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

Results of resection of forearm soft tissue sarcoma

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical Outcomes of Soft Tissue Sarcoma around the Elbow Joint: A Retrospective Single Institution Study

Background

We report a retrospective case series analysis of clinical outcomes of patients with soft tissue sarcoma around the elbow.

Methods

Twenty-two patients underwent surgical tumor excision between January 1999 and May 2017, with a mean follow-up of 85.2 months.

Results

Six tumors were localized in the upper arm, nine in the elbow, and seven in the forearm. Sixteen tumors were deep-seated, and six were superficially located. Fifteen patients underwent wide excision, including one amputation, and 18 achieved (81.8%) negative margins histologically. Two local recurrences and four distant metastases developed. The mean Musculoskeletal Tumor Society score was 92.0% (range, 33.3-100). The 5-year local recurrence-free survival rate, metastasis-free survival rate, and overall survival rate were 90.0%, 77.0%, and 79.7%, respectively.

Conclusions

Local control and limb function can have favorable outcomes when the tumor excised has a histologically negative margin without sacrificing the major structure.

Factors Affecting Delay in Initial Treatment of Patients with Soft Tissue Sarcomas

Background: Soft tissue sarcomas (STS) are rare, and little is known about the factors that affect the delays in the initial treatment. The aim of this study is to quantify the period between onset of symptoms and start of treatment of STS and determine the factors affecting delays in initial treatment. Methods: This is a retrospective study of all STS treated in our institution between October 2009 and March 2019. We analysed patient record to determine the period from onset of symptoms to start of initial treatment. We also collected data with regard to patient characteristics and features of the tumour. Tumours were classified into upper extremity, lower extremity, trunk and others based on location of the tumour. Statistical tests were done to identify factors that affected delay in initial treatment. Results: The study included 134 patients (76 male and 58 female) with STS with an average age of 56.6 years. The tumours involved the upper extremity in 20 patients, lower extremity and trunk in 50 patients each and other areas in 14 patients. The most frequent histological subtypes were liposarcomas (n = 31, 23.5%) and undifferentiated pleomorphic sarcomas (n = 24, 18.2%). Initial treatment was delayed by an average of 9.9 months for all groups. The period of treatment delay for tumours involving the upper extremity was shorter (7.9 months) and these tumours were smaller at initial presentation (57.6 mm) compared to tumours in other locations (p < 0.05). Other factors that were positively associated with treatment delays were a history of diabetes mellitus (p = 0.037) and smoking (p = 0.026). Conclusion: Patients with upper-extremity STS may have the benefit of a relatively better prognosis as they present earlier and with a smaller tumour. In addition, factors, such as diabetes and smoking, which indicate a low interest in health also influenced the delay in the initial treatment. Level of Evidence: Level III (Therapeutic).

Diagnosis and treatment of hand tumors

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

Prognostic factors, disparity, and equity variables impacting prognosis in bone sarcomas of the hand: SEER database review

BACKGROUND

Primary sarcomas originating from the bones of hand and wrist are rare but carry a significant burden of morbidity.

METHODS

National Cancer Institute's Surveillance, Epidemiology and End Result database from 1975 to 2017 was queried to report incidence and survival data in 237 patients in the United States. Kaplan-Meier and Cox regression were used to determine the prognostic factors affecting survival. χ² test was used to assess the correlation.

RESULTS

Incidence of hand and wrist sarcoma was 0.017 per 100 000 persons in 2017 and has not significantly changed since 1975 (p > 0.05). Disease-specific 5-year and 10-year survival for the entire cohort was 90% and 84%, respectively. On multivariate analysis race "others," histology other than "osteosarcoma," "undifferentiated" grade, and size "≥6 cm" were predictors of worse disease-specific survival. Cross-tabulation of race with other significant prognostic factors on univariate analysis revealed a significant correlation of race with every other significant prognostic factor except for grade.

CONCLUSIONS

The current study is an analysis of a population-based registry reporting incidence and survival data for patients with sarcoma of hand and wrist. Independent prognostic factors include race, histology, grade, and size. There is a lack of improvement in survival over the last four decades.

Patient characteristics, outcomes, and trends in extremity sarcoma management by surgeon specialty

BACKGROUND

Extremity soft tissue sarcoma is managed by oncological trained general or orthopedic surgeons, but limited data exist comparing patient characteristics and outcomes between the 2 specialties.

METHODS

Patients were identified from the 2008 to 2017 National Surgical Quality Improvement Program who underwent limb-sparing resection of extremity soft tissue sarcoma by either general surgeons or orthopedic surgeons. Multivariable logistic regression analysis identified factors associated with general surgeons compared with OS. Length of stay was assessed using Poisson regression. Procedure annual percent change was analyzed using Joinpoint Regression.

RESULTS

The majority of extremity soft tissue sarcoma cases were performed by general surgeons (N = 304, 69.4%), but general surgeons' resections significantly decreased (35.2%) over the study period (annual percent change -5.8, P < .0001). General surgeons' patients were less likely to receive neoadjuvant chemotherapy (2.0% vs 3.7%, P < .01), and more likely to receive neoadjuvant radiation (9.9% vs 5.2%, P < .01) and have normal preoperative white blood cell counts (77.0% vs. 66.4%, P = .02). Orthopedic surgeons' cases were more often performed under regional anesthesia (9.7% vs. 2.3%, P = .01), and orthopedic patients were more likely to receive postoperative transfusions (5.2% vs 0.3%, P < .01) and had a longer median length of stay (2 vs 1 days, P < .01). Thirty-day overall morbidity (7.2% general surgeon vs 9.7% orthopedic surgeon, P = .38) and all-cause mortality (0.3% general surgeon vs 0% orthopedic surgeon, P = .51) did not differ by specialty.

CONCLUSION

Although postoperative outcomes for extremity soft tissue sarcoma are comparable between general and orthopedic surgeons, treatment and perioperative management differences exist. Future investigation focused on understanding these differences in perioperative management across specialties may help identify areas for quality improvement in care of patients with extremity soft tissue sarcoma.

Diagnosis and management of primary malignant tumors in the upper extremity

Bone and soft tissue sarcomas of the upper extremity are relatively uncommon. In many cases, they are discovered incidentally during evaluation of traumatic injuries or common ailments such as rotator cuff tendonitis or tennis elbow. Thus, it is important for all orthopedic surgeons to understand the differential diagnosis, workup, and treatment for upper extremity lesions. An appreciation of the clinical and radiographic features of primary malignant lesions aids in identifying patients that need referral to an orthopedic oncologist and a multidisciplinary team.

Primary anatomical site as a prognostic factor for pleomorphic liposarcoma

BACKGROUND

Pleomorphic liposarcomas (PLS) is an aggressive, high-grade subtype of soft tissue sarcoma representing < 15% of liposarcomas. It most commonly arises in the retroperitoneum and proximal upper extremities. Current prognostic factors are centered around staging, which accounts for the grade, size, and location of the tumor in relation to the superficial fascia.

METHODS

750 patients diagnosed with pleomorphic liposarcoma from the National Cancer Database were analyzed. Kaplan-Meier survival tables, log-rank tests, and Cox proportional hazards analysis were utilized to compare survival between groups within variables.

RESULTS

The most common primary anatomical site was the lower limb/hip. The head/neck primary anatomical site demonstrated the highest 10-year overall survival probability, while the retroperitoneum/abdomen had the lowest (50% and 18.4%). Compared to the thorax/lung site, the following sites demonstrated a decreased risk of death: lower limb/hip (HR = 0.54; 95% CI: 0.35-0.82, p = 0.004), pelvis (HR = 0.49; 95% CI: 0.28-0.84, p = 0.010), and the retroperitoneum/abdomen (HR = 0.54; 95% CI: 0.33-0.89, p = 0.015). Both adjuvant radiation (HR = 0.64; 95% CI: 0.48-0.85, p = 0.002) and neoadjuvant radiation (HR = 0.70; 95% CI: 0.49-1.00, p = 0.049) provided a survival benefit to patients. There was an increased risk of death for every 10-year increment in age (HR = 1.31; 95% CI: 1.12-1.45, p < 0.001).

CONCLUSION

Statistically significant prognostic factors for PLS include primary anatomical site, age, Charlson-Deyo Comorbidity Index Scores and the use of neoadjuvant and adjuvant radiation.

Reconstruction of Brachial Artery with Great Saphenous Vein Graft in A Case of Residual Soft Tissue Sarcoma Arm

Soft tissue sarcomas of the upper extremities are very rare tumors. Due to the complex anatomy of the arm, the management of the soft tissue sarcoma becomes very challenging for the operating surgeons. Nonetheless, a large portion of the patients can be treated in a limb-sparing manner ,if surgical expertises are present .We report a case of 30 years old lady with soft tissue sarcoma of right arm operated in an another hospital, came to our institute with pain in the operated site and positive histological margins. The patient had feeble radial and ulnar artery pulses. We had done a MR angiography of that limb and it showed no flow from mid arm level in the brachial artery, but presence of collaterals around elbow joint. We had removed the residual tumor and also excised 14 cm of right brachial artery. On opening the brachial artery, tumor thrombus was seen along the whole length of the excised segment. The defect was reconstructed with reverse great saphenous vein graft taken from left leg. Post-operative period was uneventful. Doppler ultrasonography done at 6 and 12 months later showed good flow in the grafted segment with minimal narrowing of the anastomosis sites.

A Retrospective Case Series of Synovial Sarcoma of the Upper Extremity

Purpose

Previous studies have grouped the treatment of axial and appendicular synovial sarcomas. The purpose of this study was to assess the prognostic variables of upper extremity synovial sarcomas (UESS) and compare the outcomes of those who underwent a nononcologic or inadvertent excision prior to definitive resection to those who underwent an initial oncologic resection.

Methods

We reviewed the records of 23 UESS treated with definitive surgery at our institution between 1990 and 2014. There were 13 women and 10 men with a median age of 30 years (6–60) and median follow-up of 63 months (15–248). Prognostic variables, recurrence-free survival (RFS), and overall survival (OS) were then assessed.

Results

Fifteen patients (65%) had a prior unplanned excision. Five patients required an amputation to obtain local control of disease. There were 3 observed local recurrences and 2 distant metastases at a median of 45 months from presentation. We found no difference in need for amputation, RFS, or OS between those who had undergone a planned excision and those who had an unplanned excision.

Conclusion

While we were unable to find a significant difference in outcomes or amputation rates between those who underwent reexcision of a previously unplanned excision and those who underwent an initial planned resection, the high rate of unplanned excision is troubling and should remind practitioners to consider sarcoma in the differential of all upper extremity masses.

Soft tissue sarcomas of the upper extremities: Maximizing treatment opportunities and outcomes

Soft tissue sarcomas (STS) are rare tumors; they do not even equate to 1% of all malignant tumor cases. One-fifth of all STS occur in the upper extremities, where epithelioid sarcoma, synovial sarcoma, clear cell sarcoma and malignant fibrohistiocytoma are the most frequent subtypes. Surgical resection is the cornerstone of treatment. However, accomplishment of optimal oncological and functional results of STS of the upper extremities may represent a challenge for hand surgeons, due to the complex anatomy. In several cases, preoperative therapies are needed to facilitate tumor resection and improve the oncological outcome. Oligometastatic disease may also be a challenging scenario as curative strategies can be applied. Radiotherapy and chemotherapy are commonly used for this purpose albeit with conflicting evidence. Novel drug combinations have also been approved in the metastatic setting, further improving the quality of life and survival of eligible patients. Thus, prior to any approach, every case should be individually discussed in sarcoma centers with specialized multidisciplinary tumor boards. The aim of the present review was to gather the multidisciplinary experiences of the available therapeutic strategies for STS of the upper extremities.

Management and outcome of acral soft-tissue sarcomas

Aims

The aim of this study was to evaluate the surgical management and outcome of patients with an acral soft-tissue sarcoma of the hand or foot.

Patients and Methods

We identified 63 patients with an acral soft-tissue sarcoma who presented to our tertiary referral sarcoma service between 2000 and 2016. There were 35 men and 28 women with a mean age of 49 years (sd 21). Of the 63 sarcomas, 27 were in the hands and 36 in the feet. The commonest subtypes were epithelioid sarcoma in the hand (n = 8) and synovial sarcoma in the foot (n = 11).

Results

In 41 patients (65%), the tumour measured less than 5 cm in its largest dimension (median size 3 cm (2 to 6)); 27 patients (43%) were diagnosed after inadvertent excision prior to their referral to the specialist sarcoma unit. After biopsy and staging, primary surgical intervention at the sarcoma unit was excision and limb salvage in 43 (68%), partial (digit or ray) amputation in 14 (22%), and more proximal amputation in six (10%). At final follow up, local recurrence had been treated by one partial amputation and six amputations, resulting in a partial amputation rate of 24% and a proximal amputation rate of 19%. The five-year survival rate was 82%. Patients who underwent inadvertent excision showed no statistically significant difference in survival or local recurrence, but were more likely to undergo amputation (p = 0.008). Large tumour size (> 5 cm) was associated with lower survival (p = 0.04) and a higher risk of local recurrence (p = 0.009;).

Conclusion

Most acral soft-tissue sarcomas measure less than 5 cm at presentation, indicating that while size can be a useful prognostic factor, it should not be used as a diagnostic threshold for referral. Increased tumour size is associated with a higher rate of local recurrence and reduced survival. Sarcoma excision with limb preservation does not result in an increased risk of local recurrence. Cite this article: Bone Joint J 2018;100-B:1518–23.

Intramuscular Epithelioid Sarcoma Presenting as Extrinsic Flexor Tightness in the Forearm

Epithelioid sarcoma is an uncommon soft tissue sarcoma involving predominantly the distal extremities of adolescents and young adults. Its rarity makes it difficult to diagnose accurately and treat properly in the early stages. We discuss the delayed diagnosis of a 37-year-old man who presented with extrinsic flexor tightness of the wrist and fingers. We initially thought that the lesion resulted from inflamed soft tissue of the flexor muscles causing contracture. However, histological examination of a biopsy specimen revealed nodular proliferation of epithelioid and spindle cells, which were immunoreactive to epithelial and nonepithelial markers, respectively, leading to the final diagnosis of epithelioid sarcoma.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

IV, retrospective study.

Soft Tissue Sarcomas of the Arm - Oncosurgical and Reconstructive Principles within a Multimodal, Interdisciplinary Setting

Soft tissue sarcomas of the upper extremity represent a severe threat for the patient and a difficult task for the treatment team. Due to the complex anatomy of the arm, most sarcomas involve valuable functional structures. Nonetheless, a large portion of the patients can be treated in a limb-sparing manner, and surgery is the mainstay of local tumor control. This review gives an overview of the disease entities and their epidemiology, on necessary patient work-up, staging, and imaging modalities, as well as the importance of interdisciplinary decision-making. The surgical therapies and principles of tumor excision are outlined, as well as reconstructive options. Furthermore, adjuvant treatments are discussed with a special focus on the various application techniques for radiation therapy. In spite of established treatment algorithms, each case is an individual challenge and individually tailored therapy is required. This aspect is illustrated by presenting three comprehensive cases demonstrating useful strategies. A summary of the relevant literature is given.

Function and health status outcomes following soft tissue reconstruction for limb preservation in extremity soft tissue sarcoma

BACKGROUND

While advances in reconstructive surgery have facilitated limb preservation in extremity soft tissue sarcoma (ESTS), limited information exists as to the functional outcome of patients with these reconstructed extremities. The primary objective of this study is to evaluate the impact of flap reconstruction on postoperative function and health status in patients undergoing limb-salvage surgery for ESTS.

METHODS

Clinical and outcome data for eligible patients were extracted from a prospectively maintained database of sarcoma patients. Four outcome measures were used to assess three domains of function (impairments, activity limitations, and participation restrictions), and health status. The effect of soft tissue reconstruction on function and health status at 1-2-year follow-up was analyzed using univariate and multivariate regression.

RESULTS

Two hundred and forty-seven patients met eligibility criteria, including 56 patients receiving flap reconstruction and 191 patients treated with primary closure. Patients receiving flaps had larger (9.8 versus 7.1 cm; P = 0.003), higher-grade (93% versus 72%; P = 0.001) tumors, and more frequently received radiotherapy (89% versus 72%; P = 0.007), and bone (20% versus 4%; P = 0.001) and motor nerve resection (21% versus 10%; P = 0.032). Flap reconstruction was associated with more postoperative impairments [Musculoskeletal Tumor Society (MSTS) score 30.4 versus 32.2; P = 0.004] and activity limitations [Toronto Extremity Salvage Score (TESS) score 83.3 versus 89.5; P = 0.0132] on univariate analyses, but did not significantly predict postoperative function or health status outcomes on multivariate analyses.

CONCLUSIONS

Flap reconstruction was not an independent predictor of function and health status outcomes in patients with ESTS. However, ESTS patients receiving flaps had other clinical features placing them at risk for worse postoperative outcomes.

Histiocytic sarcomas in flat-coated retrievers: a summary of 37 cases (November 1998-March 2005)

Thirty-seven cases of histiocytic-like sarcomas (HLSs) in flat-coated retriever dogs were evaluated retrospectively. This tumour accounted for 36% of the malignant tumours seen in this breed during the study period. The median age at presentation was 8.2 years. Thirty-four dogs presented with a swelling or mass in a muscle group or surrounding a joint. The remaining three presented for rib (1), cutaneous (1) or primary splenic origin (1). A high rate of metastasis to local lymph nodes (45%), thorax (20%) and abdominal organs (20% confirmed) was seen. Overall metastastic rate by the time of death was 70%. The median survival for all dogs was 123 days. The most significant prognostic indicator was presence of distant metastasis at the time of diagnosis with median survival of 68 or 200 days, with or without metastasis, respectively. Chemotherapy and radiation therapy significantly improved survival. Dogs given chemotherapy survived a median of 185 versus 34 days for dogs that were not (P = 0.0008). Dogs treated with radiation survived a median of 182 versus 60 days for those that were not (P = 0.0282). Dogs receiving only palliative therapy survived a median of 17 versus 167 days in dogs receiving any kind of radiation, chemotherapy, surgery or combinations. A set protocol of radiation and CCNU (RTCCNU) induced minimal toxicity and provided a median survival of 208 versus 68 days for all other dogs. While this tumour carries a poor long-term prognosis in flat-coated retrievers, it is reasonable to treat these dogs for palliation of signs and extension of life.

Soft-tissue coverage of the hand following sarcoma resection

BACKGROUND

Hand-sparing surgery is now the most common option for sarcomas of the hand. The importance of obtaining widely negative margins has increased the complexity of operations and the importance of soft-tissue and bony reconstruction. The authors review the experience at a single institution of hand reconstruction following sarcoma resection based on prospectively collected data.

METHODS

Data were collected for all patients undergoing sarcoma resection by a single surgeon. Variables evaluated included patient demographics, tumor pathologic findings, location, size, depth, grade, stage, method of resection and reconstruction, adjuvant therapies, complications, and patient outcomes.

RESULTS

Fifty-five patients (30 male and 25 female) fulfilled eligibility criteria. The median age was 36 years (range, 1 to 80 years). The most common abnormalities were epithelioid sarcoma (n = 9), soft-tissue malignant fibrous histiocytoma (n = 8), synovial sarcoma (n = 6), and fibrosarcoma (n = 4). Flap reconstructions were required in 27 patients. The most common reconstruction method was a finger fillet flap in eight patients, followed by the radial forearm flap in five patients and the gracilis flap and skin grafting in three patients each. A suboptimal biopsy before presentation was strongly predictive of the need for flap reconstruction (p < 0.001). Nine patients had complications (delayed healing or skin necrosis, fracture, nonunion, epidermolysis, and tendon adhesion). No microvascular complications occurred.

CONCLUSIONS

The choice of hand reconstruction method following sarcoma resection depends on a complete knowledge of options, risks, and benefits. Extensive use of a limited number of techniques by the authors' institution appears to contribute to excellent success and complication rates, with safe, reliable, and effective soft-tissue coverage.

Soft-tissue sarcomas of the hand

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

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

Changing trends in the number of deaths from soft tissue sarcoma in Japan, 1955-2002

The incidence and number of deaths from soft tissue sarcoma (STS) have been reported to increase in many countries. However, those in Japan have not been analysed over a long span of time. The objective of this study was to analyse the changing trends in the number of deaths from STS in Japan. We analysed the annual trends in the number of deaths from STS from 1955 to 2002 in Japan using the data from the Vital Statistics of Japan, Statistics and Information Department, Minister's Secretariat, Ministry of Health, Labour and Welfare. Until 2000, the number of deaths from STS had increased. The recent value of the annual increased ratio of deaths from STS was 0.5%[95% confidence interval (CI): -1.2-2.2%]. Men continued to have a higher number of deaths than women. The general trends in age-standardized death rates were roughly upward before 1995, although the death rates tended to decrease thereafter. The number and proportion of deaths at or after 60 years of age were increasing. The peak age group of deaths was roughly the sixties before 1982, and the seventies after 1983. The individuals in their sixties and seventies should be the focus of health promotion activities.

Influence of site on the therapeutic ratio of adjuvant radiotherapy in soft-tissue sarcoma of the extremity

PURPOSE

The ultimate goal of adjuvant radiotherapy (RT) in soft-tissue sarcoma of the extremity is to improve the therapeutic ratio by increasing local control while minimizing morbidity. Most efforts in trying to improve this ratio have focused on the sequencing of RT and surgery, with little attention to the potential influence of the tumor site. The purpose of this study was to determine the influence of tumor site on local control and complications in a group of patients with primary high-grade soft-tissue sarcoma of the extremity treated at a single institution with postoperative RT.

METHODS AND MATERIALS

Between July 1982 and December 2000, 369 adult patients with primary high-grade soft-tissue sarcoma of the extremity were treated with limb-sparing surgery and postoperative RT. Patients who underwent surgery or RT outside our institution were excluded. The tumor site was the upper extremity (UE) in 103 (28%) and the lower extremity (LE) in 266 (72%). The tumor was < or = 5 cm in 98 patients (27%), and the microscopic margins were positive in 44 (12%). Of the 369 patients, 104 (28%) underwent postoperative external beam RT (EBRT), 233 (63%) postoperative brachytherapy (BRT), and 32 underwent a combination (9%); 325 (88%) received a "conventional" radiation dose, defined as 60-70 Gy for EBRT, 45 Gy for BRT, and 45-50 Gy plus 15-20 Gy for EBRT plus BRT. Complications were assessed in terms of wound complications requiring repeat surgery, fracture, joint stiffness, edema, and Grade 3 or worse peripheral nerve damage.

RESULTS

The UE and LE groups were balanced with regard to age, depth, margin status, and type of RT (EBRT vs. BRT +/- EBRT). However, more patients in the UE group had tumors < or = 5 cm and more received a conventional radiation dose (p = 0.01 and P = 0.03, respectively). With a median follow-up of 50 months, the 5-year actuarial rate of local control, distant relapse-free survival, and overall survival for the whole population was 82% (95% confidence interval [CI], 77-86%), 61% (95% CI, 56-66%), and 71% (95% CI, 66-76%), respectively. The 5-year local control rate in patients with UE STS was 70% (95% CI, 60-80%) compared with 86% (95% CI, 81-91%) for LE STS (p = 0.0004). On multivariate analysis, an UE site (p = 0.001; relative risk [RR], 3; 95% CI, 2-5) and positive resection margins (p = 0.02; RR, 2; 95% CI, 1-4) were significant predictors of poor local control. The RT type or radiation dose, age, tumor depth, and size were not significant predictors of local control. The 5-year wound reoperation rate was 1% (95% CI, 0-3) in the UE compared with 11% (95% CI, 7-15) in the LE (p = 0.002). On multivariate analysis, the UE site retained its significance as a predictor of low wound complications (p = 0.001; RR, 0.08; 95% CI, 0.01-0.7). The site did not significantly influence the incidence of fracture (p = 0.7), joint stiffness (p = 0.2), edema (p = 0.5), or Grade 3 or worse peripheral nerve damage (p = 0.3).

CONCLUSION

The UE site is associated with a greater rate of local recurrence compared with the LE. This difference was independent of other variables and could not be accounted for by an imbalance between the two groups. With a lower wound complication rate associated with an UE site, it would be of interest to determine whether preoperative RT and/or intensity-modulated RT can increase the local control in UE sarcomas, thus improving the therapeutic ratio.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Soft tissue sarcoma of the upper extremity

Soft tissue sarcomas of the upper extremities are rare and hand surgeons typically encounter only one or two undiagnosed soft tissue sarcomas during their careers. It is incumbent on the physician to review repeatedly the characteristics of these tumors and remain suspicious, because these lesions typically are misdiagnosed and treatment is delayed. The most common soft tissue sarcomas of the upper extremity are the epithelioid sarcoma, synovial cell sarcoma, and malignant fibrous histiocytoma. Limb salvage surgery is the treatment of choice for soft tissue sarcomas to preserve upper extremity function. Following wide tumor resection, adjuvant therapies such as chemotherapy, external beam radiation therapy, and brachytherapy may lessen local recurrence rates, but their effect on overall survival remains unclear.

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

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

Role of vascularised tissue transfer after oncological resection in the upper extremity

We reviewed 12 patients who had had vascularised tissue transfer after oncological resection in the upper extremity. All patients had immediate reconstruction, and one had a double tissue transfer. Tissues used were skin flaps, free muscles, and vascularised fibulas, for resurfacing the wound, motor recovery, and reconstruction of large bony defects, respectively. All the patients returned early to their daily activities. Although local recurrences were encountered in two patients, they were again rendered disease-free by salvage operations. Two patients had secondary reconstructions using pedicle latissimus dorsi flaps for late problems, including one of the two patients who developed a local recurrence. The mean functional score using the system devised by the Musculoskeletal Tumor Society was 84%. All the upper extremities were successfully rescued with satisfactory function. Vascularised tissue transfer was invaluable for achieving both curative resection of the tumour and a useful upper extremity.

The influence of anatomic location on outcome in patients with soft tissue sarcoma of the extremity

BACKGROUND

The anatomic location of an extremity soft tissue sarcoma may influence the patient's presentation, management, and local and systemic recurrence rates. The objective of this study was to compare the presentation, management, and outcome of patients with soft tissue sarcomas of the upper extremity and the lower extremity.

METHODS

Prospectively collected data from patients who underwent limb-sparing surgery for extremity soft tissue sarcoma between January, 1986 and April, 1997 were analyzed. Local recurrence free rates and metastasis free rates were calculated using the method of Kaplan and Meier. Univariate and multivariate analyses of potential predictive factors were evaluated with the log-rank test and the Cox proportional hazards model.

RESULTS

Of 480 eligible patients, 48 patients (10.0%) had a local recurrence, and 131 patients (27.3%) developed distant metastasis. The median follow-up of survivors was 4.8 years (range, 0.1-12.9 years). Patients with upper extremity tumors had smaller lesions (6.0 cm vs. 9.3 cm; P < 0.001), more often underwent unplanned excision before referral (89 patients [64.0%] vs. 160 patients [46.9%]; P < 0.001), and less often received radiotherapy (98 patients [70.5%] vs. 289 patients [84.8%]; P < 0.001). The 5-year local recurrence free rate was 82% for patients with sarcomas of the upper extremity and 93% for patients with sarcomas of the lower extremity (P = 0.002). The 5-year metastasis free rate was 82% for patients with sarcomas of the upper extremity and 69% for patients with sarcomas of the lower extremity (P = 0.013).

CONCLUSIONS

Local recurrence was more frequent in patients who had sarcomas of the upper extremity compared with patients who had sarcomas of the lower extremity. Factors that contributed to this difference included histologic type, the use of radiotherapy, and local anatomy. Metastasis was more frequent among patients with sarcomas of the lower extremity, because those tumors tended to be large and deeper compared with upper extremity tumors.

Scintigraphy of cubital bursitis

A 50-year-old man with psoriatic arthropathy was examined for a painful mass in the left cubital fossa. The clinical findings indicated a tumor or infection. Computed tomographic scanning and bone scintigraphy also raised the possibility of a malignant lesion. Surgical exploration revealed that the mass was a chronically inflamed bicipitoradial bursa adherent to the biceps tendon. This is a rare condition, with only a handful of cases described in the literature. This is the first scintigraphic case reported. The imaging features of the bursa are discussed in terms of the anatomy.