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Elmorsi R, Camacho L, Krijgh DD, Tilney GS, Lyu H, Traweek RS, Witt RG, Roubaud MS, Roland CL, Mericli AF. Sarcoma Size and Limb Dimensions Predict Complications, Recurrence, and Death in Patients with Soft Tissue Sarcoma in the Thigh: A Multidimensional Analysis. Ann Surg Oncol 2024; 31:5421-5430. [PMID: 38520583 DOI: 10.1245/s10434-024-15183-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/03/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Limb-sparing resections of thigh soft tissue sarcomas (STSs) can result in adverse outcomes. Identifying preoperative predictors for wound healing complications, tumor recurrence, and mortality is crucial for informed reconstructive decision-making. We hypothesized that preoperative measurements of thigh and tumor dimensions could serve as reliable indicators for postoperative complications, recurrence, and death. PATIENTS AND METHODS In this retrospective cohort study conducted from March 2016 to December 2021, we analyzed patients undergoing thigh STS excisions followed by reconstruction. Preoperative magnetic resonance imaging or computed tomography scans provided necessary thigh and tumor dimensions. Univariate and multivariate regression assessed relationships between these dimensions and postoperative outcomes, including complications, recurrence, and death. RESULTS Upon the analysis of 123 thighs, we found thigh width to be highly predictive of postoperative complications, even surpassing body mass index (BMI) and retaining significance in multivariate regression [odds ratio (OR) 1.19; 95% CI 1.03-1.39; p = 0.03]. Sarcoma-to-thigh width and thickness ratios predicted STS recurrence, with the thickness ratio retaining significance in multivariate regression (OR 1.03; 95% CI 1.001-1.05; p = 0.041). Notably, greater thigh thickness was independently protective against mortality in multivariate analysis (OR 0.80; 95% CI 0.65-0.98; p = 0.030). CONCLUSIONS Thigh width outperformed BMI in association with postoperative complications. This may create an opportunity for intervention, where weight loss can play a role during the neoadjuvant therapy period to potentially reduce complications. Sarcoma-to-thigh width and thickness ratios, particularly the latter, hold substantial predictive value in terms of STS recurrence. Moreover, thigh thickness is an independent predictor of survival.
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Affiliation(s)
- Rami Elmorsi
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Luis Camacho
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David D Krijgh
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gordon S Tilney
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Lyu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raymond S Traweek
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Russell G Witt
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Margaret S Roubaud
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alexander F Mericli
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Matsuoka M, Onodera T, Yokota I, Iwasaki K, Hishimura R, Suzuki Y, Hamasaki M, Iwata A, Kondo E, Iwasaki N. Amputation surgery associated with shortened survival in patients with localized soft tissue sarcoma. J Orthop Sci 2024; 29:637-645. [PMID: 36931976 DOI: 10.1016/j.jos.2023.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND The objectives of this study were to clarify whether localized extremity soft tissue sarcoma (STS) patients who underwent amputation surgery experienced worsened survival and to identify those patients for whom amputation surgery worsened survival. METHODS Using the Surveillance, Epidemiology, and End Results database, we identified 8897 patients with localized extremity STS between 1983 and 2016. Of these 6431 patients, 733 patients underwent amputation surgery (Amputation group), and 5698 underwent limb-sparing surgery (Limb-sparing group). RESULTS After adjusting for patient background by propensity score matching, a total of 1346 patients were included. Patients in the Amputation group showed worsened survival (cancer-specific survival (CSS): hazard ratio (HR) = 1.42, 95% confidence interval (CI) 1.15-1.75, overall survival (OS): HR = 1.41, 95%CI 1.20-1.65). In subclass analysis, patients with high-grade STS, spindle cell sarcoma and liposarcoma in the Amputation group showed shortened survival (high-grade-CSS: HR = 1.44, 95%CI 1.16-1.77, OS: HR = 1.38, 95%CI 1.18-1.62; spindle cell sarcoma-CSS: HR = 4.75, 95%CI 1.56-14.4, OS: HR = 2.32, 95%CI 1.45-3.70; liposarcoma-CSS: HR = 2.91, 95%CI 1.54-5.50, OS: HR = 2.32, 95%CI 1.45-3.70). CONCLUSIONS Survival was shortened in localized extremity STS patients who received amputation surgery.
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Affiliation(s)
- Masatake Matsuoka
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Tomohiro Onodera
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Koji Iwasaki
- Department of Functional Reconstruction for the Knee Joint, Hokkaido University, Kita-15, Nish-7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Ryosuke Hishimura
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Yuki Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Masanari Hamasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Akira Iwata
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, North 15 West 7, Kita-Ku, Sapporo, Hokkaido 060-8638, Japan.
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Kim Y, Kim HS, Han I. Amputation in patients with extremity soft tissue sarcoma: the experience of an East Asian referral center. BMC Cancer 2024; 24:61. [PMID: 38212719 PMCID: PMC10782674 DOI: 10.1186/s12885-023-11813-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/31/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND This study aimed to investigate the characteristics and clinical outcomes in a series of patients with extremity soft tissue sarcoma (STS) who underwent amputation at a large East Asian referral center. PATIENTS AND METHODS Of the 652 patients who underwent surgery for extremity STS, data of 37 consecutive patients who underwent amputation were reviewed retrospectively. The median follow-up period was 96.0 months (range, 15-216). The patients were classified in to three cohorts. The primary localized (PL) group included patients who underwent amputation as a primary surgical procedure with curative intent. The recurrent localized (RL) group included patients who underwent amputation as a revision procedure after failure of previous limb sparing surgeries. The metastatic group included patients who underwent amputation as a palliative procedure. RESULTS There were 22 cases of amputation in 596 STS patients and the amputation rate was 3.6% (22/596). Further, 1.8% (9/490) of patients with primary localized STS underwent amputation. Patients with localized STS who underwent amputation had a 5-year disease-specific survival (DSS) rate of 89.9% (95% Confidence Interval (CI), 87.1-92.7%), a local-recurrence-free survival (LRFS) of 84.1% (95% CI, 80.5-87.6%), and a metastasis-free survival (MFS) of 84.6%. (95% CI, 81.1-88.0%) Compared with previous studies, our results showed higher DSS and MFS rates with similar LRFS. CONCLUSIONS The amputation rate of extremity STS in our institute in East Asia was similar but slightly lower than that reported in Western studies. The oncologic outcome of amputation reported in this study was higher than that indicated in Western studies and oncologic outcome of amputation was not statistically different from those of limb salvage surgery. However, considering the small cohort in single institute study, there is a possibility of selection bias and future multi-center study is necessary. From our results, amputation is still a feasible option for appropriately selected patients unsuitable for limb-conserving surgery.
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Affiliation(s)
- Yongsung Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno- gu, 03080, Seoul, Korea
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Korea
| | - Han-Soo Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno- gu, 03080, Seoul, Korea
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, 03080, Seoul, Korea
| | - Ilkyu Han
- Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno- gu, 03080, Seoul, Korea.
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, 101 Daehak-ro Jongno-gu, 03080, Seoul, Korea.
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Huynh THN, Kuruvilla DR, Nester MD, Zervoudakis G, Letson GD, Joyce DM, Binitie OT, Lazarides AL. Limb Amputations in Cancer: Modern Perspectives, Outcomes, and Alternatives. Curr Oncol Rep 2023; 25:1457-1465. [PMID: 37999825 DOI: 10.1007/s11912-023-01475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW This review summarizes current findings regarding limb amputation within the context of cancer, especially in osteosarcomas and other bony malignancies. We seek to answer the question of how amputation is utilized in the contemporary management of cancer as well as explore current advances in limb-sparing techniques. RECENT FINDINGS The latest research on amputation has been sparse given its extensive history and application. However, new research has shown that rotationplasty, osseointegration, targeted muscle reinnervation (TMR), and regenerative peripheral nerve interfaces (RPNI) can provide patients with better functional outcomes than traditional amputation. While limb-sparing surgeries are the mainstay for managing musculoskeletal malignancies, limb amputation is useful as a palliative technique or as a primary treatment modality for more complex cancers. Currently, rotationplasty and osseointegration have been valuable limb-sparing techniques with osseointegration continuing to develop in recent years. TMR and RPNI have also been of interest in the modern management of patients requiring full or partial amputations, allowing for better control over myoelectric prostheses.
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Affiliation(s)
- Thien Huong N Huynh
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Davis R Kuruvilla
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Matthew D Nester
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | | | | | - David M Joyce
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Odion T Binitie
- Department of Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
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Stauss R, Graulich T, Omar Pacha T, Omar M. [Limb-sparing resection of axillary soft tissue sarcomas]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:377-389. [PMID: 37462680 DOI: 10.1007/s00064-023-00824-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/09/2023] [Accepted: 06/09/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE For patients with soft tissue sarcoma, surgical resection is a key element of curative therapy. Surgery is performed as a wide resection with microscopically negative margins (R0 resection) and as limb-sparing procedure whenever possible to preserve maximum function. INDICATIONS Soft tissue sarcoma, metastases. CONTRAINDICATIONS Extensive disease with major neurovascular involvement, placement of biopsy tract necessitates extensive resection, palliative care. SURGICAL TECHNIQUE Extended deltopectoral approach. Release of pectoralis major and minor tendons. Vascular and neurologic exploration, identification of the axillary vessels and brachial plexus, placing of loops around major structures. Mobilization of these structures to achieve adequate exposure. Clipping of vessels entering the tumor. Tumor resection, suture marking for histological analysis. Soft tissue reconstruction by transosseous reinsertion of the pectoralis minor to the coracoid process. Drill channel placement, transosseous refixation of the pectoralis major to the humerus. POSTOPERATIVE MANAGEMENT Shoulder abduction brace for 6 weeks, passive mobilization for 6-12 weeks followed by active mobilization. Compression sleeve. Oncological follow-up. RESULTS Between 2017 and 2022, wide resection was performed in 6 consecutive cases including 4 primary soft tissue sarcomas and 2 metastases. Primary R0 resection was achieved in 100%. Mean follow-up was 22.5 months (3-60 months). There were no local recurrences. Mean active shoulder abduction was 135.0 ± 41.4° (90-180°). Neurological deficits were not observed. Mean subjective shoulder function was 80.0 ± 21.0% (50-100%). The mean Musculoskeletal Tumor Society (MSTS) score was 89.5% (32-100%), indicating good functional outcome in the study cohort.
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Affiliation(s)
- Ricarda Stauss
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
- Klinik für Unfallchirurgie, Sarkom-Zentrum, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Tilman Graulich
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Tarek Omar Pacha
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Mohamed Omar
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
- Klinik für Unfallchirurgie, Sarkom-Zentrum, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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Raza A, Siraj I, Malik S, Mohammed R, Shariff MA. A Case of Locally Advanced Fibrosarcoma in a Young Male. Cureus 2023; 15:e44095. [PMID: 37750151 PMCID: PMC10518120 DOI: 10.7759/cureus.44095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/27/2023] Open
Abstract
Fibrosarcoma is a rare, highly malignant tumor that develops from uncontrolled overgrowth of fibroblastic cells. It may start as a painless lump or swelling under the skin. But as it grows, it can push surrounding structures - organs, muscles, nerves, or blood vessels - and lead to pain and tenderness. The treatment of fibrosarcoma depends on several factors such as size, grade, location of primary tumor, extent of spread, age, and general health condition of the patient. The main treatment is surgical removal of the primary tumor with wide-margin excision and amputation if localized in the limb. Prior to surgical intervention, radiotherapy can be applied to reduce the tumor size or following surgery to lower the risk of recurrence. Chemotherapy is indicated in cases of metastasis. Unfortunately, the prognosis of fibrosarcoma is not favorable. For high-grade fibrosarcoma, the five-year survival rate is around 30% and for low-grade fibrosarcoma, it is 50-80%, with recurrence in the first two to five years post-surgery. We encountered a case of high-grade fibrosarcoma with aggressive growth in a 36-year-old male, requiring above-knee amputation.
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Affiliation(s)
- Ali Raza
- Surgical Oncology, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
| | - Imrana Siraj
- Cancer Center Research Services, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
| | - Sabina Malik
- Cancer Center, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
| | - Raji Mohammed
- Pathology and Laboratory Medicine, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
| | - Masood A Shariff
- Surgical Oncology, New York City (NYC) Health and Hospitals Corporation (HHC) Lincoln, Bronx, USA
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Benabbouha A, Benyass Y, Sallahi H, Margad O. High-grade pleomorphic sarcoma associated with an orthopedic implant: a rare case report. Oxf Med Case Reports 2023; 2023:omad061. [PMID: 37377725 PMCID: PMC10292646 DOI: 10.1093/omcr/omad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 06/29/2023] Open
Abstract
The use of prosthetic implants and metallic materials is widespread in modern orthopedic surgery. Generally, these materials are non-toxic and inert. Nevertheless, a few cases of malignancy associated with certain implants have been documented in the literature. It has been reported that some components of these implants have carcinogenic properties. In most cases, these tumors are high-grade sarcomas that occur in the bone or soft tissue adjacent to the implant site. Here we present the case of a 53-year-old patient who underwent intramedullary nailing of the tibia and developed a pleomorphic sarcoma at the implant site 18 years later.
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Affiliation(s)
- Abdellatif Benabbouha
- Correspondence address. Military Training Hospital Avicenne, 40150 Marrakech, Morocco. Tel: +212662063101; E-mail:
| | - Youssef Benyass
- Department of Orthopedic Surgery and Traumatology, Military Training Hospital Avicenne, Faculty of Medicine and Pharmacy, University Cadi Ayyad, BP 40150 Marrakech, Morocco
| | - Hicham Sallahi
- Department of Orthopedic Surgery and Traumatology, Military Training Hospital Avicenne, Faculty of Medicine and Pharmacy, University Cadi Ayyad, BP 40150 Marrakech, Morocco
| | - Omar Margad
- Department of Orthopedic Surgery and Traumatology, Military Training Hospital Avicenne, Faculty of Medicine and Pharmacy, University Cadi Ayyad, BP 40150 Marrakech, Morocco
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Kang J, Choi KW, Han A, Min S, Heo SH, Yang SS, Park YJ, Min SK. Venous Reconstruction in Extremity Soft Tissue Sarcoma Is Not Essential. Vasc Endovascular Surg 2023; 57:365-372. [PMID: 36592476 DOI: 10.1177/15385744221150737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Limb salvage is an important concern following complete oncologic resection for extremity soft tissue sarcoma (STS). Vascular reconstruction is essential for limb salvage. The purpose of this study was to evaluate the outcomes of vascular reconstruction in patients with extremity STS. METHODS This is a retrospective, multi-center, case series of consecutive patients who underwent vascular reconstruction during extremity STS resection at 2 major centers in Korea. Demographics, reconstruction methods, type of conduit, surgical complications, graft patency, limb salvage rate, and patient survival were reviewed. RESULTS From March 2005 to December 2020, 43 patients underwent vascular reconstructions during STS resection. Among the patients, 22 (51.2%) received arterial only, and 21 (48.8%) received simultaneous arterial and venous reconstructions. For the types of conduits, autologous saphenous veins (56.2%), artificial grafts (26.3%), and cryopreserved allografts (15.8%) were used. During a median follow-up of 23.8 months (interquartile range; 7.7-54.5), the overall primary patency of the reconstructed vessels was significantly higher in arteries than in veins (82.5% vs 56.3% at 12 months, P < .001). According to the type of conduit, the primary patency rate of autogenous vein seemed higher in venous reconstruction, however, there was no statistical significance in both arterial and venous reconstruction. There was no significant difference in primary arterial patency rate (P = .132) or incidence of surgical complications including postoperative edema or wound problem whether or not simultaneous venous reconstruction was performed with arterial reconstruction. The overall limb salvage rate and patient survival were 97.4%, 95.1%, and 89.4% and 91.9%, 81.7%, and 65.4% at 12, 24, and 36 months, respectively. CONCLUSIONS Patency rates were poorer in venous reconstruction than in arterial reconstruction. In terms of arterial patency and postoperative complication, the role of simultaneous arterial and venous reconstruction seems not essential, however, it needs to be evaluated in future studies.
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Affiliation(s)
- Jihee Kang
- Division of Vascular Surgery, Department of Surgery, Inha University Hospital, Inha University School of Medicine, Jung-gu, Incheon, Korea
| | - Kwang Woo Choi
- Division of Vascular Surgery, Department of Surgery, 37990Seoul National University College of Medicine, Jongno-gu, Seoul, Korea
| | - Ahram Han
- Division of Vascular Surgery, Department of Surgery, 37990Seoul National University College of Medicine, Jongno-gu, Seoul, Korea
| | - Sangil Min
- Division of Vascular Surgery, Department of Surgery, 37990Seoul National University College of Medicine, Jongno-gu, Seoul, Korea
| | - Seon-Hee Heo
- Department of Surgery, Yonsei Severance Hospital, 37991Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, 36626Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Heart Vascular Stroke Institute, 36626Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Seung-Kee Min
- Division of Vascular Surgery, Department of Surgery, 37990Seoul National University College of Medicine, Jongno-gu, Seoul, Korea
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Conti L, Buriro F, Baia M, Pasquali S, Miceli R, De Rosa L, Gronchi A, Fiore M. Contemporary role of amputation for patients with extremity soft tissue sarcoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 49:934-940. [PMID: 36517316 DOI: 10.1016/j.ejso.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/01/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION limb-sparing surgery is the mainstream treatment for primary extremity soft tissue sarcoma (ESTS) at referral centers, following advances in surgical reconstructions and multimodal management. However, amputation is still needed in selected patients and has not yet been described for a ESTS cohort in a contemporary scenario. MATERIAL AND METHODS consecutive patients who underwent surgery for primary ESTS from 2006 to 2018 were extracted from a prospectively collected database at our reference center. Patients receiving amputation for either primary tumor or local recurrence (LR) after limb-sparing surgery were selected for analysis. RESULTS Among 1628 primary ESTS, 29 patients underwent primary amputation (1.8%), 22/1159 (1.9%) for upper limb and 7/469 (1.5%) for lower limb ESTS. Patients were mainly affected by grade III FNCLCC (89.6%) of notable dimension (median size 16 cm, IQR 10-24). 65.5% of patients received preoperative treatments (systemic or regional chemotherapy, radiotherapy or chemo-radiation). Secondary amputation for LR was performed after a median of 23 months in 16/1599 patients (1%). Median survival time was 16.2 and 29.6 months after primary or secondary amputation respectively. Factors prompting the need for a primary amputation were most often a combination of multifocal disease, bone invasion and pain or neurovascular bundle involvement and relevant comorbidities, mainly for grade III tumors in elderly patients. CONCLUSION Contemporary rate of amputation for ESTS at a reference center is extremely low. Still, amputation is required in selected cases with advanced presentations, especially in elderly, frail patients.
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Koulaxouzidis G, Schlagnitweit P, Anderl C, Braig D, Märdian S. Microsurgical Reconstruction in Orthopedic Tumor Resections as Part of a Multidisciplinary Surgical Approach for Sarcomas of the Extremities. Life (Basel) 2022; 12:1801. [PMID: 36362956 PMCID: PMC9695779 DOI: 10.3390/life12111801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/17/2022] [Accepted: 10/28/2022] [Indexed: 11/22/2023] Open
Abstract
A central element of modern sarcoma therapy is complete surgical tumor resection with an adequate safety margin, embedded in an interdisciplinary multimodal therapy concept. Along with ensuring patient survival, functional limb preservation is an important goal for sarcomas of the extremities. This review provides an overview of the relevant literature on indications and goals of reconstructive options, the scope and contribution of microsurgical reconstructive procedures, and the associated interdisciplinary decision making and workup. Furthermore, the impact of (neo)-adjuvant therapy on reconstructive decisions will be highlighted. These aspects will be illustrated by four comprehensive case studies that demonstrate both useful strategies and the need for individually tailored therapies. Nowadays, extremity-preserving therapy is possible in more than 90% of sarcomas. Technical and procedural innovations such as microsurgery and microsurgical reconstructive procedures have significantly contributed to this evolution of therapy.
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Affiliation(s)
- Georgios Koulaxouzidis
- Department of Plastic, Aesthetic and Reconstructive Surgery, Congregational Hospital Linz, Sisters of Mercy, 4010 Linz, Austria
| | - Paul Schlagnitweit
- Department of Plastic, Aesthetic and Reconstructive Surgery, Congregational Hospital Linz, Sisters of Mercy, 4010 Linz, Austria
| | - Conrad Anderl
- Department of Orthopaedic Surgery, Congregational Hospital Linz, Sisters of Mercy, 4010 Linz, Austria
| | - David Braig
- Department of Plastic and Hand Surgery, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich, 80336 Munich, Germany
| | - Sven Märdian
- Centre for Musculoskeletal Surgery, Charité-University Medicine Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin Insitute of Health, 13353 Berlin, Germany
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11
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Hudson T, Burke C, Mullner D, Herrera FA. Risk factors associated with 30-day complications following lower extremity sarcoma surgery: A national surgical quality improvement project analysis. J Surg Oncol 2022; 126:1253-1262. [PMID: 35856569 DOI: 10.1002/jso.27018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Our study aims to identify risk factors associated with complications in lower extremity (LE) sarcoma surgery, as well as the prevalence and complications associated with concurrent plastic surgery procedures (CPSP). METHODS ACS-NSQIP database was accessed to identify patients treated for LE sarcoma (2010-2019). Patient demographics, preoperative lab, comorbidities, tumor type, location, principle procedure, and presence/characteristics of CPSPs were recorded. Thirty-day soft tissue complications were analyzed. Bivariate and multivariate logistic regression was performed on IBM SPSS.™ RESULTS: Nine hundred eighteen patients were included (483 males and 435 females), average age and body mass index (BMI) of 57 and 27.4 kg/m,2 respectively. Comorbidities included smoking (13.9%, 128), hypertension (37.3%, 342), and insulin-dependent diabetes (3.7%, 34). Preoperative lab values included albumin <3.5 (6.8%, 63), hematocrit <30% (8.2%, 75), and platelet count <150 000 (5.9%, 54). Thirty-day soft tissue complication rate was 5.7% (52 of 918). On multivariate logistic regression, increased age (p = 0.039), higher BMI (p = 0.017), and longer operative times (p = 0.002) were significant risk factors independently associated with soft tissue complications. CONCLUSIONS Soft tissue complications within 30 days occur in 6% of patients. Graft procedures carry a 20% risk of complications. Risk factors independently associated with complications include increased age, increased BMI, and longer operative times.
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Affiliation(s)
- Todd Hudson
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Connor Burke
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Donna Mullner
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Fernando A Herrera
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
- Division of Plastic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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12
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Hirozane T, Nakayama R, Yamaguchi S, Mori T, Asano N, Asakura K, Kikuta K, Kawaida M, Sasaki A, Okita H, Nakatsuka S, Ito T. Recurrent malignant peripheral nerve sheath tumor presenting as an asymptomatic intravenous thrombus extending to the heart: a case report. World J Surg Oncol 2022; 20:8. [PMID: 34996471 PMCID: PMC8742394 DOI: 10.1186/s12957-021-02473-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/13/2021] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Toru Hirozane
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Robert Nakayama
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Sayaka Yamaguchi
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tomoaki Mori
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Naofumi Asano
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Keisuke Asakura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazutaka Kikuta
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Division of Musculoskeletal Oncology and Orthopedic Surgery, Tochigi Cancer Center, Tochigi, Japan
| | - Miho Kawaida
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Aya Sasaki
- Department of Pathology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Hajime Okita
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Seishi Nakatsuka
- Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Ito
- Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
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13
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Shields DW, Razii N, Doonan J, Mahendra A, Gupta S. Closed incision negative pressure wound therapy versus conventional dressings following soft-tissue sarcoma excision: a prospective, randomized controlled trial. Bone Jt Open 2021; 2:1049-1056. [PMID: 34905941 PMCID: PMC8711667 DOI: 10.1302/2633-1462.212.bjo-2021-0103.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Aims The primary objective of this study was to compare the postoperative infection rate between negative pressure wound therapy (NPWT) and conventional dressings for closed incisions following soft-tissue sarcoma (STS) surgery. Secondary objectives were to compare rates of adverse wound events and functional scores. Methods In this prospective, single-centre, randomized controlled trial (RCT), patients were randomized to either NPWT or conventional sterile occlusive dressings. A total of 17 patients, with a mean age of 54 years (21 to 81), were successfully recruited and none were lost to follow-up. Wound reviews were undertaken to identify any surgical site infection (SSI) or adverse wound events within 30 days. The Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) score were recorded as patient-reported outcome measures (PROMs). Results There were two out of seven patients in the control group (28.6%), and two out of ten patients in the intervention group (20%) who were diagnosed with a SSI (p > 0.999), while one additional adverse wound event was identified in the control group (p = 0.593). No significant differences in PROMs were identified between the groups at either 30 days (TESS, p = 0.987; MSTS, p = 0.951) or six-month (TESS, p = 0.400) follow-up. However, neoadjuvant radiotherapy was significantly associated with a SSI within 30 days of surgery, across all patients (p = 0.029). The mean preoperative modified Glasgow Prognostic Score (mGPS) was also significantly higher among patients who developed a postoperative adverse wound event (p = 0.028), including a SSI (p = 0.008), across both groups. Conclusion This is the first RCT comparing NPWT with conventional dressings following musculoskeletal tumour surgery. Postoperative wound complications are common in this group of patients and we observed an overall SSI rate of 23.5%. We propose proceeding to a multicentre trial, which will help more clearly define the role of closed incision NPWT in STS surgery. Cite this article: Bone Jt Open 2021;2(12):1049–1056.
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Affiliation(s)
- David W Shields
- Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - Nima Razii
- Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - James Doonan
- Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - Ashish Mahendra
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, Glasgow, UK
| | - Sanjay Gupta
- Department of Musculoskeletal Oncology, Glasgow Royal Infirmary, Glasgow, UK
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14
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Hagi T, Nakamura T, Nagano A, Koike H, Yamada K, Aiba H, Fujihara N, Wasa J, Asanuma K, Kozawa E, Ishimura D, Kawanami K, Izubuchi Y, Shido Y, Sudo A, Nishida Y. Clinical outcome in patients who underwent amputation due to extremity soft tissue sarcoma: Tokai Musculoskeletal Oncology Consortium study. Jpn J Clin Oncol 2021; 52:157-162. [PMID: 34875695 DOI: 10.1093/jjco/hyab184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Soft tissue sarcomas are a diverse group of rare malignant tumours, mostly occurring in the lower extremities. Amputations are necessary for achieving local control when the soft tissue sarcomas are too large and/or have neurovascular involvement. Patients who require amputation have a poorer prognosis than those who undergo limb-salvage surgery. PATIENTS AND METHODS We investigated the tumour characteristics and the clinical outcomes in 55 patients with primary soft tissue sarcomas, who underwent amputation. We excluded patients with amputation performed distal to the wrist or ankle joints and those with recurrent soft tissue sarcomas. RESULTS The mean tumour size was 11.1 cm. Hip disarticulation was performed in 6 patients, 20 underwent above the knee amputation, 8 underwent knee disarticulation and 12 underwent below the knee amputation. Shoulder disarticulation was performed in three patients, five underwent above the elbow amputation, and one underwent below the elbow amputation. The 5-year disease-specific survival rate was 52.8%. The 5-year recurrence-free survival rate and 5-year metastasis-free survival rates were 90.1% and 38.5%, respectively. Larger tumour size, age and the distant metastases at first presentation were predictors of poor prognosis for survival in multivariate analysis. Twenty-eight patients could walk using artificial limbs. The level of amputation (above versus below the knee) showed a significant difference in achieving independent gait. CONCLUSION Amputation is a useful treatment option for achieving local control in patients with large soft tissue sarcomas. Patients had an opportunity of walking, especially for those who underwent below the knee amputation.
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Affiliation(s)
- Tomohito Hagi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akihito Nagano
- Department of Orthopaedic Surgery, Gifu University, Gifu, Japan
| | - Hiroshi Koike
- Department of Orthopaedic Surgery, Nagoya University Hospital, Nagoya, Japan
| | - Kenji Yamada
- Department of Orthopaedic Oncology, Okazaki City Hospital, Okazaki, Japan
| | - Hisaki Aiba
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nasa Fujihara
- Division of Orthopaedic Surgery, Aichi Cancer Centre Hospital, Nagoya, Japan
| | - Junji Wasa
- Division of Orthopaedic Oncology, Shizuoka Cancer Centre Hospital, Shizuoka, Japan
| | - Kunihiro Asanuma
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Eiji Kozawa
- Department of Orthopaedic Surgery, Nagoya Memorial Hospital, Nagoya, Japan
| | - Daisuke Ishimura
- Department of Orthopaedic Surgery, Fujita Medical University, Nagoya, Japan
| | - Katsuhisa Kawanami
- Department of Orthopaedic Surgery, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Yuya Izubuchi
- Department of Orthopaedic Surgery, Fukui University Graduate School of Medicine, Fukui, Japan
| | - Yoji Shido
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yoshihiro Nishida
- Department of Orthopaedic Surgery, Nagoya University Hospital, Nagoya, Japan.,Department of Rehabilitation, Nagoya University Hospital, Nagoya, Japan
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15
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Forequarter amputation for local recurrence of sarcoma after previous amputation through the shoulder in a female patient – A case report. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2021. [DOI: 10.1016/j.cpccr.2021.100093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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16
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Amputation for Extremity Sarcoma: Indications and Outcomes. Cancers (Basel) 2021; 13:cancers13205125. [PMID: 34680274 PMCID: PMC8533806 DOI: 10.3390/cancers13205125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/07/2021] [Accepted: 10/09/2021] [Indexed: 12/23/2022] Open
Abstract
Simple Summary Sarcomas are malignant tumors of soft tissues or bone. While limb salvage surgery (LSS) is the standard treatment, amputation is an option especially in local recurrence (LR) or complications after LSS. Two groups with primary amputations (n = 120) or secondary amputations after failed LSS due to LR or complications (n = 29) were compared. Five-year LR-free survival was 84% and 17 (16%) patients developed LR, of which 16 were in group I and only one in group II. Overall survival (OS) at five years was 44%, and the rate was identical in both groups. In those group II patients who had a secondary amputation after LSS due to contaminated margins or LR (n = 12) five-year OS was 33% compared to 48% in patients with complications (n = 17). This study indicates the worse oncological outcomes with respect to OS of sarcoma patients needing an amputation as compared to LSS. Patients with primary amputation or those who had a secondary amputation after failed LSS for whatever reason showed the same results. Abstract Background: Sarcomas are rare, malignant tumors of soft tissues or bone. Limb salvage surgery (LSS) is the standard treatment, but amputation is still an option, especially in local recurrence or complications after LSS. Methods: We retrospectively reviewed indications and oncological outcomes in patients who underwent an amputation. Two groups with either primary amputations (n = 120) or with secondary amputations after failed LSS with local recurrence or complications (n = 29) were compared with the main end points of LRFS and OS. Results: Five-year LRFS was 84% with 17 (16%) patients developing local recurrence, of which 16 (13%) occurred in group I. Forty-two (28%) patients developed metastatic disease and overall survival at five years was 44%. Overall survival (OS) was the same in both groups. In those group II patients who had a secondary amputation due to LR or insufficient margins after LSS (n = 12) the five-year OS was 33% compared to 48% in patients with amputation due to complications (n = 17) (n.s.). Conclusions: This study indicates the worse oncological outcomes with respect to OS of sarcoma patients requiring an amputation as compared to LSS. Patients with primary amputation or those who had a secondary amputation after failed LSS for whatever reason showed the same oncological results.
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17
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Hasan O, Nasir M, Jessar M, Hashimi M, An Q, Miller BJ. Is local recurrence in bone and soft tissue sarcomas just a local recurrence or does it impact the overall survival, retrospective cohort from a sarcoma referral center. J Surg Oncol 2021; 124:1536-1543. [PMID: 34472103 DOI: 10.1002/jso.26663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/01/2021] [Accepted: 08/25/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Sarcoma local recurrence (LR) is often associated with metastasis, but it is unclear if LR can be a causal event leading to metastasis. We question if LR is best viewed as an independent oncologic event or as a worrisome harbinger threatening a patient's overall survival. METHODS We identified patients with LR and/or metastasis from an ongoing cohort of 629 patients with primary sarcoma and performed a detailed review to assess the timing of metastasis resulting in the following groups: (1) Isolated LR, (2) LR before metastasis, (3) LR within 6 months of metastasis, (4) LR 6-12 months after metastasis, (5) LR >12 months after metastasis, and (6) metastasis at diagnosis. RESULTS Overall, 43 patients met the inclusion criteria with an LR rate of 7%. Ten patients (2% of the entire cohort, 23% of LR) developed an LR before or within 6 months of metastasis. For patients without systemic disease preceding LR, 3 of 23 soft tissue sarcoma STS (13%) and 7 of 10 bone sarcoma (70%) subsequently developed metastasis (p < 0.01). CONCLUSION LR with subsequent metastasis is a rare event. LR appears to be best viewed as a marker of tumor aggressiveness rather than the cause of metastasis and poor survival. LR in bone sarcoma patients should warn providers of a high risk of imminent metastasis.
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Affiliation(s)
- Obada Hasan
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Momin Nasir
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Muneeba Jessar
- Chandka Medical College Teaching Hospital, Larkana, Pakistan
| | - Mustafa Hashimi
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Qiang An
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Benjamin J Miller
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
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18
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AlDossary NM, Ostler C, Donovan-Hall M, Metcalf CD. Non-oncological outcomes following limb salvage surgery in patients with knee sarcoma: a scoping review. Disabil Rehabil 2021; 44:4531-4545. [PMID: 33756091 DOI: 10.1080/09638288.2021.1900409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: Limb salvage surgery is a surgical procedure for tumour resection in bone and soft-tissue cancers. Guidelines aim to preserve as much function and tissue of the limb as possible. Surgical outcome data is routinely available as part of surgical reporting processes. What is less known are important non-oncological outcomes throughout recovery from both clinical and patient perspectives. The objective of this review was to explore non-oncological outcomes in patients diagnosed with sarcoma around the knee following limb salvage surgery. Materials and Methods: A scoping review methodology was used, and results analysed using CASP checklists. Results: Thirteen studies were included and following appraisal and synthesis, three themes emerged as providing important measures intrinsic to successful patient recovery: (1) physical function, (2) quality of life and, (3) gait and knee goniometry. Specifically, patients develop range of motion complications that alter gait patterns and patients often limit their post-operative participation in sport and leisure activities. Conclusions: This study has shown the importance of exploring confounding factors, adopting a holistic view of patient recovery beyond surgical outcomes, proposing evidence-based guidance to support and inform healthcare providers with clinical decision-making. This review highlights the paucity and lack of quality of research available, emphasising how under-represented this population is in the research literature.IMPLICATIONS FOR REHABILITATIONPatients having undergone LSS often have limited participation in sport and leisure activities.Patients can develop range of motion complications, such as flexion contracture or extension lag, which may affect the pattern of gait.Clinical consideration should be given to walking ability and gait patterns during the rehabilitation phase to prevent poor functional outcomes during recovery.Variation of treatment protocols, outcome measurement and rehabilitative care has been identified as important in predicting the outcomes in recovery from LSS procedures.
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Affiliation(s)
- Nafla M AlDossary
- Physical Therapy Department, King Fahad Specialist Hospital, Dammam City, Saudi Arabia
| | - Chantel Ostler
- Portsmouth Enablement Centre, Portsmouth University Hospitals NHS Trust, Portsmouth, UK.,School of Health Sciences, University of Southampton, Southampton, UK.,Exceed Research Network, Lisburn, UK
| | - Maggie Donovan-Hall
- Portsmouth Enablement Centre, Portsmouth University Hospitals NHS Trust, Portsmouth, UK.,School of Health Sciences, University of Southampton, Southampton, UK
| | - Cheryl D Metcalf
- Portsmouth Enablement Centre, Portsmouth University Hospitals NHS Trust, Portsmouth, UK.,School of Health Sciences, University of Southampton, Southampton, UK
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19
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Ayaz T, Fredrickson S, O'Mary K, Panchbhavi MA, Panchbhavi VK. Differences in cancer amputee survival based on marital status: an analysis of the Surveillance, Epidemiology, and End Results (SEER) database. J Psychosoc Oncol 2021; 40:203-214. [PMID: 33606611 DOI: 10.1080/07347332.2021.1887429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE Limb amputation is a life-altering procedure used to treat certain cancer patients. The influence of psychosocial factors (such as marital status) on outcomes is poorly understood, hindering the development of targeted resources for the specific needs of these patients. This study was conducted to characterize the influence of marital status on survival after cancer-related amputation. DESIGN/RESEARCH APPROACH Retrospective cohort study. SAMPLE 1,516 patients with cancer-related amputation were studied from the Surveillance, Epidemiology and End Results database. METHODS Patients were grouped by marital status as single, married or divorced/separated/widowed and survival was compared using multivariate cox regression adjusted for demographic, tumor and treatment factors. FINDINGS Adjusted analysis showed that single (HR, 1.213; p = .044) patients had a significantly higher overall mortality-risk, while divorced/separated/widowed patients had both a significantly higher overall (HR, 1.397; p < .001) and cause-specific mortality-risk (HR, 1.381; p = .003) compared to married patients. CONCLUSION We posit that the increased psychosocial support available to married cancer patients may play a key role in improving survival. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS These findings provide new insight about the psychosocial needs of cancer amputees and the prognostic implications for those lacking social support of a spouse.
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Affiliation(s)
- Talha Ayaz
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA
| | - Saul Fredrickson
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA
| | - Kevin O'Mary
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA
| | - Megna A Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA
| | - Vinod K Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA
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20
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Abstract
Surgical resection with wide margins and perioperative radiation therapy is the standard treatment of extremity soft tissue sarcomas. This combination often results in complex wounds and functional compromise. Reconstructive surgery is integral to limb salvage after sarcoma resection. Advances in adjuvant therapy and reconstructive surgical techniques have made functional limb salvage, instead of amputation, possible for most patients. This article reviews key concepts in the multidisciplinary care of patients with extremity soft tissue sarcomas and details reconstructive surgical techniques, including locoregional and free tissue transfer, free functional muscle transfer, and vascularized bone transfer, to optimize functional limb restoration after sarcoma resection.
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Affiliation(s)
- Rajiv P Parikh
- Plastic and Reconstructive Surgical Service, Center for Advanced Reconstruction, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Suite 1150 NWT, St Louis, MO 63110, USA.
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21
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Dilday JC, Nelson DW, Fischer TD, Goldfarb M. Disparities in Amputation Rates for Non-metastatic Extremity Soft Tissue Sarcomas and the Impact on Survival. Ann Surg Oncol 2020; 28:576-584. [PMID: 32409968 DOI: 10.1245/s10434-020-08586-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are no definitive recommendations guiding amputation use in extremity soft tissue sarcomas (STSs). This study explores disparities in amputation rates and survival in patients with non-metastatic adult-type extremity STSs. METHODS Patients with non-metastatic adult-type extremity STSs were identified from the 1998-2012 National Cancer Database. Factors affecting amputation were examined across all ages and separately in adults (> 40 years), adolescent/young adults (AYA: ages 15-39), and children (age < 15). Impact on 10-year overall survival (OS) was explored. RESULTS Of 15,886 patients, 4.65% had an amputation. AYAs had the most amputations (6.4%) compared to children (5.9%) and adults (4.2%) (p < 0.001). Patients with public insurance (OR 1.3, CI 1.08-1.58) and from central states (OR 1.5, CI 1.2-1.86) were more likely to undergo amputation, whereas those from high income brackets (OR 0.8, CI 0.62-0.94) and treated at community cancer centers were less likely (OR 0.7, CI 0.62-0.90). Amputation was an independent risk factor for death at 10 years, with the greatest impact in AYAs compared to older adults (HR 1.7, p < 0.001). Treatment in eastern or central states, lower income, lack of private insurance, and comorbidities were all associated with decreased OS (all p < 0.05). Female gender (HR 0.8, CI 0.78-0.89) and high-volume centers (HR 0.8, CI 0.74-0.94) were associated with improved OS. CONCLUSIONS Although amputations for extremity STSs are rare, disparities exist across age groups, insurance and geography when it comes to the use of amputation in patients with extremity STSs. Moreover, having an amputation is an independent risk factor for death, with the greatest impact in AYAs.
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Affiliation(s)
- Joshua C Dilday
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX, USA
| | - Trevan D Fischer
- Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA
| | - Melanie Goldfarb
- Division of Surgical Oncology, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA. .,Center for Endocrine Tumors and Disorders, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, USA.
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22
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Abstract
OBJECTIVE This study aimed to present the results of a series of forequarter amputations (FQAs) and to evaluate the reconstructive methods used. SUMMARY BACKGROUND DATA Although FQA has become a rare procedure in the era of limb-sparing treatment of extremity malignancies, it is a useful option when resection of a shoulder girdle or proximal upper extremity tumor cannot be performed so as to retain a functional limb. METHODS Thirty-four patients were treated with FQA in 1989 to 2017. Various reconstructive techniques were used, including free fillet flaps from the amputated extremity. RESULTS All patients presented with intractable symptoms such as severe pain, motor or sensory deficit, or limb edema. Seventeen patients were treated with palliative intent. Chest wall resection was performed in 9 patients. Free flap reconstruction was necessary for 15 patients, with 11 free flaps harvested from the amputated extremity. There was no operative mortality, and no free flaps were lost. In curatively treated patients, estimated 5-year disease-specific survival was 60%. Median survival in the palliatively treated group was 13 months (1-35 months). CONCLUSIONS Limb-sparing treatment is preferable for most shoulder girdle and proximal upper extremity tumors. Sometimes, FQA is the only option enabling curative treatment. In palliative indications, considerable disease-free intervals and relief from disabling symptoms can be achieved. The extensive tissue defects caused by extended FQA can be safely and reliably reconstructed by means of free flaps, preferably harvested from the amputated extremity.
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23
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Abou Chaar MK, Jaber OI, Asha W, Abdel Al S. Novel Double Central Ray Amputation of the Third and Fourth Digits: Case Report and Literature Review. Case Rep Oncol 2020; 13:91-99. [PMID: 32110226 PMCID: PMC7036542 DOI: 10.1159/000504934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 11/20/2019] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
| | - Omar I Jaber
- Department of Pathology and Laboratory Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Wafa Asha
- Department of Radiation Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Samer Abdel Al
- Department of Orthopedic Oncology, King Hussein Cancer Center, Amman, Jordan
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Rath B, Hardes J, Tingart M, Braunschweig T, Eschweiler J, Migliorini F. [Resection margins in soft tissue sarcomas]. DER ORTHOPADE 2019; 48:768-775. [PMID: 31463543 DOI: 10.1007/s00132-019-03795-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignant tumors that arise from the mesenchymal tissue. STS can form anywhere in the human body, with the extremities being preferred sites of predilection. TREATMENT A fundamental pillar of treatment is the surgical resection of soft tissue sarcomas. The goal is always an R0 resection with a safety margin. There is no consensus in the literature about the desired tumor-free resection margin. The decisive factors for these resection margins are histopathology, presence of anatomical barriers (capsule, tendon, fascia, cartilage, periosteum) and possibilities of (neo-) adjuvant therapy. DISCUSSION References in the literature support the role of resection margins as a predictor of local recurrence. Regarding the role of resection margins in overall survival, available data is divergent. There are known prognostic factors that influence overall survival, such as histological subtype, tumor size, tumor grading, and presence of metastases. So far, several studies have attempted to quantify the margins of resection, but no consensus has been reached, and debates are ongoing. When analyzing all the results of the data in the literature, it seems appropriate to aim for a negative resection margin >1 mm including an anatomical border structure, if possible.
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Affiliation(s)
- B Rath
- Klinik für Orthopädie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland.
| | - J Hardes
- Abteilung für Tumororthopädie und Sarkomchirurgie, Westdeutsches Tumorzentrum, Universitätsklinikum Essen, Essen, Deutschland
| | - M Tingart
- Klinik für Orthopädie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - T Braunschweig
- Institut für Pathologie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - J Eschweiler
- Klinik für Orthopädie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - F Migliorini
- Klinik für Orthopädie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
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Bajpai J, Khanna N, Vora T, Gulia A, Laskar S, Puri A, Sanduptla B, Chinnaswamy G, Nayak P, Juvekar SL, Janu A, Desai S, Ghosh J, Purandare N, Ramadwar M, Rangarajan V, Rekhi B. Analysis of bone and soft-tissue sarcomas registered during the year 2012 at Tata Memorial Hospital, Mumbai, with clinical outcomes. Indian J Cancer 2018; 55:37-44. [PMID: 30147091 DOI: 10.4103/ijc.ijc_481_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Primary bone and soft tissue sarcomas are rare, but diagnostically and therapeutically challenging group of tumors, requiring multidisciplinary management. There are limited documented studies from multidisciplinary teams , in the form of comprehensive analysis of these tumors, from our country. This study is an analysis of cases of osteosarcomas, Ewing sarcomas (ESs), chondrosarcomas (CSs), and soft-tissue sarcomas (STSs), registered at our institution during 2012. Methods Clinical details, including outcomes of cases of bone and STSs, during the year 2012, were retrieved from the medical records of our institution and were further analyzed. Results Ninety-five high-grade, extremity-based, treatment-naïve cases of osteosarcomas were treated with a novel, dose-dense, nonhigh-dose methotrexate-based OGS-12 protocol. Good histopathologic response (necrosis ≥90%) was achieved in 59% nonmetastatic and 56% metastatic patients. At a median follow-up of 48 months, the estimated 5-year event-free survival and overall survival (OS) were 67% and 78%, respectively. In the metastatic cohort at a median follow-up of 51 months, the 5-year estimated progression-free survival was 24% and OS was 26%. Among 87 (73.2%) nonmetastatic and 32 (26.8%) metastatic, analyzable cases of ES, at a median follow-up of 40 months, the disease-free survival (DFS) and OS in the nonmetastatic group were 62% and 83%; in the metastatic group, they were 37.5% and 65.6%, respectively. Among 40 cases of CSs (33 nonmetastatic and 7 metastatic), 21 had limb salvage surgery while 5 had amputation. Microscopically, 90.4% were Grade II CSs. Five-year OS and DFS were 84.6% and 71%, respectively. Among 189 high-grade, extremity-based STSs (89% nonmetastatic), synovial sarcoma was the most common subtype (31%). Eighty-five percent had limb preservation surgery; a majority were offered adjuvant radiation with or without chemotherapy. At a median follow-up of 51 (1-63) months, 3-year local control, DFS, and OS were 81%, 48%, and 64%, respectively. Conclusions The novel OGS 12 and Ewing Family of Tumors 2001 protocols have shown comparable outcomes to international standards in cases of osteosarcoma and ES, respectively, and merit wider applications, especially in low- and middle-income countries (LMICs). Outcomes in STS and CSs were also comparable and underscore the importance of a multidisciplinary approach for the management of sarcomas in LMICS.
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Affiliation(s)
- Jyoti Bajpai
- Department of Medical Oncology, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nehal Khanna
- Department of Radiation Oncology, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Tushar Vora
- Department of Medical Oncology, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ashish Gulia
- Department of Surgical Oncology, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Siddhartha Laskar
- Department of Radiation Oncology, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ajay Puri
- Department of Surgical Oncology, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Bhanupriya Sanduptla
- Trial Coordinator, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Girish Chinnaswamy
- Department of Medical Oncology, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Prakash Nayak
- Department of Surgical Oncology, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Shashikant L Juvekar
- Department of Radio Diagnosis, Bone and Soft Tissues, Disease Management Group (DMG), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Amit Janu
- Department of Radio Diagnosis, Bone and Soft Tissues, Disease Management Group (DMG), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Subhash Desai
- Department of Radio Diagnosis, Bone and Soft Tissues, Disease Management Group (DMG), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jaya Ghosh
- Department of Medical Oncology, Clinical Research Secretariat, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nilendu Purandare
- Department of Nuclear Medicine and Molecular Imaging, Bone and Soft Tissues, Disease Management Group (DMG), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Mukta Ramadwar
- Department of Surgical Pathology, Bone and Soft Tissues, Disease Management Group (DMG), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine and Molecular Imaging, Bone and Soft Tissues, Disease Management Group (DMG), Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Bharat Rekhi
- Department of Surgical Pathology, Bone and Soft Tissues, Disease Management Group (DMG), Tata Memorial Hospital, Mumbai, Maharashtra, India
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Erstad DJ, Ready J, Abraham J, Ferrone ML, Bertagnolli MM, Baldini EH, Raut CP. Amputation for Extremity Sarcoma: Contemporary Indications and Outcomes. Ann Surg Oncol 2017; 25:394-403. [PMID: 29168103 DOI: 10.1245/s10434-017-6240-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Derek J Erstad
- Department of Surgery, Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA. .,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - John Ready
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - John Abraham
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marco L Ferrone
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Monica M Bertagnolli
- Department of Surgery, Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA.,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Elizabeth H Baldini
- Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA, USA
| | - Chandrajit P Raut
- Department of Surgery, Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA.,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Smolle MA, Andreou D, Tunn PU, Szkandera J, Liegl-Atzwanger B, Leithner A. Diagnosis and treatment of soft-tissue sarcomas of the extremities and trunk. EFORT Open Rev 2017; 2:421-431. [PMID: 29209518 PMCID: PMC5702952 DOI: 10.1302/2058-5241.2.170005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The relatively low incidence and often atypical clinical presentation of soft-tissue sarcomas (STS) impedes early and adequate diagnosis. Patients may report on recently enlarged soft-tissue swellings, infrequently complain of painful lesions, or even have no symptoms at all. A thorough diagnostic work-up is essential in order to distinguish between benign soft-tissue tumours and STSs. Patient history, clinical features and radiological findings all help in assessing the underlying pathology. ‘Worrying’ features such as recent increase in size, deep location relative to the fascia, a tumour exceeding 4 cm in size, and invasive growth patterns seen on imaging should prompt verification by biopsy. Even though acquisition of biopsy material may be incomplete, one should bear in mind some essential rules. Regardless of the biopsy technique applied, the most direct route to the lump in question should be identified, contamination of adjacent structures should be avoided and a sufficient amount of tissue acquired. Treatment of STS is best planned by a multidisciplinary team, involving experts from various medical specialities. The benchmark therapy consists of en bloc resection of the tumour, covered by a safety margin of healthy tissue. Depending on tumour histology, grade, local extent and anatomical stage, radiotherapy, chemotherapy and isolated hyperthermic limb perfusion may be employed. Due to the complexity of treatment, any soft-tissue swelling suspected of malignancy is best referred directly to a sarcoma centre, where therapeutic management is carefully planned by an experienced multidisciplinary team.
Cite this article: EFORT Open Rev 2017;2:421-431. DOI: 10.1302/2058-5241.2.170005
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Affiliation(s)
| | | | - Per-Ulf Tunn
- Sarcoma Center Berlin-Brandenburg, HELIOS Klinikum Berlin-Buch, Germany
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Stevenson MG, Musters AH, Geertzen JH, van Leeuwen BL, Hoekstra HJ, Been LB. Amputations for extremity soft tissue sarcoma in an era of limb salvage treatment: Local control and survival. J Surg Oncol 2017; 117:434-442. [DOI: 10.1002/jso.24881] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 09/18/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Marc G. Stevenson
- Department of Surgical Oncology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Annelie H. Musters
- Department of Surgical Oncology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Jan H.B. Geertzen
- Department of Rehabilitation Medicine; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Barbara L. van Leeuwen
- Department of Surgical Oncology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Harald J. Hoekstra
- Department of Surgical Oncology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
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29
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Smith HG, Thomas JM, Smith MJ, Hayes AJ, Strauss DC. Major Amputations for Extremity Soft-Tissue Sarcoma. Ann Surg Oncol 2017; 25:387-393. [DOI: 10.1245/s10434-017-5895-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Indexed: 12/31/2022]
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Abstract
The diagnostic methods and treatment modalities of soft tissue sarcomas have evolved with the multidisciplinary approach. The soft tissue sarcoma team must have specialists capable of using and combining modern methods of radiology and pathology, cytogenetics, tumour surgery, tissue transfer techniques, radiotherapy and chemotherapy for optimal local and systemic treatment. Limb sparing surgery combined with radiotherapy has lowered the amputation rate and maintained low rates of local recurrence. Reconstructive surgery facilitates treatment of patients with soft tissue sarcoma by permitting tumour resection with adequate margins, protects vital structures, enables early postoperative radiation therapy, maintains extremity length, and if necessary assists in palliative procedures. The ability to maintain function and aesthetics after tumour resection, and effective palliation improves the quality of life for these patients. Early recognition and appropriate referral to a tumour centre improve the outcome.
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Affiliation(s)
- E Tukiainen
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland.
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31
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Scaglioni MF, Lindenblatt N, Barth AA, Fuchs B, Weder W, Giovanoli P. Free fillet flap application to cover forequarter or traumatic amputation of an upper extremity: A case report. Microsurgery 2016; 36:700-704. [DOI: 10.1002/micr.30124] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 09/21/2016] [Accepted: 09/30/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Mario F. Scaglioni
- Department of Plastic and Hand Surgery; University Hospital Zurich; Switzerland
| | - Nicole Lindenblatt
- Department of Plastic and Hand Surgery; University Hospital Zurich; Switzerland
| | - André A. Barth
- Department of Plastic and Hand Surgery; University Hospital Zurich; Switzerland
| | - Bruno Fuchs
- Balgrist University Hospital, Sarcoma Center-UZH University of Zurich; Switzerland
| | - Walter Weder
- Division of Thoracic Surgery; University Hospital Zurich, University of Zurich; Switzerland
| | - Pietro Giovanoli
- Department of Plastic and Hand Surgery; University Hospital Zurich; Switzerland
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Hoefkens F, Dehandschutter C, Somville J, Meijnders P, Van Gestel D. Soft tissue sarcoma of the extremities: pending questions on surgery and radiotherapy. Radiat Oncol 2016; 11:136. [PMID: 27733179 PMCID: PMC5062836 DOI: 10.1186/s13014-016-0668-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 07/13/2016] [Indexed: 12/18/2022] Open
Abstract
Soft tissue sarcomas are uncommon tumours of mesenchymal origin, most commonly arising in the extremities. Treatment includes surgical resection in combination with radiotherapy. Resection margins are of paramount importance in surgical treatment of soft tissue sarcomas but unambiguous guidelines for ideal margins of resection are still missing as is an uniform guideline on the use of radiotherapy. The present paper reviews the literature on soft tissue sarcomas of the extremities regarding the required resection margins, the impact of new radiotherapy techniques and the timing of radiotherapy, more particularly if it should be administered before or after surgical resection. This review was started by searching guidelines in different databases (National Guideline Clearinghouse, EBMPracticeNet, TRIP database, NCCN guidelines,…). After refinement of the query, more specific articles were found using MEDLINE, PubMed, Web of Science and Google Scholar. Used keywords include “soft tissue sarcoma”; “extremities OR limbs”; “radiotherapy”, “surgery”, “margins”, “local recurrence” and “overall survival”. Finally, the articles were selected based on the accessibility of the full text, use of the English language and relevance based on title and abstract. Literature demonstrates positive resection margins to be an important adverse prognostic factor for local recurrence of soft tissue sarcomas of the extremities. Still, no consensus is reached on the definition of what a good margin might be. The evolution of new radiation techniques, especially Intensity Modulated Radiotherapy, resulted in a s healthy surrounding tissues. However, the timing of radiotherapy treatment remains controversial as both preoperative and postoperative radiotherapy are characterised by several advantages and disadvantages.
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Affiliation(s)
- Fien Hoefkens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | | | - Johan Somville
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Orthopaedic Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Paul Meijnders
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Radiotherapy, University Radiotherapy Antwerp UZA/ZNA, Antwerp, Belgium
| | - Dirk Van Gestel
- Department of Radiotherapy, University Radiotherapy Antwerp UZA/ZNA, Antwerp, Belgium. .,Department of Radiotherapy, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.
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De Vita A, Mercatali L, Recine F, Pieri F, Riva N, Bongiovanni A, Liverani C, Spadazzi C, Miserocchi G, Amadori D, Ibrahim T. Current classification, treatment options, and new perspectives in the management of adipocytic sarcomas. Onco Targets Ther 2016; 9:6233-6246. [PMID: 27785071 PMCID: PMC5067014 DOI: 10.2147/ott.s112580] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Sarcomas are a heterogeneous group of mesenchymal tumors arising from soft tissue or bone, with an uncertain etiology and difficult classification. Soft tissue sarcomas (STSs) account for around 1% of all adult cancers. Till date, more than 50 histologic subtypes have been identified. Adipocyte sarcoma or liposarcoma (LPS) is one of the most common STS subtypes, accounting for 15% of all sarcomas, with an incidence of 24% of all extremity STSs and 45% of all retroperitoneal STSs. The new World Health Organization classification system has divided LPS into four different subgroups: atypical lipomatous tumor/well-differentiated LPS, dedifferentiated LPS, myxoid LPS, and pleomorphic LPS. These lesions can develop at any location and exhibit different aggressive potentials reflecting their morphologic diversity and clinical behavior. Patients affected by LPS should be managed in specialized multidisciplinary cancer centers. Whereas surgical resection is the mainstay of treatment for localized disease, the benefits of adjuvant and neoadjuvant chemotherapy are still unclear. Systemic treatment, particularly chemotherapy, is still limited in metastatic disease. Despite the efforts toward a better understanding of the biology of LPS, the outcome of advanced and metastatic patients remains poor. The advent of targeted therapies may lead to an improvement of treatment options and clinical outcomes. A larger patient enrollment into translational and clinical studies will help increase the knowledge of the biological behavior of LPSs, test new drugs, and introduce new methodological studies, that is, on treatment response.
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Affiliation(s)
- Alessandro De Vita
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
| | - Laura Mercatali
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
| | - Federica Recine
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
| | - Federica Pieri
- Pathology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Nada Riva
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
| | - Alberto Bongiovanni
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
| | - Chiara Liverani
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
| | - Chiara Spadazzi
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
| | - Giacomo Miserocchi
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
| | - Dino Amadori
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
| | - Toni Ibrahim
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC
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Gronchi A, Olmi P, Casali PG. Combined modalities approach for localized adult extremity soft-tissue sarcoma. Expert Rev Anticancer Ther 2014; 7:1135-44. [DOI: 10.1586/14737140.7.8.1135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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35
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36
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Biau DJ, Weiss KR, Bhumbra RS, Davidson D, Brown C, Griffin A, Wunder JS, Ferguson PC. Monitoring the Adequacy of Surgical Margins After Resection of Bone and Soft-Tissue Sarcoma. Ann Surg Oncol 2013; 20:1858-64. [DOI: 10.1245/s10434-012-2863-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Indexed: 12/20/2022]
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37
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Shukla NK, Deo SVS. Soft tissue sarcoma-review of experience at a tertiary care cancer centre. Indian J Surg Oncol 2012. [PMID: 23204787 DOI: 10.1007/s13193-011-0119-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
This study is a retrospective analysis of prospective data base of soft tissue sarcoma (STS) maintained in the department of Surgical Oncology, Bhim Rao Ambedkar Institute Rotary Cancer Hospital (BRA-IRCH), All India Institute of Medical Sciences, which is a tertiary care cancer centre. A total of 300 patients of STS were treated between 1995 and 2006. The mean age at presentation was 40.6 years and males were more affected then females. Extremity sarcomas were more common than non extremity sarcoma and lower limb dominated upper limb. The median size of tumor was 8 cm (range 1-40 cm). MRI scan was the preferred imaging modality and tissue diagnosis was obtained by core biopsy. Synovial Sarcoma and Malignant Fibrous Histiocytoma were the common histology. Majority (75%) tumors were of high grade. Patients were staged according to MSKCC staging system. Limb Salvage Surgery was offered to all patients where ever feasible. Wide excision with a gross three dimensional tumor free margin of 2 cm was performed. Adjuvant external beam radiotherapy was offered to all high grades, large and recurrent tumors along with perioperative brachytherapy implant for tumor bed. High grade tumors were also offered adjuvant Adriamycin based Chemotherapy. Limb salvage rate was 68% in extremity sarcoma. During follow up 114 (38%) patients had relapse of disease mainly systemic, lungs being the commonest site.
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Affiliation(s)
- N K Shukla
- Department of Surgical Oncology, BRA-IRCH, All India Institute of Medical Sciences, New Delhi, 110029 India
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38
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Alamanda V, Crosby S, Archer K, Song Y, Schwartz H, Holt G. Amputation for extremity soft tissue sarcoma does not increase overall survival: A retrospective cohort study. Eur J Surg Oncol 2012; 38:1178-83. [DOI: 10.1016/j.ejso.2012.08.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 08/23/2012] [Indexed: 01/22/2023] Open
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Trabulsi NH, Patakfalvi L, Nassif MO, Turcotte RE, Nichols A, Meguerditchian AN. Hyperthermic isolated limb perfusion for extremity soft tissue sarcomas: systematic review of clinical efficacy and quality assessment of reported trials. J Surg Oncol 2012; 106:921-8. [PMID: 22806575 DOI: 10.1002/jso.23200] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 05/29/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Extremity soft tissue sarcomas (STS) are managed with radiotherapy and limb-sparing surgery however aggressive or recurrent cases require amputation. Hyperthermic isolated limb perfusion (HILP) has been proposed as an alternative. Our aim was to systematically review phase II HILP trials, assess tumor response, limb salvage (LS), and quality of scientific publications on this technique. METHODS We conducted a literature search of electronic databases (MEDLINE, EMBASE, Scopus, Cochrane Library) and clinical trial registries for phase II HILP trials on non-resectable extremity STS. Outcomes of interest were complete response (CR), partial response (PR), and LS rates. Quality of published trials was assessed using a quality checklist. RESULTS Of 518 patients across 12 studies, 408 had some response (CR or PR), and 428 had the limb spared. Median CR, PR, and LS rates were 31%, 53.5%, and 82.5%, respectively. Median Wieberdink loco-regional toxicity rates were 3.8%, 45.5%, 17%, 1%, and 0% for levels 1-5, respectively. No trial fulfilled either all ideal or essential quality criteria. Seven trials did not include statistical methodology. CONCLUSION HILP seems effective in treating advanced extremity STS. However, poor publication quality hinders results validity. Technical and methodological standardization, well-designed, multi-institutional trials are warranted.
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Affiliation(s)
- N H Trabulsi
- Department of Clinical Epidemiology, McGill University, Montreal, Canada
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Cutts S, Andrea F, Piana R, Haywood R. The management of soft tissue sarcomas. Surgeon 2011; 10:25-32. [PMID: 22137871 DOI: 10.1016/j.surge.2011.09.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 09/25/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Soft tissue sarcomas are a rare and heterogenous group of malignancies that are derived from the mesenchymal cell lines. In the last few decades, the management of these lesions has been improved by the introduction of dedicated Multi Disciplinary Teams (MDTs) where most bone and soft tissue tumours are now treated.(1) Following the recent changes to management outlined by the NICE/IOGs, we believe it is pertinent to review the current thinking on soft tissue tumour management.(2) We also discuss the principles of diagnosis and treatment and the role of adjuvant therapy. METHODS This is a retrospective review. In the preparation of this paper, we have referred to recent NICE guidelines in this field and have performed a Medline search of the existing literature. RESULTS The key to the success is early and appropriate patient referral. Whilst the responsibility for performing surgery has shifted away from the generalist and towards the super specialist, improvements in survivability can be achieved by promoting basic knowledge within the medical profession as a whole. CONCLUSIONS Both excision and biopsy of a soft tissue sarcoma by a non-specialist surgeon have been shown to increase the risk of tumour recurrence and all invasive procedures should now be performed within the MDT setting.
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Affiliation(s)
- Steven Cutts
- James Paget University Hospital, Lowestoft Road, Gorleston, Great Yarmouth, Norfolk NR31 6LA, United Kingdom.
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Parsons CM, Pimiento JM, Cheong D, Marzban SS, Gonzalez RJ, Johnson D, Letson GD, Zager JS. The role of radical amputations for extremity tumors: a single institution experience and review of the literature. J Surg Oncol 2011; 105:149-55. [PMID: 21837679 DOI: 10.1002/jso.22067] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 07/24/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Major amputations are indicated for advanced tumors when limb-preservation techniques have been exhausted. Radical surgery can result in significant palliation and possible cure. METHODS We identified 40 patients who underwent forequarter (FQ) or hindquarter (HQ) amputations between May 2000 and January 2011. Patient demographics, tumor-related factors, and outcomes were reviewed. RESULTS There were 30 FQ and 10 HQ amputations. The most common diagnoses were sarcoma (55%) and squamous cell carcinoma (25%). Patients presented with primary tumors (35%), regional recurrence (57.5%), or unresectable limb metastatic disease (7.5%). Presenting symptoms included fungating wounds (35%), intractable pain (78%), and limb dysfunction (65%). Operations were performed with curative intent (10%), curative/palliative intent (70%), or palliation alone (20%). Wound complications occurred in 35%. Pain was improved in 78% of patients following surgery. Despite a 91% negative margin rate, 79% of patients recurred either locally or distantly. Median overall survival was 10.9, 13.2, and 3.4 months in the curative, curative/palliative, and palliative groups, respectively. CONCLUSIONS In the absence of conservative options, major amputations are indicated for the management of advanced tumors. These operations can be performed safely, resulting in effective palliation of debilitating symptoms. While recurrence rates remain high, some patients can achieve prolonged survival.
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Eralp L, Özger H, Eren I, Dikici F. Forequarter amputation as a life-saving procedure. Musculoskelet Surg 2011; 95:127-130. [PMID: 21660446 DOI: 10.1007/s12306-011-0144-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Accepted: 05/26/2011] [Indexed: 05/30/2023]
Abstract
Forequarter amputation is performed for high-grade malignant tumours in the proximal part of the upper extremity with palliative or curative intentions. Two cases are included in this report of patients who presented in need of urgent surgical intervention. Both patients had an actively bleeding, ulcerated or fungating mass and were haemodynamically unstable. The purpose of this report is to highlight the importance of emergency surgical intervention for such selected patients.
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Affiliation(s)
- Levent Eralp
- Istanbul Faculty of Medicine, Orthopaedics and Traumatology, Istanbul University, Fatih, Istanbul, Turkey.
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Wray CJ, Benjamin RS, Hunt KK, Cormier JN, Ross MI, Feig BW. Isolated limb perfusion for unresectable extremity sarcoma: results of 2 single-institution phase 2 trials. Cancer 2011; 117:3235-41. [PMID: 21246524 DOI: 10.1002/cncr.25850] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 10/14/2010] [Accepted: 11/08/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND Controversy has surrounded the role of isolated limb perfusion (ILP) for unresectable extremity sarcomas. However, there remains a group of sarcoma patients for whom amputation is the only potential treatment. Because systemic therapies are limited, the authors evaluated ILP in an effort to provide a limb-salvage option. METHODS Since 1995, patients with unresectable extremity sarcomas were entered in 2 prospective trials using ILP. Study 1 used tumor necrosis factor (TNF) and melphalan in the perfusion circuit at hyperthermic temperatures (39-41°C). Study 2 used doxorubicin at normothermic temperatures. All ILPs were performed using the standard, previously described technique. RESULTS Seventeen patients were entered into study 1; there were 10 (58%) partial responses, 1 (6%) near complete response (CR), 1 (6%) CR, and 5 (30%) no response/minor response. Fourteen patients died of their disease, with a median follow-up of 17 months. Seven (41%) patients maintained their limb intact until the time of death. Twelve patients were entered into study 2; there were no partial or CRs and 2 (20%) minor responses. With a median follow-up of 35 months, there are 3 patients alive (2 with their extremity intact and 1 with an amputation). Six patients developed myonecrosis with creatine phosphokinase levels up to 54,000 U/dL. CONCLUSIONS Although doxorubicin is active systemically, TNF and melphalan appear to have greater activity and less toxicity during ILP. Future clinical trials are needed to clearly identify the role for ILP in patients with unresectable extremity sarcomas. Cancer 2011. © 2011 American Cancer Society.
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Affiliation(s)
- Curtis J Wray
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Kalson NS, Gikas PD, Aston W, Miles J, Blunn G, Pollock R, Skinner J, Briggs TWR, Cannon SR. Custom-made endoprostheses for the femoral amputation stump: an alternative to hip disarticulation in tumour surgery. THE JOURNAL OF BONE AND JOINT SURGERY. BRITISH VOLUME 2010; 92:1134-7. [PMID: 20675760 DOI: 10.1302/0301-620x.92b8.23682] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Disarticulation of the hip in patients with high-grade tumours in the upper thigh results in significant morbidity. In patients with no disease of the proximal soft tissue a femoral stump may be preserved, leaving a fulcrum for movement and weight-bearing. We reviewed nine patients in whom the oncological decision would normally be to disarticulate, but who were treated by implantation of an endoprosthesis in order to create a functioning femoral stump. The surgery was undertaken for chondrosarcoma in four patients, pleomorphic sarcoma in three, osteosarcoma in one and fibrous dysplasia in one. At follow-up at a mean of 80 months (34 to 132), seven patients were alive and free from disease, one had died from lung metastases and another from a myocardial infarction. The mean functional outcome assessment was 50 (musculoskeletal tumor society), 50 and 60 (physical and mental Short-form 36 scores). Implantation of an endoprosthesis into the stump in carefully selected patients allows fitting of an above-knee prosthesis and improves wellbeing and the functional outcome.
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Affiliation(s)
- N S Kalson
- Medical School, The Stopford Building, Manchester University, Oxford Road, Manchester, M13 9PT, UK.
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Barner-Rasmussen I, Popov P, Böhling T, Blomqvist C, Tukiainen E. Microvascular reconstructions after extensive soft tissue sarcoma resections in the upper limb. Eur J Surg Oncol 2010; 36:78-83. [DOI: 10.1016/j.ejso.2009.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 08/03/2009] [Accepted: 08/06/2009] [Indexed: 10/20/2022] Open
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Nonreferral of possible soft tissue sarcomas in adults: a dangerous omission in policy. Sarcoma 2009; 2009:827912. [PMID: 20066170 PMCID: PMC2804052 DOI: 10.1155/2009/827912] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 09/18/2009] [Accepted: 10/22/2009] [Indexed: 12/18/2022] Open
Abstract
Introduction. The aim of this study is to compare outcomes in three groups of STS patients treated in our specialist centre: patients referred immediately after an inadequate initial treatment, patients referred after a local recurrence, and patients referred directly, prior to any treatment. Patients and methods. We reviewed all our nonmetastatic extremity-STS patients with a minimum follow-up of 2 years. We compared three patient groups: those referred directly to our centre (group A), those referred after an inadequate initial excision (group B), and patients with local recurrence (group C). Results. The study included 174 patients. Disease-free survival was 73%, 76%, and 28% in groups A, B, and C, respectively (P < .001). Depth, size, and histologic grade influenced the outcome in groups A and B, but not in C. Conclusion. Initial wide surgical treatment is the main factor that determines local control, being even more important than the known intrinsic prognostic factors of tumour size, depth, and histologic grade. The influence on outcome of initial wide local excision (WLE), which is made possible by referral to a specialist centre, is paramount.
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Thévenin FS, Drapé JL, Biau D, Campagna R, Richarme D, Guerini H, Chevrot A, Larousserie F, Babinet A, Anract P, Feydy A. Assessment of vascular invasion by bone and soft tissue tumours of the limbs: usefulness of MDCT angiography. Eur Radiol 2009; 20:1524-31. [DOI: 10.1007/s00330-009-1678-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 09/18/2009] [Accepted: 09/18/2009] [Indexed: 11/28/2022]
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Papagelopoulos PJ, Mavrogenis AF, Mastorakos DP, Vlastou C, Vrouvas J, Soucacos PN. Free vascularised tissue transfer and brachytherapy for soft-tissue sarcomas of the extremities. Injury 2008; 39 Suppl 3:S83-9. [PMID: 18687428 DOI: 10.1016/j.injury.2008.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We reviewed the medical files of nine patients with localised soft-tissue sarcomas of the extremities treated with surgical resection, free vascularised tissue transfer, and computerised after-loading iridium-192 high dose rate brachytherapy over a period of 8 years. All patients had external beam radiation therapy in fractions with a total dose of 48-52 Gy, followed by surgery at approximately 4-5 weeks post-irradiation. Surgical treatment included wide resection of the primary tumour in six patients, and marginal resection in three patients. Microsurgical reconstruction of the soft-tissue defect used a free vascularised musculocutaneous flap that included the gracilis flap in five patients, the latissimus dorsi flap in four patients, and the radiovolar flap in one patient. Postoperative brachytherapy dose ranged from 12 to 24 Gy. Adjuvant chemotherapy was administered in five patients with large tumours and marginal resection. At a mean follow-up of 36 months, eight patients were still alive with no evidence of local recurrence or distant metastases; all these patients had good cosmetic and functional outcomes. Two patients died with lung metastases; one of these patients had local tumour recurrence. Wound healing problems and seroma formations were observed in two patients. Intramedullary nailing was required in one patient for a pathological fracture. Tumour resection for soft-tissue sarcomas combined with microsurgical reconstruction of the soft-tissue defect, preoperative external beam radiation and high dose rate brachytherapy results in a high degree of local control with acceptable complications.
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Affiliation(s)
- Panayiotis J Papagelopoulos
- First Department of Orthopaedics, Athens University Medical School, Attikon General University Hospital, Athens, Greece.
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Abed R, Younge D. Surgical Management of Very Large Musculoskeletal Sarcomas. Ann N Y Acad Sci 2008; 1138:77-83. [DOI: 10.1196/annals.1414.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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