (RT).

RESULTS

The postoperative median MSTS score was 28. Bone resection or major nerve palsy was the only factor that influenced MSTS scores. The median MSTS scores in patients with or without bone resection or major nerve palsy were 24 and 29, respectively (P < 0.001). The 5-year LRFS rates was 87%. Univariate analysis revealed that the histological diagnosis of myxofibrosarcoma was the only factor that influenced LRFS (P = 0.047). The 5-year MFS rates was 71%. In univariate analysis, no factors were associated with MFS. The 5-year OS rates was 79%. Age was the only factor that influenced OS (P = 0.01).

CONCLUSION

In the treatment of forearm STS, reconstruction of the skin and tendon can compensate for function, while bone resection and major nerve disturbance cannot. Careful follow-up is important, especially in patients with myxofibrosarcoma, due to its likelihood of local recurrence.

Sarcomas of the hand: A retrospective series of 26 cases

BACKGROUND

Hand sarcomas frequently suffer from a delayed diagnosis, and the current guidelines for their management are often not followed.

METHODS

The objectives of our study were to determine: (1) the rate of inadequate initial treatments; (2) the rates of mortality, recurrence, and complementary excision in a cohort of patients with a sarcoma of the hand who were treated at our reference center between 2000 and 2015.

RESULTS

The series comprised 26 patients (mean age 40 years). Of the 20 patients not initially treated at a reference center, 17 had inadequate initial treatment. Of the six patients treated at our center, one had inadequate initial care. Significantly more patients had inadequate initial care outside a reference center (p=0.0045). The cumulative probabilities of recurrence or metastases at 5 years were 15% and 30%, respectively. Survival by cumulative incidence was 71% at 5 years and 56% at 10 years.

CONCLUSIONS

Sarcomas of the hand are a deadly pathology. All diagnostic uncertainty warrants referral of the patient to a reference center.

LEVEL OF PROOF

IV.

Diagnosis and treatment of hand tumors

Hand tumors are a very common problem in hand surgery. While these lesions are most often benign, malignant lesions often have an atypical presentation and are discovered late, very often during an inappropriate treatment. To optimize the care of hand tumors and to reduce diagnostic and treatment errors, we will review the broad diagnostic and therapeutic principles and the most common clinical presentations.

Tricks and pitfalls in the surgical treatment of malignant bone tumours of the forearm in children and adolescents

Malignant bone tumours around the forearm are rare. Nowadays, oncological and surgical management of bone sarcomas of this region has improved significantly. Although the anatomical features are complex, limb-sparing surgery is possible with wide surgical resection. Biological reconstruction methods are promising in this anatomically unique region. In addition, meticulous soft-tissue reconstruction yields good functional results in the hand and wrist. This study reviews malignant bone tumours of the forearm and their oncological and surgical management. Malignant bone tumours should be treated with a multidisciplinary approach based on chemotherapy, radiotherapy and limb salvage procedures.

Oncological and prognostic analysis of soft tissue sarcoma of the elbow: report using the bone and soft tissue tumor registry in Japan

OBJECTIVE

Soft tissue sarcomas in the elbow are extremely rare, and they have primarily been described in case series. Definitive concerning the prevalence and prognostic factors of elbow soft tissue sarcomas remain unknown. We examined the outcome of patients with elbow soft tissue sarcomas and identified the relevant prognostic factors.

METHODS

In total, 219 patients with elbow soft tissue sarcomas were identified using data from the bone and soft tissue tumor registry in Japan. Differences in demographics, disease characteristics, treatment and survival were compared among the patients. Survival analyses including local recurrence-free survival, distant metastasis-free survival, and overall survival were performed using the Kaplan-Meier method with log-rank tests and the Cox proportional hazards model.

RESULTS

Two hundred nineteen patients with elbow soft tissue sarcomas were identified, including 119 males (54.3%) and 100 females (45.7%). In total, 189 patients (86.3%) underwent surgery including re-excision. Of the surgically treated patients, 180 (95.2%) underwent limb salvage surgery, and nine patients (4.8%) underwent amputation. The 5-year overall survival, local recurrence-free survival, and distant metastasis-free survival rates for the entire patient cohort were 76.3, 70.1, and 69.3%, respectively. After adjusting for clinically relevant factors, overall survival was significantly worse among patients with tumors: >10 cm (hazard ratio = 4.34; 95% confidence interval = 1.03-18.2) and metastatic disease (hazard ratio = 6.94; 95% confidence interval = 1.55-31.0).

CONCLUSIONS

Tumor size was identified as an independent risk factor for poor prognosis.

Hand tumors: A review of 186 patients at a single institute

PURPOSE

The spectrum of diagnoses and clinical features of hand tumors differ from those of tumors in other body parts. However, only a few reports have comprehensively referenced the diagnosis and clinical features of hand tumors. This study aimed to elucidate the diagnostic distribution and the clinical features of hand tumors undergone surgery in our institute.

PATIENTS AND METHODS

A total of 235 lesions in 186 patients diagnosed with hand tumors between 1978 and 2020 were reviewed. Age at surgery, gender, chief complaint, tumor location, and pathological diagnosis were analyzed.

RESULTS

There were 121 benign bone tumors, 98 benign soft tissue tumors, and 16 malignant tumors. Chondroma and tenosynovial giant cell tumor were common benign bone and soft tissue tumors at the proximal phalanx of the ring finger and the palm, respectively. Meanwhile, chondrosarcoma and synovial sarcoma were common malignant tumors at the dorsal part of the hand. Local pain and painless mass were the chief complaints in patients with benign bone and soft tissue tumors, respectively. Most patients with malignant tumors were referred after unplanned resection. When patients were classified into two categories by tumor size according to maximal diameter, tumors larger than 19 mm had a significantly higher risk of malignant (p = 0.031) despite being smaller than other tumors in different body parts.

CONCLUSION

When a tumor malignancy is suspected, the patient should be referred to a specialist to avoid unplanned resection or delayed diagnosis due to misdiagnosis. Knowing the distribution and clinical features should help in diagnosing hand tumors.

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.

Novel Double Central Ray Amputation of the Third and Fourth Digits: Case Report and Literature Review

Whenever partial hand amputations for soft tissue sarcomas are attempted, special consideration should be given to achieve a balance between complete resection associated with negative margins and preservation of functionality to the patient so that the hand can support the contralateral intact hand for bimanual activities. This difficult decision is even more challenging within the limited anatomical confines of the hand. Based on our literature review, this is the first case of double central 3rd and 4th ray amputation, as far as we know with good hand function, evaluated by the Musculoskeletal Tumor Rating Scale.

Factors associated with functional outcome in patients having limb salvage surgery for primary malignant bone sarcoma using TESS

INTRODUCTION

Achieving maximum functional outcome in primary malignant bone sarcoma surgery (PMBS) patients, is challenging for both patients and clinicians. This study, aimed to evaluate different factors that affect postoperative functional outcome of the primary malignant bone sarcoma patients following upper limb (UL) and lower limb (LL) salvage surgery using Toronto Extremity Salvage Score (TESS).

METHODS

136 PMBS adult patients were identified and were grouped as lower limb (LL) and upper limb (UL). Each group then sub-grouped to major and minor surgeries. Their functional outcome was compared using TESS by demographic variables(gender and age), neoadjuvant/adjuvant therapy and tumour variables (anatomical sites). In the UL groups, TESS was also compared for major and minor surgery subgroups based on their dominant or non-dominant limb.

RESULTS

The result of TESS has revealed that chemotherapy, radiotherapy, and gender have no effect on the functional outcome in PMBS patients. Functional outcome however was significantly affected by age in both LL and UL groups. The TESS was significantly different between major and minor subgroups in UL group with p= 0.0001. In patients with upper LSS on their dominant limb, no significant difference between major/ minor surgery subgroups was observed with p=0.077.

CONCLUSION

Our findings using TESS revealed that factors such as patient's age, and type of surgery (major or minor) in PMBS patients will affect the patients' functional outcome after LSS especially in those PMBS patients with upper LSS.

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.

Management of soft tissue tumors of the upper extremity: a review

Introduction: Management of malignant tumors of the hand and wrist is challenging and is generally approached by limb salvage or amputation. With advances in care, amputation has been superseded by limb salvage as the treatment of choice.

Methods: A narrative literature review was performed to identify articles on the topic of management of soft tissue tumors of the upper extremity, including surgical management, adjuvant radiation therapy, and chemotherapy.

Results: A total of 29 articles were selected. Earlier reports favored radical tumor resection, which often led to amputation, whereas later articles demonstrated limb salvage as the preferential treatment modality.

Conclusions: Given the detrimental effects on function and psychologic outcomes, amputation has been superseded by limb salvage in most cases, although it can occasionally be the only option. A variety of adjuvant therapies have been described, including radiation or brachytherapy, chemotherapy, and regional hyperthermia. Radiation treatment, and specifically brachytherapy, is beneficial to select patients. Controversy surrounds chemotherapy in certain subtypes, and regional hyperthermia requires further investigation.

Extensive limb-sparing surgery with reconstruction for sarcoma of the hand and wrist

BACKGROUND

Sarcoma rarely involves the hand or wrist. Extensive surgical excision is the current standard of care. At the extremities, such as the hand and wrist, limb-sparing surgery with reconstruction to provide optimal function is increasingly performed. A descriptive case-series study of 16 patients with sarcoma of the hand and wrist managed using limb-sparing surgery is reported here.

MATERIAL AND METHODS

Of 19 patients with sarcoma of the hand or wrist treated between 1999 and 2012, 16 were managed using limb-sparing surgery. These were consecutive patients managed at a single-centre and studied retrospectively. The tumour involved the hand in 7 patients and the wrist in 9 patients. The procedure was primary in 6 patients, whereas 10 patients underwent secondary revision surgery. In 12 patients, reconstruction was performed for one or more of the following structures: nerves (n=2), tendons (n=3), bone (n=3), and/or skin (n=8). After surgical excision, the margins were R0 in 15 patients and R1 in 1 patient. At last follow-up, survival, pain, and function as reflected by the DASH and MSTS scores were assessed.

RESULTS

After the median follow-up of 4.5years [1-13], 15 patients were alive with no local recurrence and 1 patient had lung metastases. Mean values were 18 [0-49] for the DASH score and 88.8% [53-100] for the MSTS score.

DISCUSSION

Limb-sparing surgery reconciles the need to achieve complete tumour excision with the need to restore function. No limits should be placed on tumour excision, given the availability of effective reconstructive methods. The functional outcome depends on the tolerance of adjuvant treatments, most notably radiotherapy.

LEVEL OF EVIDENCE

IV, retrospective study.

Elbow Reconstruction With Compression Plate Arthrodesis and Circumferential Muscle-Sparing Latissimus Dorsi Flap After Tumor Resection: A Case Report

BACKGROUND

The goals of limb-sparing surgery in the setting of extremity malignancies are 2-fold: oncological clearance and the rehabilitation of function and aesthetics. Treatment success should be defined by the extent of restoration of the patient's premorbid function for reintegration into society.

METHODS

We would like to report an unusual case of a patient with a chronically ankylosed elbow with joint invasion by basal cell carcinoma which resulted from malignant transformation of an overlying, long-standing wound due to inadequately treated septic arthritis from his childhood years.

RESULTS

Following R0 resection, upper limb shortening and compression plate elbow arthrodesis were performed with the aim of restoring the degree of upper limb function that the patient had been accustomed to preoperatively. The resultant circumferential defect was then closed with a contralateral, free muscle-sparing latissimus dorsi flap.

CONCLUSIONS

Functional preservation may therefore be more important than the mere restoration of anatomical defects in these especially challenging situations.

Management of infection following reconstruction in bone tumors

Limb salvage surgery in bone tumors has evolved in recent years and includes all of the surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result. This dramatic change came about as the result of three important developments, i.e. effective chemotherapy, improved precision imaging techniques and advances in reconstructive surgery. Reconstruction with a modular custom-made oncological endoprosthesis (megaprosthesis) has become a common procedure nowadays. These large foreign bodies make infection a common and feared complication. However, the occurrence of complications may be multifactorial, including a poor nutritional and compromised immune status due to chemotherapy and/or radiotherapy, a lengthy operation, extensive dissection and resection of soft tissues, inadequate soft-tissue coverage, a longer exposure of the wound resulting in infection, etc. Management of postoperative infection in these cases remains a challenge. This article analyses the current literature available for these cases and summarizes the cause and different available methods of treatment.

Study of Preoperative Radiotherapy for Sarcomas of the Extremities with Intensity-Modulation, Image-Guidance and Small Safety-margins (PREMISS)

Background

The aim of the trial is to demonstrate that with the use of modern IMRT/IGRT and reduction of safety margins postoperative wound complications can be reduced.

Methods/ Design

The trial is designed as a prospective, monocentric clinical phase II trial. The treatment is performed with helical IMRT on the Tomotherapy HiArt System© or with RapidArc© IMRT as available. All treatments are performed with 6 MV photons and daily online CT-based IGRT.

A dose of 50 Gy in 2 Gy single fractions (5 fractions per week) is prescribed. Restaging including MRI of the primary tumor site as well as CT of the thorax/abdomen is planned 4 weeks after RT. PET-examinations or any other imaging can be performed as required clinically. In cases of R1 resection, brachytherapy is anticipated in the 2nd postoperative week. Brachytherapy catheters are implanted into the tumor bed depending on the size and location of the lesion. Surgery is planned 5–6 weeks after completion of neoadjuvant RT. All patients are seen for a first follow-up visit 2 weeks after wound healing is completed, thereafter every 3 months during the first 2 years. The endpoints of the study are evaluated in detail during the first (2 weeks) and second (3 months) follow-up. Functional outcome and QOL are documented prior to treatment and at year 1 and 2. Treatment response and efficacy will be scored according to the RECIST 1.1 criteria. A total patient number of 50 with an expected 20 % rate of wound complications were calculated for the study, which translates into a 95 % confidence interval of 10.0-33.7 % for wound complication rate in a binomial distribution.

Discussion

The present study protocol prospectively evaluates the use of IMRT/IGRT for neoadjuvant RT in patients with soft tissue sarcomas of the extremity with the primary endpoint wound complications, which is the major concern with this treatment sequence. Besides complications rates, local control rates and survival rates, as well as QOL, functional outcome and treatment response parameters (imaging and pathology) are part of the protocol. The data of the present PREMISS study will enhance the current literature and support the hypothesis that neoadjuvant RT with IMRT/IGRT offers an excellent risk-benefit ratio in this patient population.

Trial registration

NCT01552239

Intraoperative extracorporeal autogenous irradiated tendon grafts for functional limb salvage surgery of soft tissue sarcomas of the wrist and hand

BACKGROUND

In patients with soft tissue sarcoma of the wrist and hand, limb salvage operation is extremely challenging for surgeons in attempting a complete tumor resection with negative surgical margins. In this study, we report four patients with soft tissue sarcoma of the wrist and hand treated by limb salvage operation with intraoperative extracorporeal autogenous irradiated tendon grafts.

METHODS

The patients were all male, and the mean age at the time of surgery was 45 years. Histological diagnoses included clear cell sarcoma in two patients, synovial sarcoma in one, and angiosarcoma in one. All four patients had high grade tumors, wherein three had American Joint Committee on Cancer (AJCC) stage III disease and one with AJCC stage IV disease. The tumors were resected en bloc with involved tendons. The tendons were isolated from the resected tissues, irradiated ex vivo, and re-implanted into the host tendons. In one patient, the bone was resected additionally because of tumor invasion to the bone. Hand function was evaluated using Musculoskeletal Tumor Society (MSTS) rating system.

RESULTS

Of the four patients, three died of distant metastatic disease. The remaining patient lives and remains disease-free. The mean follow-up period was 33 months. One patient had local recurrence outside the irradiated graft at 20 months after surgery. The functional rating was 22. Lower scores were seen in patients with reconstruction of flexor tendons than extensor tendons.

CONCLUSIONS

Limb salvage operation with intraoperative extracorporeal autogenous irradiated tendon grafts is an acceptable method in selected patients with soft tissue sarcoma of the wrist and hand.

Local tendon transfer for knee extensor mechanism reconstruction after soft tissue sarcoma resection

PURPOSE

Aim of this study was to measure the outcome of hamstring transfer for quadriceps reconstruction after soft tissue sarcoma resection and to identify risk factors influencing postoperative results.

METHODS

43 patients underwent hamstring transfer after sarcoma resection. Medical records were reviewed for surgical technique and complications. Physical examination included assessment of range of motion and muscle strength as well as plantar pressure distribution by computerized dynamometer and podometry, respectively. Additionally, patients' satisfaction, quality of life and karnofsky index were assessed.

RESULTS

Sole biceps transfer was performed in 31 (74%) and combined biceps/semitendinosus or gracilis transfer in 12 patients (26%). In 91%of cases 3/4 or more of the quadriceps muscle had to be removed. Postoperative complications occurred in 16 patients (37%). 17 patients (40%) were available for physical examination. Mean follow-up was 61 months (22-107). Average knee flexion was 74° (35-110°). All patients had full knee extension. Average extension force was 44% (19-79%) and flexion-force 74% (55-100%) of the unaffected leg. Mean plantar pressure distribution was 119% (44-200%) on the forefoot and 107% (60-169%) on the heel. Average patient satisfaction score was 16 (9-25), quality of life assessment was 78 (54-92) and Karnofsky Index was 82% (70-90%). Besides patient's age and the extent of resection, the surgical technique had statistically significant influence on functional outcome and postoperative complications (p < 0.05).

CONCLUSION

Hamstring transfer is feasible for quadriceps reconstruction after massive tumor resection from the thigh. In contrast to biceps alone, combined semitendinosus or gracilis transfer revealed comparable outcome but higher complication rates.

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.

Isolated limb perfusion with TNF-alpha and melphalan for distal parts of the limb in soft tissue sarcoma patients

BACKGROUND

Approximately 10% of soft tissue sarcomas (STS) occur in the most distal parts of the extremities. The standard therapy is local excision with adjuvant radiotherapy, but achieving wide resection margins might be difficult in the distal parts of the limb. Tumor necrosis factor-alpha (TNF) and melphalan-based isolated limb perfusion (TM-ILP) is effective in locally advanced STS of the extremities. We report the results of TM-ILP for STS in the most distal parts of the limb.

METHODS

Between 1991 and 2009, 34 ILPs were performed in patients with irresectable STS of the wrist, hand, ankle, or foot. Disease was unifocal in 21 (62%) patients.

RESULTS

Overall response rate was 71% (n = 24). After a median follow-up of 34 (range 1-143) months the local recurrence rate was 32%. Amputation was unavoidable in four patients (13%), four other patients (13%) underwent a partial amputation of the hand or foot.

CONCLUSION

With a limb salvage rate of 87%, TM-ILP is an effective treatment modality in patients with distal STS. In all patients with an indication for amputation surgery due to an STS in the distal part of the limb, TM-ILP should be considered.

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.

Double ray amputation for tumors of the hand

BACKGROUND

Partial hand amputations for malignant tumors allow tumor resection with negative resection margins, which is associated with lower local recurrence rates and improved overall survival while preserving native tissue, which improves functional outcome.

QUESTIONS/PURPOSES

We conducted this study to assess the functional outcome of double ray amputations of the hand.

METHODS

We retrospectively reviewed the records of five patients who underwent double ray amputations at our center over 12 years: four amputations of the fourth and fifth rays and one amputation of the second and third rays. Mean age at surgery was 34 years (range, 10-45 years), and minimum followup was 64 months (mean, 98 months; range, 64-136 months). All five patients had high-grade soft tissue sarcomas of the hand, two synovial sarcomas, two malignant peripheral nerve sheath tumors, and one undifferentiated sarcoma. No patients had detectable metastases at surgery.

RESULTS

Four of the five patients were completely disease-free at latest followup. One patient was alive with lung metastases detected 32 months after surgery. No patients developed local tumor recurrence. Functional assessment showed a mean Musculoskeletal Tumor Society score of 24 (range, 19-28) and mean grip strength 24% of the contralateral side (range, 17%-35%).

CONCLUSIONS

Although double ray amputation results in worse functional outcome than single ray, good key, tip, and tripod pinch can be preserved when the deep motor branch of the ulnar nerve is preserved, and this hand can still assist in bimanual hand activities. Our observations suggest double ray amputation is an acceptable hand-preserving procedure.

Predictive value of magnetic resonance imaging in determining presence of residual disease after marginal excision of unsuspected soft tissue sarcomas of the hand

PURPOSE

Diagnosis of a soft tissue sarcoma of the hand is at times made only in retrospect after marginal excision of a presumed benign soft tissue mass. Magnetic resonance imaging (MRI) helps determine the presence of residual disease and the extent of contamination caused by marginal excision of unsuspected soft tissue sarcomas and assists in the planning of definitive treatment with surgery and radiotherapy when required. We sought to determine the accuracy of MRI in detecting residual sarcoma after marginal excision.

METHODS

We retrospectively studied case records and imaging studies for all patients with soft tissue sarcomas of the hand evaluated and treated at our institution from 1996 to 2005. We included in this study 33 patients who underwent definitive surgery at our center after prior marginal excision. MRI scans done before definitive wide resection were classified as positive or negative for residual tumor. A musculoskeletal radiologist, blinded to the sarcoma type, findings on histopathology, and surgery, reviewed 19 scans to see whether the accuracy could be improved.

RESULTS

There were 8 epithelioid sarcomas, 6 synovial sarcomas, 4 malignant fibrous histiocytomas, 2 leiomyosarcomas, 2 liposarcomas, 2 myxofibrosarcomas, and one each of 9 other diagnoses. A total of 11 were low-grade and 22 were high-grade tumors, with 4 superficial and 29 deep tumors. Pathology examination after definitive wide resection or partial hand amputation showed that 15 patients had residual tumor, 9 gross and 6 microscopic. The sensitivity of MRI in detecting residual soft tissue sarcoma of the hand was 60%, specificity was 78%, positive predictive value was 69%, and negative predictive value was 70%. The sensitivity of MRI in detecting gross residual soft tissue sarcoma of the hand was 89%, specificity was 79%, positive predictive value was 62%, and negative predictive value was 95%. Even when an experienced musculoskeletal radiologist reassessed 19 MRI scans, the accuracy did not improve.

CONCLUSIONS

Magnetic resonance imaging does not reliably detect residual gross or microscopic soft tissue sarcoma after marginal excision of unsuspected soft tissue sarcomas of the hand, with residual tumor not readily distinguished from postoperative change. The absence of disease on MRI should not be used as the sole criterion in determining whether a repeat resection should be performed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Limb salvage in malignant tumors

Limb-sparing resection and reconstruction has become the treatment of choice in extremity malignancies, as amputation does not provide better long-term survival rates or functional advantages. R0 resection, the removal of the tumor in sano, remains the prerequisite and most important oncologic parameter to avoid local recurrence. Successful treatment requires the combination of surgical eradication and the patient's specific functional and aesthetic rehabilitation. Our clinical rationale resulting from more than 2000 cases will be demonstrated. The problematic aspects of different tumor entities and the locoregional clearance of lymphatic pathways will be discussed. Differential diagnosis and multimodality treatment in high-volume tumor centers is likely to achieve superior oncologic statistics. Long-term survivors after microsurgical reconstructions and possible secondary malignancies will be addressed.

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.

Soft tissue sarcomas of the hand: functional reconstruction and outcome analysis

Functional hand reconstruction following treatment of soft tissue sarcomas (STS) is a difficult surgical problem. Because survival rates between amputation and limb salvage do not differ, there is a trend toward reconstruction. Unlike amputation, hand salvage usually requires multiple complex operations in combination with adjuvant radiation or chemotherapy, prolonged rehabilitation, and carries a high complication rate. We investigated tumor recurrence, survival, and scored functional outcomes to determine if limb salvage is justified after hand STS resection. Patients treated for hand STS between years 1985 and 2005 were reviewed by two surgeons in three medical centers. All patients having functional reconstruction instead of amputation were reviewed. Patient demographics, tumor type and grade, resection extent, reconstruction procedure, timing, adjuvant therapy use, complications, tumor recurrence, survival, and functional outcome were recorded and analyzed. Five patients underwent functional reconstruction for hand STS. All patients underwent attempted curative resections, and four patients received neoadjuvant or postoperative radiation therapy. Three patients received adjuvant chemotherapy. Reconstructive techniques included three modified pollicizations, one free-tissue transfer, and one groin flap. All patients were alive and disease-free at a mean follow-up of 5 years (range 1.5-17 years). Three patients (60%) had local complications, requiring secondary surgeries. Two complications were related to radiation therapy. Hand function was evaluated using the Enneking Scoring System, and ranged from 17 to 28. The average Enneking score was 22.4, representing an average preservation of 74.6% of function. Because most patients retain excellent function and survival is unaffected, we advocate functional reconstruction despite high complication rates.

Functional and oncological outcomes after limb-salvage surgery for primary sarcomas of the upper limb

The surgical treatment of upper limb sarcoma poses an oncological and reconstructive challenge. Limb-salvage surgery aims to balance adequate excision margins for disease control and preservation of all important structures to retain maximum function. Reported here is an assessment of the functional and oncological outcomes of limb salvage surgery for primary sarcoma of the upper limb and limb girdle in 72 patients referred to a specialist musculoskeletal tumour unit over 9 years. All patients underwent excision of the sarcoma with reconstruction and adjuvant treatment as needed. Functional outcome was assessed using the Toronto Extremity Salvage Score (TESS) after discharge from hospital. The upper limb sarcomas treated by limb-salvage surgery achieved planned margins of excision in 85% of cases with primary surgery. This increased to 100% with re-excision, resulting in local recurrence in 15% and survival of 75% among those at 5 years or more after surgery, while retaining good to excellent function (TESS mean of 87 out of 100). A total of 38 patients completed TESS questionnaires and, as a single group, had a mean TESS of 87. Patient age, anatomical site of tumour and adjuvant treatment made no significant difference to TESS. Liposarcomas had a significantly better TESS than leiomyosarcomas, chondrosarcomas and malignant peripheral nerve sheath tumours. Oncological outcome was assessed in terms of excision margins achieved, local recurrence, re-excision and disease-free survival. Eight patients died of disease, all with high-grade primary tumours. Fourteen had local recurrence, four low-grade disease and the remaining high-grade disease. All four low-grade recurrences were successfully re-excised, as were five of the high-grade recurrences. The remaining five died of disease, with or without further recurrences. Consistently good functional results as measured by TESS were reported by responders, but high-grade disease and early recurrence were identified as predictors of recurrence and death from disease, respectively.

Soft-tissue sarcomas of the hand

We have investigated the oncological outcome of 63 patients with soft-tissue sarcomas of the hand managed at three major centres in the United Kingdom. There were 44 males and 19 females with a mean age of 45 years (11 to 92). The three most common diagnoses were synovial sarcoma, clear cell sarcoma and epithelioid sarcoma. Local excision was carried out in 45 patients (71%) and amputation in 18 (29%). All those treated by amputation had a wide margin of excision but this was only achieved in 58% of those treated by local excision. The risk of local recurrence was 6% in those treated by amputation compared with 42% for those who underwent attempted limb salvage. An inadequate margin of excision resulted in a 12 times greater risk of local recurrence when compared with those in whom a wide margin of excision had been achieved. We were unable to demonstrate any role for radiotherapy in decreasing the risk of local recurrence when there was an inadequate margin of excision. Patients with an inadequate margin of excision had a much higher risk of both local recurrence and metastasis than those with wide margins. The overall survival rate at five years was 87% and was related to the grade and size of the tumour and to the surgical margin.

We have shown that a clear margin of excision is essential to achieve local control of a soft-tissue sarcoma in the hand and that failure to achieve this results in a high risk of both local recurrence and metastastic disease.

[Late outcome of 89 patients with soft-tissue sarcomas treated by surgery and three different radiotherapy schedules]

PURPOSE

To evaluate the outcome of patients treated for soft tissue sarcoma using three different post-operative radiotherapy schedules.

METHODS AND MATERIALS

Between 1990 and 2003, 89 patients (median age 50.8 years) presenting with soft tissue sarcoma (located to the limbs for 66 of them) underwent post-conservative-surgery radiotherapy. Pathology was liposarcoma in 35 cases and 54 others tumors. Tumors grades (FNCLCC classification) were 1, 2, 3 or unknown in 29, 32, 19 and 9 cases, respectively. Surgery was considered as complete in 68 patients. Irradiation was normofractionated (NF) in 62 cases, hyperfractionated (BF) in 19 cases and hypofractionated (HF) in 8 cases. For all the patients, median delivered dose was 61 Gy [34-76 Gy].

RESULTS

Median follow-up of alive patients was 73,8 months [3-184]. Five-year local control (LC) and overall survival (OS) rates were 85.5 and 71.2% respectively. According to multifactorial analysis, favourable prognostic factors were for local control, complete surgery (P=0.0075) and for overall survival, complete surgery (P=0.0267), grade 1 tumor (P=0.012) and absence of distant recurrence (P=0.0488). There was no statistical evidence of difference for the five-year LC and OS rates between the patients who received NF, BF or HF. There were few complications and there were comparable in the three groups.

CONCLUSIONS

This retrospective serie showed similar results for all the schedules. There is no evidence to recommend bifractionation. Hypofractionation should be used only in selected patients with poor performans status.

Preoperative chemoradiation and flap reconstruction provide high local control and low wound complication rates for patients undergoing limb salvage surgery for upper extremity tumors

BACKGROUND AND OBJECTIVES

Neoadjuvant protocols in the management of upper extremity sarcoma have improved local control rates but have been associated with high complication rates. We present a refinement of the Eilber protocol using judicious preoperative chemoradiation, limb salvage surgery, and flap coverage to achieve high local control rates with acceptable wound healing complications.

METHODS

Patients presenting with upper extremity neoplasms from 1986 to 2002 were treated with a modified Eilber protocol, consisting of 3 days of adriamycin (30 mg/day) and sequential radiotherapy (300 cGy/day for 10 days). Limb salvage surgery with flap coverage where needed was performed 4-8 weeks later. Patients were followed prospectively for recurrence.

RESULTS

Fifty-three consecutive patients with upper extremity tumors were treated and followed for a mean of 6.1 years. This cohort included 44 sarcomas and nine non-metastasizing, locally aggressive tumors. There were two local recurrences (3.8%). Limb salvage was achieved in all patients. Flaps were required in 43.4% of patients. Major complications occurred in 11%, were all flap related (partial flap loss, venous congestion), and went on to heal promptly with treatment.

CONCLUSION

This modified Eilber protocol achieved 96% local control for upper extremity tumors with a wound complication rate of 11%. The liberal use of flaps of resulted in healed, stable wounds in all patients.

Sentinel node biopsy as an adjunct to limb salvage surgery for epithelioid sarcoma of the hand

Background

Epithelioid sarcomas of the hand are rare, high-grade tumors with a propensity for regional lymphatic spread approaching 40%.

Case presentation

A 54-year-old male with an epithelioid sarcoma of the palm was treated with neoadjuvant radiation, wide excision, and two-stage reconstruction. Sentinel lymph node biopsy was used to stage the patient's axilla. Sentinel node biopsy results were negative. The patient has remained free of local, regional and distant disease for the follow-up time of 16 months.

Conclusion

The rarity of this tumor makes definitive conclusions difficult but SLN biopsy appears to be a useful adjunct in the treatment of these sarcomas.

Upper Extremity Reconstruction Following Resection of Soft Tissue Sarcomas: A Functional Outcomes Analysis

BACKGROUND

Treatment for soft tissue sarcoma of the upper extremity has evolved to include limb salvage techniques. We reviewed our experience with limb salvage therapy for upper extremity sarcomas with an emphasis on functional outcomes following the reconstructive surgery.

METHODS

A retrospective analysis was performed of 81 consecutive patients with soft tissue sarcoma of the upper extremity who had limb salvage therapy with reconstruction by a plastic surgeon. Univariate and multivariate regression analyses of relevant outcome variables were performed. Enneking functional scores were obtained from 43 patients.

RESULTS

The study included 16 microvascular reconstructions and 67 non-microvascular reconstructions for a total of 83 reconstructions in 81 patients. The mean defect size was 129 cm(2) (standard deviation: 106 cm(2)). The mean total functional score was 23.1 (range, 9 to 30). Any reconstruction-related complication and preoperative chemotherapy use were associated with a 7.3 point (P = .03) and 4.7 point (P = .01) decrease in total functional score, respectively. Kaplan-Meier product-limit analysis showed 82% 5-year overall survival and 67% 5-year disease-free survival rates.

CONCLUSIONS

For soft tissue sarcoma of the upper extremity, limb salvage with good functional outcome is possible with a judicious approach to reconstruction.

Upper Extremity Limb Salvage with Microvascular Reconstruction in Patients with Advanced Sarcoma

Limb salvage is a viable alternative to amputation in many cases of advanced sarcoma. The authors examined their experience with microvascular reconstruction of upper extremity defects after sarcoma resection, focusing on oncologic and functional outcomes. A retrospective analysis yielded 17 patients who underwent 18 free flap procedures and met the inclusion criteria. Most patients (71 percent, n = 12) had recurrent sarcoma at presentation to the authors' institution. Malignant fibrous histiocytoma was the most common pathologic subtype (n = 6). High-grade tumors were present in 94 percent of patients (n = 16). The free flap survival rate was 100 percent. The rectus abdominis flap was the most common free flap used (39 percent; n = 7). Local recurrence occurred in nine flaps (50 percent), and five patients ultimately required amputations. Six patients (35 percent) had distant recurrence. The mean Enneking score for limb function was 73 percent of the maximum (21.9 of 30). The 5-year disease-specific survival rate was 61.3 percent. In select patients with advanced upper extremity sarcoma undergoing limb salvage, microvascular flap reconstruction can provide reliable, safe coverage with reasonable preservation of function.

Upper-extremity sarcomas in the United States: analysis of the surveillance, epidemiology, and end results database, 1973-1998

PURPOSE

Upper-extremity soft-tissue sarcomas are a rare disease with unclear epidemiology and evolving treatment strategies. Our purpose is to evaluate the incidence of upper-extremity soft-tissue sarcomas and the use of adjuvant radiotherapy in this patient population.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database, a national population-based database, we identified all cases of primary upper-extremity sarcoma reported to the 9 national SEER registries in the Untied States from 1973 to 1998.

RESULTS

Of the 1,286 upper-extremity soft-tissue sarcomas the average incidence rate is 2.2 cases/million/y, which has not changed significantly from 1973 to 1998. Caucasians' average incidence rate is significantly higher than African Americans' (incidence rate ratio [IRR] = 1.3, p =.02); and men are at a significantly higher risk compared with women (IRR = 1.3, p <.01). The use of adjuvant radiotherapy has increased significantly from 17% in 1973 to 47% in 1998 (p <.01). African-Americans, compared with Caucasians, are significantly less likely to receive adjuvant radiotherapy (odds ratio [OR] =.5, p =.01).

CONCLUSIONS

The incidence of upper-extremity sarcomas has not changed significantly over the past 3 decades; however, the disease differentially affects the population with higher rates in Caucasians and men. Based on the results of this study the use of adjuvant radiotherapy is increasing but African Americans are less likely than Caucasians to receive this treatment for upper-extremity sarcoma.

Soft tissue sarcoma of the upper extremity: a 5-year experience at two institutions emphasizing the role of soft tissue flap reconstruction

BACKGROUND

The objective of this study was to define the impact of soft tissue flap reconstruction on multimodality therapy for patients with soft tissue sarcomas of the upper extremity. Treatment standards continue to evolve for these patients, and, with multimodality therapy, most of them are candidates for limb-preserving surgery. Consequently, the role of soft tissue flap reconstruction is expanding.

METHODS

A review was conducted of 100 consecutive patients with soft tissue sarcomas of the upper extremity who underwent surgery at several institutions between 1992 and 1997.

RESULTS

Seventy-one patients underwent direct closure of defects after tumor resection, and 29 patients required soft tissue reconstruction with flaps. These groups were similar in most respects, except that 52% of the patients who required soft tissue reconstruction presented with recurrent disease (P = 0.0004), and 79% of them had tumors measuring > 5 cm in greatest dimension (P = 0.0003). The patients who required flap reconstruction had larger skin deficits after undergoing tumor resection (140 cm2) compared with the patients who had wounds that were managed by direct closure (40 cm2; P < 0.00001). Margins around the resected tumors were larger (1.62 cm) when flaps were employed compared with margins when defects were closed directly (0.87 cm; P = 0.0005). However, the number of patients with intralesional, marginal, wide, and radical resections was the same regardless of wound management. Major complications occurred in 14% of patients, but none led to death or amputation. The median follow-up was 31 months, and 66% of patients had no evidence of disease at that time. Rates of local recurrence and survival were similar for patients who underwent flap reconstruction compared with patients who underwent direct closure.

CONCLUSIONS

Soft tissue flap reconstruction facilitates therapy for patients with soft tissue sarcomas of the upper extremity, so that patients with larger tumors can undergo resection, limiting complications and limb sacrifice.

Uncommon hand tumours

This paper presented clinical examples of some rare or uncommon presentations of tumours of the hand, including glomus tumour, intraosseous dermoid, fibrolipoma of the radial nerve, blastomycotic cyst and synovial sarcoma. Each lesion is illustrated by review of case histories, radiological and pathological features.

Soft tissue sarcoma of the upper extremity: descriptive data and outcome in a population-based series of 108 adult patients

We report a population-based, 29-year review of 108 adult patients with soft tissue sarcoma of the upper extremity who had a minimum follow-up period of 3 years. Fifty tumors were localized in the upper arm, 8 in the elbow, 40 in the forearm, and 10 in the hand. Thirty-four tumors were subcutaneous and 74 were deep-seated. The median tumor size was 6 cm. Malignant fibrous histiocytoma was the most common histotype (n = 43), and grade IV (on a 4-grade scale) was the most common malignancy grade (n = 54). All but 6 patients underwent surgery; limb-sparing surgery of the primary tumor was performed in 89 patients. Twenty-four patients were given adjuvant radiotherapy; 11 received adjuvant chemotherapy. Inadequate local treatment was more common in patients treated outside the tumor center. Local recurrence occurred in 15 of 28 with inadequate local treatment and in 16 of 74 patients with adequate local treatment (20 of the 39 patients treated outside the center and 11 of the 63 patients treated at the center). At the latest follow-up visit, 32 patients had developed metastases, giving a 5-year metastasis-free survival rate of 0.72. In a multivariate analysis, tumor size larger than 5 cm and vascular invasion emerged as independent prognostic factors. Patients without these 2 factors had excellent survival. When compared with soft tissue sarcoma of the lower extremity or trunk wall, tumors in the upper extremity were smaller at the time of diagnosis and had a higher 5-year metastasis-free survival rate.

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.