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Khakzad T, Putzier M, Paksoy A, Rau D, Thielscher L, Taheri N, Wittenberg S, Märdian S. Outcome of Endoprosthetic Hip Reconstruction Following Resection of Malignant Bone Tumors. Cancers (Basel) 2024; 16:2890. [PMID: 39199660 PMCID: PMC11353244 DOI: 10.3390/cancers16162890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/14/2024] [Accepted: 08/16/2024] [Indexed: 09/01/2024] Open
Abstract
INTRODUCTION Over the past few decades, tumor arthroplasty has evolved into an established therapeutic approach for addressing bone defects following tumor resection in the extremities. As the diagnosis has a significant impact on patients' lives, it is important to give clear expectations for functional recovery. Therefore, we investigated both the functional outcomes and the quality of life (QoL) after tumor arthroplasty for malignant hip tumors. METHODS This retrospective study included patients who had undergone resections of malignant hip tumors with consecutive modular hip arthroplasty between 2010 and 2018. Demographics, tumor entity, and complications stemming from both tumors and treatments were evaluated through the analysis of medical records and perioperative records. The assessment of functional outcomes was conducted with the following patient-reported outcome measures (PROMs): the Harris Hip Score (HHS), Musculoskeletal Tumor Society Score (MSTS), and the Short Form Survey 36 (SF-36). Furthermore, we performed subgroup analysis in two groups: one divided into survivors and non-survivors, as well as younger individuals (<57 years) and older individuals (>57 years). RESULTS A total of 30 patients were included in the study. At the time of follow-up, 19 patients were deceased. The average duration of follow-up was 3.2 (±2.51) years. The average age at the time of surgery was 60.3 (±15.20) years. Notably, there were no cases of amputation reported (0%). Five cases of implant failure were identified (16.67%). Among these, one was attributed to infection (3.3%), while four resulted from aseptic loosening (13.3%). In terms of functional outcomes, MSTS indicated good results (18 ± 7; range: 7-28; 60%), and the HHS demonstrated moderate outcomes (75.3%). Younger survivors (<57 years) exhibited notably superior results in terms of both the MSTS and physical functioning in the SF-36 (p = 0.03). CONCLUSION In summary, this study shows declining tumor arthroplasty-related complications and satisfying functional outcomes as well as QoL. Noteworthy aspects include the relatively low rates of amputation and local tumor recurrences, which significantly favor the selection of appropriate therapeutic options. Moreover, the findings underscore the substantial impact of patients' age on overall functionality and engagement in daily activities.
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Affiliation(s)
- Thilo Khakzad
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité—Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany (A.P.); (S.M.)
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Matsuoka M, Onodera T, Iwasaki K, Hamasaki M, Ebata T, Hosokawa Y, Fukuda R, Kondo E, Iwasaki N. Radiation therapy improves survival in elderly patients with localized extremity soft tissue sarcoma. J Orthop Sci 2024:S0949-2658(24)00140-4. [PMID: 39013754 DOI: 10.1016/j.jos.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/26/2024] [Accepted: 06/29/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND This study aims to evaluate the efficacy of radiation therapy in enhancing survival outcomes among elderly patients diagnosed with localized extremity soft tissue sarcomas (STSs). Furthermore, it seeks to explore whether the survival benefits conferred by radiation therapy differ according to tumor characteristics and treatment modalities. METHODS We conducted a retrospective analysis using the Surveillance, Epidemiology, and End Results (SEER) database to identify patients aged 80 years and older diagnosed with localized extremity STSs. The study assessed 1498 eligible patients, analyzing cancer-specific survival (CSS) and overall survival (OS) through Kaplan-Meier survival analysis and Cox proportional hazards modeling. Propensity score matching was employed to adjust for potential confounders. RESULTS Among the analyzed patients, 773 patients underwent radiation therapy (Radiation group), while 725 patients either did not receive radiation therapy or it was unknown if they had (No-Radiation group). The 5-year OS rate was 40% in the radiation group compared to 38% in the no-radiation group. After propensity score matching, radiation therapy was associated with a significant improvement in OS (P = 0.005, HR = 0.8, 95% CI 0.7-0.9). Subgroup analyses indicated that patients undergoing primary tumor resection benefited most from radiation therapy in terms of OS. CONCLUSION Radiation therapy is associated with improved overall survival in elderly patients with localized extremity STSs. These findings suggest that radiation therapy should be considered as a key component of the treatment strategy for this patient population, taking into account individual patient characteristics and comorbidities.
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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.
| | - Koji Iwasaki
- Department of Functional Reconstruction for the Knee Joint, Hokkaido University, Kita-15, Nish-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.
| | - Taku Ebata
- 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.
| | - Yoshiaki Hosokawa
- 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.
| | - Ryuichi Fukuda
- 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 14 West 5, Kita-Ku, Sapporo, Hokkaido 060-8648, 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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Salunke AA, Nandy K, Kamani M, Parmar R, Bharwani N, Pathak S, Patel K, Pandya S. Is polypropylene mesh reconstruction functionally superior to non reconstructive group following total scapular resection? A retrospective analysis of 16 patients and a systematic review of the literature. J Orthop 2024; 52:37-48. [PMID: 38404696 PMCID: PMC10891286 DOI: 10.1016/j.jor.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/09/2024] [Indexed: 02/27/2024] Open
Abstract
Background Various reconstruction methods have been described in medical literature on scapular tumor resection depending on the type of resection and other factors. However the ideal method of reconstructions has been still debatable. The purpose of the current study was to assess whether polypropylene mesh reconstruction is superior as compared to non reconstructive group following total scapular resection.We also evaluated how our method of reconstruction fare as compared to reported reconstruction methods in the published literature. Methods During 2014 to 2019; Total scapulectomy (Type III scapular resection) was performed in 16 patients for malignant tumor involving scapula bone. Reconstruction with polyprolene mesh(Group I) was performed in 56 % patient and non reconstruction technique (Group II) was observed in 44 % patient. The mean follow-up duration of current study was 28.3 months (range 13-67 months). The search method of PubMed and Cochrane databases provided 121 articles; of which 5 studies having 144 cases were utilised for final analysis. The reconstruction method used were dynamic humeral suspension (39.5%), non reconstruction method (35 %), scapular prosthesis (18 %) and static humeral suspension (5.5%). Results The mean Musculoskeletal tumor society score (MSTS) of the study cohort was 19.8(0-23); and that in polyprolene mesh or static suspension method (Group I) and non reconstructive technique (Group II) was 67 % and 61% respectively. The emotional acceptance score in group I was 4.5 and that in group II was 4.2 points. There was no difference in the shoulder movements in both the groups. The mean surgical durations in group I and group II was was 186 min and 140 min respectively. The systematic review showed the mean Musculoskeletal tumor society score (MSTS) of dynamic suspension and non reconstruction method were 63 % and 63.5% respectively. The mean Musculoskeletal tumor society score (MSTS) of scapula prosthesis tended to be higher than those with dynamic suspension (77 % vs 65 %). Conclusions The reconstruction with polypropylene mesh had better functional outcome and emotional acceptance as compared to non-reconstructive group in patients with total scapular resection surgery. The findings of systematic review suggest that; patients treated by reconstruction with polypropylene mesh and non-reconstructive group as compared to scapular prosthesis had limited shoulder movements with no difference in hand position, manual dexterity and lifting ability.
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Affiliation(s)
- Abhijeet Ashok Salunke
- Department of Surgical Oncology, Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
| | - Kunal Nandy
- Department of Surgical Oncology, Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
| | - Mayur Kamani
- Department of Surgical Oncology, Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
| | - Rahul Parmar
- Department of Surgical Oncology, Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
| | - Nandlal Bharwani
- Department of Surgical Oncology, Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
| | | | - Keval Patel
- Department of Surgical Oncology, Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
| | - Shashank Pandya
- Gujarat Cancer Research Institute (GCRI), Ahmedabad, Gujarat, India
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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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Banskota N, Lei S, Yuan D, Fang X, Banskota S, Zhang W, Duan H. Comparing quality of life in lower extremity tumor patients undergoing limb salvage surgery and amputation: a meta-analysis. Front Oncol 2024; 13:1201202. [PMID: 38234404 PMCID: PMC10792662 DOI: 10.3389/fonc.2023.1201202] [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] [Received: 04/06/2023] [Accepted: 11/21/2023] [Indexed: 01/19/2024] Open
Abstract
Purpose Limb salvage surgery and amputation are two commonly performed procedures for lower extremity tumors. When comparing these procedures in tumor patients, it is important to consider their impact on quality of life (QOL) and functional mobility. These patients often experience physical, emotional, and psychological challenges, making these factors crucial in determining the most suitable treatment approach. Method The outcomes of lower extremity tumors patients for QOL were collected from PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar until 28 February 2023. The physical function, mental health, role function, social function, emotional function, Toronto Extremity Salvage Score, and Musculoskeletal Tumor Society Score outcomes were analyzed to determine the differences between the two procedures. Results Five articles were included according to the selection criteria with a total of 245 patients. The standard mean difference (SMD) values of each parameter were slightly higher in limb salvage surgery patients but not higher enough to produce statistically significant results; the SMD values for physical function and mental health were 0.72 and 0.04, respectively. This study did not report any heterogeneity or publication bias. Conclusions QOL is a large and enhanced term, which carries its importance and is challenging to compare between any procedures. The minimal rise in SMD of different QOL parameters highlighted only a slight advantage of limb salvage surgery over amputation. Therefore, further research is required to explore the impact of this crucial topic.
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Affiliation(s)
- Nishant Banskota
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Senlin Lei
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Dechao Yuan
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Xiang Fang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Sonali Banskota
- Department of General Practice and Emergency Medicine, District Hospital Achham, Mangalsen, Sudurpaschim, Nepal
| | - Wenli Zhang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Duan
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
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Morris CD, Banks LB, Fitzhugh VA, McGill KC, Deville C. Team Approach: Extremity Soft Tissue Sarcoma. JBJS Rev 2023; 11:01874474-202312000-00009. [PMID: 38117909 DOI: 10.2106/jbjs.rvw.23.00171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
» Synovial sarcoma is a soft tissue sarcoma that most commonly presents in the extremity in a periarticular location.» As the history and physical examination of patients with synovial sarcoma can overlap considerably with those of patients with non-oncologic orthopedic conditions, it is important that orthopedic surgeons maintain a high level of suspicion when caring for patients with extremity masses.» Soft tissue sarcomas are best treated using a team approach. Early recognition and referral to a multidisciplinary sarcoma team are crucial to ensure the best clinical outcome for the patient.
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Affiliation(s)
- Carol D Morris
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lauren B Banks
- Department of Medicine, Sarcoma Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Valerie A Fitzhugh
- Department of Pathology, Immunology and Laboratory Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
- Department of Pathology and Laboratory Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kevin C McGill
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
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Fanfan D, Alvarez JC, Gonzalez MR, Larios F, Shae J, Pretell-Mazzini J. Foot and Ankle Soft Tissue Sarcomas-Treatment and Oncologic Outcomes: A Systematic Review of the Literature. Foot Ankle Int 2023; 44:1199-1207. [PMID: 37750365 DOI: 10.1177/10711007231198516] [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] [Indexed: 09/27/2023]
Abstract
BACKGROUND Foot and ankle soft tissue sarcomas (STSs) are rare neoplasms associated with a high risk of local recurrence and metastasis. Although amputation is often performed, its impact on prognosis remains unknown. The aims of our systematic review were identifying risk factors for (1) disease-specific death, (2) local recurrence, (3) metastasis, and assessing (4) whether the type of surgery (amputation or limb-salvage) affected disease-specific survival. METHODS This systematic review was conducted following PRISMA guidelines. The PubMed, Embase, and Scopus databases were searched. Our study was registered in PROSPERO (ID: 415624). Quality appraisal was done using STROBE guidelines. RESULTS A total of 7 studies and 123 patients were included. Metastasis was the only risk factor for disease-specific death (OR = 107.85, P< .001). Previous unplanned excision (OR = 22.29, P = .009) and positive margins (OR = 64.48, P = .011) were associated with higher risk of local recurrence. Patients with high-grade tumors (OR = 13.22, P = .023) and tumors ≥6 cm (OR = 7.40, P = .022) were more likely to develop metastases. After adjusting for confounders (age, sex, and presence of metastasis), amputation was not associated with poorer disease-specific survival. CONCLUSION Metastasis was the single most important risk factor for death with foot and ankle soft tissue sarcoma. Positive margins and history of previous unplanned excision are risk factors for local recurrence. The most important risk factors for metastasis are tumor grade and size ≥6 cm. Amputation was not associated with poorer disease-specific survival.
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Affiliation(s)
- Dino Fanfan
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Juan C Alvarez
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Felipe Larios
- Facultad de Medicina Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jillian Shae
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Juan Pretell-Mazzini
- Miami Cancer Institute, Division of Orthopedic Oncology, Baptist Health System South Florida, Plantation, FL, USA
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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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Yonezawa H, Yamamoto N, Hayashi K, Takeuchi A, Miwa S, Igarashi K, Morinaga S, Asano Y, Saito S, Tada K, Nojima T, Tsuchiya H. Do Liquid Nitrogen-treated Tumor-bearing Nerve Grafts Have the Capacity to Regenerate, and Do They Pose a Risk of Local Recurrence? A Study in Rats. Clin Orthop Relat Res 2022; 480:2442-2455. [PMID: 35976198 PMCID: PMC10540061 DOI: 10.1097/corr.0000000000002336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/01/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Under most circumstances, the resection of soft tissue sarcomas of the extremities can be limb-sparing, function-preserving oncologic resections with adequate margins. However, en bloc resection may require resection of the major peripheral nerves, causing poor function in the extremities. Although liquid nitrogen treatment has been used to sterilize malignant bone tumors, its use in the preparation of nerve grafts has, to our knowledge, not been reported. Hence, this study aimed to investigate the tumor recurrence and function after peripheral nerve reconstruction using liquid nitrogen-treated tumor-bearing nerves in a rat model. QUESTIONS/PURPOSES (1) Do liquid nitrogen-treated frozen autografts have regeneration capabilities? (2) Do liquid nitrogen-treated tumor-bearing nerves cause any local recurrences in vivo in a rat model? METHODS Experiment 1: Twelve-week-old female Wistar rats, each weighing 250 g to 300 g, were used. A 10-mm-long section of the right sciatic nerve was excised; the prepared nerve grafts were bridge-grafted through end-to-end suturing. The rats were grouped as follows: an autograft group, which underwent placement of a resected sciatic nerve after it was sutured in the reverse orientation, and a frozen autograft group, which underwent bridging of the nerve gap using a frozen autograft. The autograft was frozen in liquid nitrogen, thawed at room temperature, and then thawed in distilled water before application. The third group was a resection group in which the nerve gap was not reconstructed. Twenty-four rats were included in each group, and six rats per group were evaluated at 4, 12, 24, and 48 weeks postoperatively. To assess nerve regeneration after reconstruction using the frozen nerve graft in the nontumor rat model, we evaluated the sciatic functional index, tibialis anterior muscle wet weight ratio, electrophysiologic parameters (amplitude and latency), muscle fiber size (determined with Masson trichrome staining), lower limb muscle volume, and immunohistochemical findings (though neurofilament staining and S100 protein produced solely and uniformly by Schwann cells associated with axons). Lower limb muscle volume was calculated via CT before surgery (0 weeks) and at 4, 8, 12, 16, 20, 24, 32, 40, and 48 weeks after surgery. Experiment 2: Ten-week-old female nude rats (F344/NJcl-rnu/rnu rats), each weighing 100 g to 150 g, were injected with HT1080 (human fibrosarcoma) cells near the bilateral sciatic nerves. Two weeks after injection, the tumor grew to a 10-mm-diameter mass involving the sciatic nerves. Subsequently, the tumor was resected with the sciatic nerves, and tumor-bearing sciatic nerves were obtained. After liquid nitrogen treatment, the frozen tumor-bearing nerve graft was trimmed to a 5-mm-long tissue and implanted into another F344/NJcl-rnu/rnu rat, in which a 5-mm-long section of the sciatic nerve was resected to create a nerve gap. Experiment 2 was performed with 12 rats; six rats were evaluated at 24 and 48 weeks postoperatively. To assess nerve regeneration and tumor recurrence after nerve reconstruction using frozen tumor-bearing nerve grafts obtained from the nude rat with human fibrosarcoma involving the sciatic nerve, the sciatic nerve's function and histologic findings were evaluated in the same way as in Experiment 1. RESULTS Experiment 1: The lower limb muscle volume decreased once at 4 weeks in the autograft and frozen autograft groups and gradually increased thereafter. The tibialis anterior muscle wet weight ratio, sciatic functional index, muscle fiber size, and electrophysiologic evaluation showed higher nerve regeneration potential in the autograft and frozen autograft groups than in the resection group. The median S100-positive areas (interquartile range [IQR]) in the autograft group were larger than those in the frozen autograft group at 12 weeks (0.83 [IQR 0.78 to 0.88] versus 0.57 [IQR 0.53 to 0.61], difference of medians 0.26; p = 0.04) and at 48 weeks (0.86 [IQR 0.83 to 0.99] versus 0.74 [IQR 0.69 to 0.81], difference of median 0.12; p = 0.03). Experiment 2: Lower limb muscle volume decreased at 4 weeks and gradually increased thereafter. The median muscle fiber size increased from 0.89 (IQR 0.75 to 0.90) at 24 weeks to 1.20 (IQR 1.08 to 1.34) at 48 weeks (difference of median 0.31; p< 0.01). The median amplitude increased from 0.60 (IQR 0.56 to 0.67) at 24 weeks to 0.81 (IQR 0.76 to 0.90) at 48 weeks (difference of median 0.21; p < 0.01). Despite tumor involvement and freezing treatment, tumor-bearing frozen grafts demonstrated nerve regeneration activity, with no local recurrence observed at 48 weeks postoperatively in nude rats. CONCLUSION Tumor-bearing frozen nerve grafts demonstrated nerve regeneration activity, and there was no tumor recurrence in rats in vivo. CLINICAL RELEVANCE A frozen nerve autograft has a similar regenerative potential to that of a nerve autograft. Although the findings in a rat model do not guarantee efficacy in humans, if they are substantiated by large-animal models, clinical trials will be needed to evaluate the efficacy of tumor-bearing frozen nerve grafts in humans.
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Affiliation(s)
- Hirotaka Yonezawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Katsuhiro Hayashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Akihiko Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shinji Miwa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kentaro Igarashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Sei Morinaga
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yohei Asano
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shiro Saito
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kaoru Tada
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Takayuki Nojima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
- Department of Diagnostic Pathology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
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10
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Thomas B, Bigdeli AK, Nolte S, Gazyakan E, Harhaus L, Bischel O, Lehner B, Egerer G, Mechtersheimer G, Hohenberger P, Horch RE, Andreou D, Schmitt J, Schuler MK, Eichler M, Kneser U. The Therapeutic Role of Plastic and Reconstructive Surgery in the Interdisciplinary Treatment of Soft-Tissue Sarcomas in Germany-Cross-Sectional Results of a Prospective Nationwide Observational Study (PROSa). Cancers (Basel) 2022; 14:cancers14174312. [PMID: 36077847 PMCID: PMC9454490 DOI: 10.3390/cancers14174312] [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: 08/08/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The mainstay of soft-tissue-sarcoma treatment remains ablative surgery with complete tumor resection. In this context, reconstructive plastic surgery has become an important aspect of multidisciplinary sarcoma therapy aiming at limb preservation as an alternative to amputations. In this present study, cross-sectional data collected prospectively at 39 study centers across Germany were analyzed, focusing on both the inhouse availability of plastic surgery and external accessibility to plastic surgery in 621 cases. In summary, unplanned and incomplete primary tumor resections carried out at centers with lower degrees of specialization were associated with a significantly increased need for subsequent flap-based defect coverage. In line with this, a readily available team of plastic surgeons was independently associated with successful defect reconstruction, which in turn was associated with significantly higher chances of limb preservation. We conclude that easily accessible plastic surgery and a high degree of expertise in the field of sarcoma treatment are indispensable for limb preservation following sarcoma resection. Plastic and reconstructive surgery therefore plays a vital role in achieving the best possible outcomes in the interdisciplinary treatment of soft-tissue sarcomas. Abstract Although the involvement of plastic surgery has been deemed important in the treatment of sarcoma patients to avoid oncological compromises and ameliorate patient outcomes, it is not ubiquitously available. The accessibility of defect reconstruction and its therapeutic impact on sarcoma care is the subject of this analysis. Cross-sectional data from 1309 sarcoma patients were collected electronically at 39 German study centers from 2017 to 2019. A total of 621 patients with surgical treatment for non-visceral soft-tissue sarcomas were included. The associated factors were analyzed exploratively using multifactorial logistic regression to identify independent predictors of successful defect reconstruction, as well Chi-squared and Cochran–Mantel–Haenszel tests to evaluate subgroups, including limb-salvage rates in extremity cases. A total of 76 patients received reconstructive surgery, including 52 local/pedicled versus 24 free flaps. Sarcomas with positive margins upon first resection (OR = 2.3, 95%CI = 1.2–4.4) that were excised at centers with lower degrees of specialization (OR = 2.2, 95%CI = 1.2–4.2) were independently associated with the need for post-oncological defect coverage. In this context, the inhouse availability of plastic surgery (OR = 3.0, 95%CI = 1.6–5.5) was the strongest independent predictor for successful flap-based reconstruction, which in turn was associated with significantly higher limb-salvage rates (OR = 1.4, 95%CI = 1.0–2.1) in cases of extremity sarcomas (n = 366, 59%). In conclusion, consistent referral to specialized interdisciplinary sarcoma centers significantly ameliorates patient outcomes by achieving higher rates of complete resections and offering unrestricted access to plastic surgery. The latter in particular proved indispensable for limb salvage through flap-based defect reconstruction after sarcoma resection. In fact, although there remains a scarcity of readily available reconstructive surgery services within the current sarcoma treatment system in Germany, plastic and reconstructive flap transfer was associated with significantly increased limb-salvage rates in our cohort.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Steffen Nolte
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Oliver Bischel
- Department of Trauma and Orthopedics, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
| | - Burkhard Lehner
- Department of Orthopaedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Gerlinde Egerer
- Department of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | | | - Peter Hohenberger
- Division of Surgical Oncology, Department of Surgery, Mannheim University Medical Center, University of Heidelberg, 68167 Mannheim, Germany
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Dimosthenis Andreou
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Münster, 48149 Münster, Germany
- Department of Orthopedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Jochen Schmitt
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Center for Evidence-based Healthcare, University Hospital Carl Gustav Carus, Technical University Dresden, 01307 Dresden, Germany
| | - Markus K. Schuler
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Martin Eichler
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
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11
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Homsy P, Kantonen I, Salo J, Albäck A, Tukiainen E. Reconstruction of the superficial femoral vessels with muscle flap coverage for soft tissue sarcomas of the proximal thigh. Microsurgery 2022; 42:568-576. [PMID: 35730696 PMCID: PMC9543357 DOI: 10.1002/micr.30932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 05/02/2022] [Accepted: 06/10/2022] [Indexed: 11/24/2022]
Abstract
Background Surgical resection of soft tissue sarcoma with a margin of healthy tissue may necessitate resection and reconstruction of major blood vessels together with soft tissues of the proximal thigh to preserve the limb. The long‐term functional outcomes of these reconstructions remain unestablished. The aim of this report was to assess the vascular and functional outcomes of soft tissue sarcoma patients with femoral vessel reconstructions. Patients and Methods Patients who had undergone oncovascular reconstruction during the treatment of proximal thigh soft tissue sarcoma in 2014–2020 were reviewed for details of the vascular and soft tissue reconstructions, and the oncological and functional outcomes. This included eight patients of a median age 59 (range 19–77) years. All had a reconstruction of at least the superficial femoral artery and vein as well as soft tissue reconstruction with a muscle flap. All vessel reconstructions were done with either autologous vein (six grafts/four patients) or allograft (10 grafts/six patients). A microvascular latissimus dorsi flap, with a skin island, was incorporated to cover the vascular grafts in five patients. A pedicled sartorius or gracilis muscle flap was used to fill the defect in three patients. Results Graft patency was assessed in seven patients with a median follow‐up of 48 (1–76) months. The arterial graft was patent in 6/8 and the vein graft in 2/8 patients. The gait had returned to normal in five of the six patients assessed. The median MTSS was 70 (43–87)% and the TESS 90 (75–100)%. No local recurrence of the sarcoma was detected. Conclusions Vascular reconstruction combined with soft tissue reconstruction enables limb‐sparing surgery in patients with soft tissue sarcoma involving proximal femoral vessels. Although the surgeries are complex with high early morbidity, the achieved long‐term functional outcomes are worthwhile.
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Affiliation(s)
- Pauliina Homsy
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Kantonen
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juho Salo
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anders Albäck
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erkki Tukiainen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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12
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Nigam A, Aminpour N, Zeymo A, Desale S, Villano AM, Unger KR, Aboulafia AJ, Al-Refaie WB. National evaluation of patterns and predictors of underuse of multimodal therapy for high-risk extremity soft tissue sarcoma. Surgery 2022; 171:1348-1357. [DOI: 10.1016/j.surg.2021.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 12/01/2022]
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13
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Indications and outcomes of palliative major amputation in patients with metastatic cancer. Surg Oncol 2021; 40:101700. [PMID: 34992030 DOI: 10.1016/j.suronc.2021.101700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/30/2021] [Accepted: 12/28/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with stage IV cancer often experience diminished quality of life and pain. Although palliative amputation (PA) can reduce pain, it is infrequently performed because of the morbidity associated with amputation and the limited life expectancy in this population. Here, we describe the indications for PA in patients with stage IV carcinoma or sarcoma and discuss their clinical courses and outcomes. We hypothesized that PA would be associated with reduced pain and improved quality of life in these patients. METHODS We retrospectively reviewed medical records of all patients who underwent major amputation (proximal to the ankle or wrist) for metastatic sarcoma or carcinoma from January 1995 to April 2021. We excluded patients who underwent amputation for indications other than palliation. Cox proportional hazards regression analysis was used to determine factors associated with survival after PA. RESULTS Twenty-six patients underwent PA (11 for carcinoma, 15 for sarcoma). The most common indications for PA were pain (all patients) and fungating tumor (16 patients). PA was the initial surgery in 7 patients. Forequarter amputations were the most common procedure (6 patients). All patients reported reduced pain after PA, with the mean (±standard deviation) visual analog pain score (on a 10-point scale) decreasing from 5.7 ± 2.9 preoperatively to 0.43 ± 1.3 postoperatively (p < 0.001). The mean preoperative ECOG score was 1.9 ± 0.2 compared with 1.3 ± 0.1 postoperatively (p < 0.001). Fourteen patients were fitted for prostheses (6 upper extremity, 8 lower extremity). Two patients had local recurrence, both within 6 months after PA. The mean survival time after PA was 13 ± 12 months, and mean follow-up was 28 ± 29 months. Mean survival time after PA was not significantly different between patients with sarcoma (11 ± 11 months) versus carcinoma (15 ± 14 months) (p = 0.51). Adjuvant chemotherapy was positively associated with survival; no other factors were associated with survival. CONCLUSIONS PA was associated with significantly reduced pain in all patients with stage IV cancer. PA should be considered for those with intractable pain, fungating tumors, or symptoms that diminish quality of life. LEVEL OF EVIDENCE Level III.
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14
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Lee Y, Guertin MP, Summers S, Conway SA, Al Maaieh M, Yechieli R, Trent J, Rosenberg AE, Pretell-Mazzini J. Oncological Outcomes in Patients with Appendicular Myxofibrosarcomas: A Retrospective Study. JOURNAL OF ONCOLOGY 2021; 2021:1844816. [PMID: 34876901 PMCID: PMC8645367 DOI: 10.1155/2021/1844816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/28/2021] [Accepted: 11/09/2021] [Indexed: 12/05/2022]
Abstract
BACKGROUND Myxofibrosarcoma (MFS) is notorious for its infiltrative growth pattern, making wide excisions difficult to achieve. Our objective was to assess the impact of surgical margins and other factors that affected rates of local recurrence (LR), distant metastasis (DM), and overall survival (OS) of individuals undergoing resection for MFS. METHODS We retrospectively reviewed the medical records of 209 patients with appendicular soft tissue sarcomas between January 2012 and June 2018. Of these, 29 patients (14%) were diagnosed with myxofibrosarcoma. These patients underwent a total of 33 resections. The pathological analyses were conducted by an experienced musculoskeletal (MSK) pathologist. Demographics data, operative details, adjuvant therapy, and oncological outcomes were assessed. RESULTS Of the 29 patients (33 resections), the overall LR rate was 24% (7/29) and the 2-year LR rate was 17% (5/29). Factors associated with negative oncological outcomes were as follows: tumor size ≤10 cm (2-year local recurrence-free rates (LRFRs), 65%; 95% CI, 44-86%; p=0.02) and positive surgical margins grouped with surgical margins ≤0.1 cm (hazard ratio (HR), 11.74; 95% CI, 1.41-97.74; p=0.02). Chemotherapy and radiotherapy together increased the 2-year LRFR (LRFR, 100%; 95% CI, 100%, p=0.001). Two-year DM and OS rates were 15% and 79%, respectively. Female gender was a predictor of distant metastasis. Local recurrence had a negative impact on overall survival. Intraoperative analysis of resection margin accuracy was 75% (12/16) when non-MSK pathologists were involved but 100% accurate (12/12) when analyzed by an MSK pathologist. CONCLUSION Myxofibrosarcomas showed high LR rates after treatment. Close margins (≤0.1 cm) should be considered as a risk factor for LR, and LR is associated with negative overall survival. Neoadjuvant therapy in terms of combined chemotherapy and radiation therapy associates with decreased LR rates. If intraoperative assessment of margins is to be done, it should be performed by an experienced MSK pathologist.
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Affiliation(s)
- Yonghoon Lee
- Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | | | - Spencer Summers
- Orthopedic Surgery Resident, Department of Orthopedic Surgery, Jackson Memorial Hospital, Miami, FL, USA
| | - Sheila A. Conway
- Musculoskeletal Oncology Division, Department of Orthopedics, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | | | | | - Jonathan Trent
- University of Miami, Jackson Memorial Hospital, Miami, FL, USA
| | - Andrew E. Rosenberg
- Director of Anatomic Pathology, Director of Bone & Soft Tissue Pathology, Department of Pathology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Juan Pretell-Mazzini
- Director of Clinical Research Musculoskeletal Oncology Division, Musculoskeletal Oncology Division, Department of Orthopedics, Miller School of Medicine, University of Miami, Miami, FL, USA
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15
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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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16
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Reijers SJM, Husson O, Soomers VLMN, Been LB, Bonenkamp JJ, van de Sande MAJ, Verhoef C, van der Graaf WTA, van Houdt WJ. Health-related quality of life after isolated limb perfusion compared to extended resection, or amputation for locally advanced extremity sarcoma: Is a limb salvage strategy worth the effort? Eur J Surg Oncol 2021; 48:500-507. [PMID: 34389213 DOI: 10.1016/j.ejso.2021.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/12/2021] [Accepted: 08/06/2021] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION The aim of this study was to compare long-term patient reported outcomes (PROs) in patients with locally advanced extremity soft tissue sarcoma (eSTS) after isolated limb perfusion followed by resection (IR), compared to extended resection (ER), primary amputation (A) or secondary amputation after IR (IR-A). METHODS Patients were selected from the respondents of a multi-institutional cross-sectional cohort survivorship study (SURVSARC) conducted among sarcoma survivors registered in the Netherlands Cancer Registry (NCR), 2-10 years after diagnosis. Used PROs were the EORTC QLQ-C30, the Cancer worry scale (CWS), the Hospital Anxiety and Depression Scale (HADS), and the Toronto Extremity Salvage Score (TESS). RESULTS We identified 97 eSTS survivors: IR = 20, ER = 49, A = 20, IR-A = 8. While there were no differences in PROs between IR and ER, results showed better functioning and functionality in both groups versus the amputation groups. The amputation groups scored significantly lower on physical functioning (A = 62.7, IR-A = 65.7 versus IR = 78.0, ER = 82.7, p = 0.001) and role functioning (A = 67.5, IR-A = 52.8 versus IR = 79.2, ER = 80.6, p = 0.039), both EORTC QLQ-C30 scales. Also for the TESS, the scores were significantly lower for the amputation groups compared to the limb sparing groups (upper extremity p = 0.007 with A = 68.9, IR-A = 71.6 versus IR = 93.3, ER = 91.1; lower extremity p < 0.001 with A = 72.2, IR-A50.9 versus IR = 84.5 and ER = 85.5). There were no significant differences between the groups on cancer worry, anxiety and depression. CONCLUSION HRQoL in eSTS survivors treated with IR or ER is equal; for maintenance of physical functioning and functionality IR and ER outperform an amputation.
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Affiliation(s)
- Sophie J M Reijers
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Olga Husson
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Division of Clinical Studies, Institute of Cancer Research, London, United Kingdom
| | - Vicky L M N Soomers
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lukas B Been
- Department of Surgical Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Johannes J Bonenkamp
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Winan J van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
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17
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Merino-Rueda LR, Barrientos-Ruiz I, Bernabeu-Taboada D, Pozo-Kreilinger JJ, Peleteiro-Pensado M, Cordero-García JM, Ortiz-Cruz EJ. Radiological and histopathological assessment of bone infiltration in soft tissue sarcomas. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:631-639. [PMID: 34057623 DOI: 10.1007/s00590-021-03018-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/21/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Deep soft tissue sarcomas are frequently in contact with bone. The therapeutic decision of a composite resection strategy may be challenging, which is usually based on clinical and radiological criteria. The aims of the study were to evaluate the overall frequency of bone and periosteal infiltration in these patients in whom composite resection was indicated, and evaluate the role of magnetic resonance imaging and bone scintigraphy in this scenario. METHODS Forty-nine patients with a composite surgical resection (soft tissue sarcoma and bone), treated at a single institution between 2006 and 2018, were retrospectively included. Presurgical planning of the resection limits was based on clinical and imaging findings (magnetic resonance imaging and bone scintigraphy). Magnetic resonance imaging was performed in all patients (100%) and bone scintigraphy in 41 (83.7% of the cases). According to magnetic resonance imaging results, patients were divided into two groups: Group A, in which the tumor is adjacent to the bone without evidence of infiltration (n = 24, 48,9%), and Group B, patients with evidence of bone involvement by magnetic resonance imaging (n = 25, 51,1%). BS showed a pathological deposit in 28 patients (68.3%). Histological analysis of the resection specimen was preceded to identify bone and periosteal infiltration. For the analysis of the diagnostic validity of imaging tests, histological diagnosis was considered as the gold standard in the evaluation of STS bone infiltration. RESULTS Histological bone infiltration was identified in 49% of patients and isolated periosteal infiltration in 14.3%. In terms of diagnostic accuracy, magnetic resonance imaging and bone scintigraphy sensitivity values were 92% and 90%, and their specificity values were 91.7% and 52.4%, respectively. CONCLUSIONS The incidence of bone and periosteal infiltration of soft tissue sarcomas in contact with bone is high. Presurgical bone assessment by MRI has proven to be a sensitive and specific tool in the diagnosis of bone infiltration. Due to its high negative predictive value, BS is a useful test to rule out it. In those cases, in which there is suspicion of bone infiltration not confirmed by MRI, new diagnostic protocols should be established in order to avoid inappropriate resections.
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Affiliation(s)
- Luis Rodrigo Merino-Rueda
- Orthopaedic Oncology Unit, "Doce de Octubre" University Hospital, Avda. De Córdoba s/n, 28041, Madrid, Spain. .,Orthopaedic Oncology Unit, La Paz University Hospital, Paseo de La Castellana, 26, 28046, Madrid, Spain.
| | - Irene Barrientos-Ruiz
- Orthopaedic Oncology Unit, La Paz University Hospital, Paseo de La Castellana, 26, 28046, Madrid, Spain
| | - Daniel Bernabeu-Taboada
- Radiology Department, La Paz University Hospital, Paseo de La Castellana, 26, 28046, Madrid, Spain
| | - José J Pozo-Kreilinger
- Pathology Department, La Paz University Hospital, Paseo de La Castellana, 26, 28046, Madrid, Spain
| | - Manuel Peleteiro-Pensado
- Orthopaedic Oncology Unit, La Paz University Hospital, Paseo de La Castellana, 26, 28046, Madrid, Spain
| | - José M Cordero-García
- Nuclear Medicine Department, La Paz University Hospital, Paseo de La Castellana, 26, 28046, Madrid, Spain
| | - Eduardo J Ortiz-Cruz
- Orthopaedic Oncology Unit, La Paz University Hospital, Paseo de La Castellana, 26, 28046, Madrid, Spain
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18
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Evans DR, Lazarides AL, Cullen MM, Visgauss JD, Somarelli JA, Blazer DG, Brigman BE, Eward WC. Identifying Modifiable and Non-modifiable Risk Factors of Readmission and Short-Term Mortality in Osteosarcoma: A National Cancer Database Study. Ann Surg Oncol 2021; 28:7961-7972. [PMID: 34018083 DOI: 10.1245/s10434-021-10099-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND There are limited data to inform risk of readmission and short-term mortality in musculoskeletal oncology. The goal of this study was to identify factors independently associated with 30-day readmission and 90-day mortality following surgical resection of osteosarcoma. METHODS We retrospectively reviewed patients (n = 5293) following surgical resection of primary osteosarcoma in the National Cancer Database (2004-2015). Univariate and multivariate methods were used to correlate variables with readmission and short-term mortality. RESULTS Of 210 readmissions (3.97%), risk factors independently associated with unplanned 30-day readmission included comorbidity burden (odds ratio [OR] 2.4, p = 0.042), Medicare insurance (OR 1.9, p = 0.021), and axial skeleton location (OR 1.5, p = 0.029). A total of 91 patients died within 90 days of their surgery (1.84%). Risk factors independently associated with mortality included age (hazard ratio 1.1, p < 0.001), increasing comorbidity burden (OR 6.6, p = 0.001), higher grade (OR 1.7, p = 0.007), increasing tumor size (OR 2.2, p = 0.03), metastatic disease at presentation (OR 8.5, p < 0.001), and amputation (OR 2.0, p = 0.04). Chemotherapy was associated with a decreased risk of short-term mortality (p < 0.001). CONCLUSIONS Several trends were clear: insurance status, tumor location and comorbidity burden were independently associated with readmission rates, while age, amputation, grade, tumor size, metastatic disease, and comorbidity burden were independently associated with short-term mortality.
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Affiliation(s)
| | | | | | - Julia D Visgauss
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA.,Duke Cancer Institute, Duke University Hospital, Durham, NC, USA
| | - Jason A Somarelli
- Duke Cancer Institute, Duke University Hospital, Durham, NC, USA.,Department of Medicine, Duke University Hospital, Durham, NC, USA
| | - Dan G Blazer
- Duke Cancer Institute, Duke University Hospital, Durham, NC, USA.,Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - Brian E Brigman
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA.,Duke Cancer Institute, Duke University Hospital, Durham, NC, USA
| | - William C Eward
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA.,Duke Cancer Institute, Duke University Hospital, Durham, NC, USA
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19
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O'Brien AL, West JM, Zewdu A, Grignol VP, Scharschmidt TJ, Moore AM. Nerve transfers to restore femoral nerve function following oncologic nerve resection. J Surg Oncol 2021; 124:33-40. [PMID: 33831232 DOI: 10.1002/jso.26487] [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: 12/30/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Advances in the care of soft-tissue tumors, including imaging capabilities and adjuvant radiation therapy, have broadened the indications and opportunities to pursue surgical limb salvage. However, peripheral nerve involvement and femoral nerve resection can still result in devastating functional outcomes. Nerve transfers offer a versatile solution to restore nerve function following tumor resection. METHODS Two cases were identified by retrospective review. Patient and disease characteristics were gathered. Preoperative and postoperative motor function were assessed using the Medical Research Council Muscle Scale. Patient-reported pain levels were assessed using the numeric rating scale. RESULTS Nerve transfers from the obturator and sciatic nerve were employed to restore knee extension. Follow up for Case 1 was 24 months, 8 months for Case 2. In both patients, knee extension and stabilization of gait without bracing was restored. Patient also demonstrated 0/10 pain (an average improvement of 5 points) with decreased neuromodulator and pain medication use. CONCLUSION Nerve transfers can restore function and provide pain control benefits and ideally are performed at the time of tumor extirpation. This collaboration between oncologic and nerve surgeons will ultimately result in improved functional recovery and patient outcomes.
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Affiliation(s)
- Andrew L O'Brien
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie M West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Abbie Zewdu
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Valerie P Grignol
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas J Scharschmidt
- Department of Orthopaedic Surgery, The Ohio State University James Wexner Medical Center, Columbus, Ohio, USA
| | - Amy M Moore
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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20
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Shah A, Ramanujan V, Muralidharan K, AnRaja A. Outcomes of Vascular Resection and Reconstruction in Extremity Soft Tissue Sarcoma and Bone Tumors. Vasc Specialist Int 2021; 37:22-28. [PMID: 33795550 PMCID: PMC8021495 DOI: 10.5758/vsi.200064] [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: 10/13/2020] [Revised: 12/09/2020] [Accepted: 03/16/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose This study aimed to evaluate and analyze the feasibility and the oncological and functional outcomes of limb salvage surgery in extremity soft tissue sarcomas (ESTS) and bone tumors invading vessels. Materials and Methods This single-center retrospective analysis included patients with ESTS encasing or invading major blood vessels that were treated by limb salvage surgery with vascular resection and reconstruction between January 1995 and December 2019. Patients with contiguous involvement of major blood vessels and nerves and patients requiring amputation were excluded from the study. Results A total of 24 vessels (14 arteries and 10 veins) in 14 patients were reconstructed. Ten (71.4%) patients underwent both arterial and venous reconstruction, and four (28.6%) underwent only arterial reconstruction. Reconstruction was performed with a reversed saphenous vein (RSV) graft in 12 patients and with a synthetic graft (SG) in the other 12 patients. At a median follow-up of 27 months, RSV grafts were patent in 10 of 12 (83.3%) vessels and SGs were patent in 6 of 12 (50.0%) vessels (log-rank test, P=0.083). Out of 14 arteries and 10 veins, 11 arteries and 5 veins were patent, respectively. No patient developed local recurrence, and 2 (14.3%) patients developed distant metastases. Limb salvage rate was 13/14 (92.9%). The mean Musculoskeletal Tumor Society score was 83.3%. The 5- and 10-year overall survival rates were 80% and 50%, respectively. Conclusion Limb salvage surgery in ESTS with vascular resection and reconstruction is feasible and provides favorable oncological and functional outcomes.
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Affiliation(s)
- AnChetan Shah
- Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India
| | - Vishnu Ramanujan
- Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India
| | - Krishna Muralidharan
- Department of Vascular Surgery, Government Multi Super Speciality Hospital, Chennai, India
| | - Anand AnRaja
- Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India
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21
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Hesla AC, Papakonstantinou A, Tsagkozis P. Current Status of Management and Outcome for Patients with Ewing Sarcoma. Cancers (Basel) 2021; 13:1202. [PMID: 33801953 PMCID: PMC7998375 DOI: 10.3390/cancers13061202] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/26/2021] [Accepted: 02/27/2021] [Indexed: 12/16/2022] Open
Abstract
Ewing sarcoma is the second most common bone sarcoma in children after osteosarcoma. It is a very aggressive malignancy for which systemic treatment has greatly improved outcome for patients with localized disease, who now see survival rates of over 70%. However, for the quarter of patients presenting with metastatic disease, survival is still dismal with less than 30% of patients surviving past 5 years. Patients with disease relapse, local or distant, face an even poorer prognosis with an event-free 5-year survival rate of only 10%. Unfortunately, Ewing sarcoma patients have not yet seen the benefit of recent years' technical achievements such as next-generation sequencing, which have enabled researchers to study biological systems at a level never seen before. In spite of large multinational studies, treatment of Ewing sarcoma relies entirely on chemotherapeutic agents that have been largely unchanged for decades. As many promising modern therapies, including monoclonal antibodies, small molecules, and immunotherapy, have been disappointing to date, there is no clear candidate as to which drug should be investigated in the next large-scale clinical trial. However, the mechanisms driving tumor development in Ewing sarcoma are slowly unfolding. New entities of Ewing-like tumors, with fusion transcripts that are related to the oncogenic EWSR1-FLI1 fusion seen in the majority of Ewing tumors, are being mapped. These tumors, although sharing much of the same morphologic features as classic Ewing sarcoma, behave differently and may require a different treatment. There are also controversies regarding local treatment of Ewing sarcoma. The radiosensitive nature of the disease and the tendency for Ewing sarcoma to arise in the axial skeleton make local treatment very challenging. Surgical treatment and radiotherapy have their pros and cons, which may give rise to different treatment strategies in different centers around the world. This review article discusses some of these controversies and reproduces the highlights from recent publications with regard to diagnostics, systemic treatment, and surgical treatment of Ewing sarcoma.
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22
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Smolle MA, Leithner A, Kapper M, Demmer G, Trost C, Bergovec M, Windhager R, Hobusch GM. Complications, mobility, and quality of life in ankle sarcoma patients. Bone Joint J 2021; 103-B:553-561. [PMID: 33641415 DOI: 10.1302/0301-620x.103b3.bjj-2020-1308.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aims of the study were to analyze differences in surgical and oncological outcomes, as well as quality of life (QoL) and function in patients with ankle sarcomas undergoing three forms of surgical treatment, minor or major limb salvage surgery (LSS), or amputation. METHODS A total of 69 patients with ankle sarcomas, treated between 1981 and 2017 at two tumour centres, were retrospectively reviewed (mean age at surgery: 46.3 years (SD 22.0); 31 females (45%)). Among these 69 patients 25 were analyzed prospectively (mean age at latest follow-up: 61.2 years (SD 20.7); 11 females (44%)), and assessed for mobility using the Prosthetic Limb Users Survey of Mobility (PLUS-M; for amputees only), the Toronto Extremity Salvage Score (TESS), and the University of California, Los Angeles (UCLA) Activity Score. Individual QoL was evaluated in these 25 patients using the five-level EuroQol five-dimension (EQ-5D-5L) and Fragebogen zur Lebenszufriedenheit/Questions on Life Satisfaction (FLZ). RESULTS Of the total number of patients in the study, 22 (32%) underwent minor LSS and 22 (32%) underwent major LSS; 25 underwent primary amputation (36%). Complications developed in 26 (38%) patients, and were more common in those with major or minor LSS in comparison to amputation (59% vs 36% vs 20%; p = 0.022). A time-dependent trend towards higher complication risk following any LSS was present (relative risk: 0.204; 95% confidence interval (CI) 0.026 to 1.614; p = 0.095). In the prospective cohort, mean TESS was higher following minor LSS in comparison to amputation (91.0 vs 67.3; p = 0.006), while there was no statistically significant difference between major LSS and amputation (81.6 vs 67.3; p = 0.099). There was no difference in mean UCLA (p = 0.334) between the three groups (p = 0.334). None of the items in FLZ or EQ-5D-5L were different between the three groups (all p > 0.05), except for FLZ item "self-relation", being lower in amputees. CONCLUSION Complications are common following LSS for ankle sarcomas. QoL is comparable between patients with LSS or amputation, despite better mobility scores for patients following minor LSS. We conclude that these results allow a decision for amputation to be made more easily in patients particularly where the principles of oncological surgery would otherwise be at risk. Cite this article: Bone Joint J 2021;103-B(3):553-561.
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Affiliation(s)
- Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Martin Kapper
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Gregor Demmer
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Carmen Trost
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Marko Bergovec
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Martin Hobusch
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
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23
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Hoftiezer YAJ, Lans J, van der Heijden BEPA, Chen NC, Eberlin KR, Lozano-Calderón SA. Long-term patient-reported outcome measures following limb salvage with complex reconstruction or amputation in the treatment of upper extremity sarcoma. J Surg Oncol 2021; 123:1328-1335. [PMID: 33650694 DOI: 10.1002/jso.26426] [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: 11/30/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES This study compares long-term patient-reported outcomes between patients that underwent limb-salvage surgery with complex reconstruction by free or pedicled flap (LS) or amputation. Additionally, the need for revision surgery is compared. METHODS A total of 43 patients were studied at a median follow-up of 9.54 years. Sixteen patients completed questionnaires regarding functional outcome and mental wellbeing. Functional outcomes were measured by using the Toronto Extremity Salvage Score (TESS), QuickDASH, and PROMIS Upper Extremity instruments. Mental wellbeing was assessed using the PROMIS Anxiety and Depression instruments. Revision surgery was assessed for the entire follow-up. RESULTS The median TESS scores were 96.0 versus 71.7 (p = 0.034) and the PROMIS Upper Extremity scores were 50.1 versus 40.3 (p = 0.039) for the LS and amputation cohorts, respectively. No significant difference was found regarding symptoms of anxiety (52.7 vs. 53.8; p = 0.587) or depression (52.0 vs. 50.5; p = 0.745). Of the patients in the LS cohort 51.6% required at least one reoperation compared to 8.33% in the amputation cohort. CONCLUSIONS LS surgery maintains functional benefits over amputation after almost a decade of follow-up. Still, mental wellbeing seems to be comparable between these patients, whereas LS procedures are associated with a sixfold increased need for reoperations.
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Affiliation(s)
- Yannick A J Hoftiezer
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Plastic, Reconstructive, and Hand Surgery, Radboud UMC, Nijmegen, The Netherlands
| | - Jonathan Lans
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brigitte E P A van der Heijden
- Department of Plastic, Reconstructive, and Hand Surgery, Radboud UMC, Nijmegen, The Netherlands.,Department of Plastic Surgery, Jeroen Bosch Hospital, Utrecht, The Netherlands
| | - Neal C Chen
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kyle R Eberlin
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Santiago A Lozano-Calderón
- Department of Orthopedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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24
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Perrault DP, Lee GK, Yu RP, Carre AL, Chattha A, Johnson MB, Gardner DJ, Carey JN, Tseng WW, Menendez LR, Wong AK. Risk Factors for Wound Complications After Soft Tissue Sarcoma Resection. Ann Plast Surg 2021; 86:S336-S341. [PMID: 33234885 DOI: 10.1097/sap.0000000000002592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Soft tissue sarcomas are a heterogenous group of malignant tumors that represent approximately 1% of adult malignancies. Although these tumors occur throughout the body, the majority involved the lower extremity. Management may involve amputation but more commonly often includes wide local resection by an oncologic surgeon and involvement of a plastic surgeon for reconstruction of larger and more complex defects. Postoperative wound complications are challenging for the surgeon and patient but also impact management of adjuvant chemotherapy and radiation therapy. To explore risk factors for wound complications, we reviewed our single-institution experience of lower-extremity soft tissue sarcomas from April 2009 to September 2016. We identified 127 patients for retrospective review and analysis. The proportion of patients with wound complications in the cohort was 43.3%. Most notably, compared with patients without wound complications, patients with wound complications had a higher proportion of immediate reconstruction (34.5% vs 15.3%; P = 0.05) and a marginally higher proportion who received neoadjuvant radiation (30.9% vs 16.7%; P = 0.06).
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Affiliation(s)
| | - Gene K Lee
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | - Roy P Yu
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | - Antoine Lyonel Carre
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Maxwell B Johnson
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Joseph N Carey
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Lawrence R Menendez
- Department of Orthopedic Surgery, Keck School of Medicine of USC, Los Angeles, CA
| | - Alex K Wong
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
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25
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Soft Tissue Reconstructions After Sarcoma Resection. Sarcoma 2021. [DOI: 10.1007/978-981-15-9414-4_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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26
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Farzaliyev F, Touma A, Taeger G, Steinau HU, Hardes J, Streitbürger A, Podleska LE. Efficacy of hyperthermic isolated limb perfusion in the treatment of locally recurrent high-grade soft tissue sarcoma of the extremities. World J Surg Oncol 2020; 18:332. [PMID: 33349267 PMCID: PMC7754588 DOI: 10.1186/s12957-020-02110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/08/2020] [Indexed: 11/23/2022] Open
Abstract
Background This novel study compared the use of tumor necrosis factor (TNF)-alpha and melphalan-based isolated limb perfusion (TM-ILP) to the standard treatment of locally recurrent soft tissue extremity sarcoma. The aim was to assess whether TM-ILP positively influences the recurrence-free survival of locally recurrent high-grade soft tissue sarcoma (STS) of the extremities. Methods We retrospectively analyzed our clinical database for patients with STS. Variables were analyzed using chi-square test or Mann-Whitney rank-sum test. Furthermore, Kaplan-Meier survival plots were calculated and a proportional hazard regression model was developed. Results Out of 448 patients with extraabdominal STS treated between August 2012 and December 2015, 52 cases involving 47 patients had locally recurrent STS. Twenty-eight of these patients were treated with TM-ILP prior to surgical resection (TM-ILP-group), and 24 were treated with standard therapy (without TM-ILP). The 3-year recurrence-free survival for the TM-ILP-group was estimated at 75% (95% confidence interval (CI), 71.5–78.5). Local recurrence-free survival in the standard group was significantly lower (LRFS: 43.4%, 95% CI 38.7–48.1, p = 0.026). Multivariable analysis revealed resection with negative margins, lower number of previous recurrences, and TM-ILP as positive predictors for recurrence-free survival. Conclusions TM-ILP and consecutive resection of residual tumor with negative resection margins significantly improves local recurrence-free survival for patients with a first local recurrence of high-grade STS in the extremities.
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Affiliation(s)
- Farhad Farzaliyev
- Department of General, Visceral and Transplantation Surgery, Division of Plastic and Reconstructive Surgery, University Hospital Essen, University Essen-Duisburg, Hufelandstr.55, 45147, Essen, Germany.
| | - Alexander Touma
- Department of General, Visceral and Transplantation Surgery, Division of Plastic and Reconstructive Surgery, University Hospital Essen, University Essen-Duisburg, Hufelandstr.55, 45147, Essen, Germany
| | - Georg Taeger
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
| | - Hans-Ulrich Steinau
- Department of General, Visceral and Transplantation Surgery, Division of Plastic and Reconstructive Surgery, University Hospital Essen, University Essen-Duisburg, Hufelandstr.55, 45147, Essen, Germany
| | - Jendrik Hardes
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
| | - Arne Streitbürger
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
| | - Lars Erik Podleska
- Department of Tumor Orthopedics and Sarcoma Surgery, University Hospital Essen, Essen, Germany
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27
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Nazemi AK, Bui DT, Oberly S, Khan FA. Hip disarticulation with pedicled total leg fillet flap for recurrent fungating sarcoma. J Orthop Surg (Hong Kong) 2020; 28:2309499020902539. [PMID: 32124672 DOI: 10.1177/2309499020902539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Soft tissue sarcomas may be treated with limb-sparing procedures in the majority of cases; however, certain cases involving significant tumor spread and fungation may call for amputation. In the thigh, hip disarticulation typically involves a pedicled gluteus maximus flap or a pedicled anterior quadriceps flap. In this case report, we describe a rare situation in which the anterior flap, posterior flap, and adductor flap musculature were contaminated with tumor; therefore, a hip disarticulation was performed applying a pedicled total leg fillet flap for closure. Eighteen months after treatment, the patient continues to have no local recurrence of disease, a stable flap site, and ambulates with a walker. We present this amputation and closure method as a potentially effective modality in treating extensive oncologic disease of the proximal lower extremity.
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Affiliation(s)
- Alireza K Nazemi
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Duc T Bui
- Department of Plastic and Reconstructive Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Susannah Oberly
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Fazel A Khan
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, NY, USA
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28
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Surgical resection, intraoperative radiotherapy and immediate plastic reconstruction: A good option for the treatment of distal extremity soft tissue sarcomas. Rep Pract Oncol Radiother 2020; 25:919-926. [PMID: 33088227 DOI: 10.1016/j.rpor.2020.09.008] [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] [Received: 05/18/2020] [Revised: 07/06/2020] [Accepted: 09/10/2020] [Indexed: 12/24/2022] Open
Abstract
Aim To show three patients with soft tissue sarcomas of distal extremities conservatively treated after tumor-board discussion, involving margin-free surgery, exclusive intraoperative radiotherapy, and immediate reconstruction. Background Current guidelines show clear and robust recommendations regarding the composition of the treatment of sarcomas of extremities. However, little evidence exists regarding the application of these treatments depending on the location of the primary neoplasia. Tumors that affect the distal extremities present different challenges and make multidisciplinary discussions desirable. Methods/Results We reported 3 patients who were approached with a conservative intention, after tumor board recomendation. The goals from the treatment performed were aesthetic and functional preservation, while enruring locoregional control. We had wound healing complications in 2 of the cases, requiring additional reconstruction measures. Patients are followed up for 24, 20 and 10 months; local control is 100%, and functional preservation is 100%. Conclusions Despite being a small series, it was sufficient to illustrate successful multidisciplinary planning, generating a therapeutic result with improved quality of life for patients who had an initial indication for extremity amputation.
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29
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Vassos N, Brunner M, Perrakis A, Göhl J, Grützmann R, Hohenberger W, Croner RS. Oncological outcome after hyperthermic isolated limb perfusion for primarily unresectable versus locally recurrent soft tissue sarcoma of extremities. Surg Oncol 2020; 35:162-168. [PMID: 32882523 DOI: 10.1016/j.suronc.2020.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/08/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The management of locally advanced extremity soft tissue sarcomas, particularly in terms of a limb salvage strategy, represents a challenge, especially in recurrent tumors. In the context of a patient-tailored multimodal therapy, hyperthermic isolated limb perfusion (ILP) is a promising limb-saving treatment option. We report the outcome of patients with primarily irresectable and locally recurrent soft tissue sarcoma (STS) treated by ILP. PATIENTS AND METHODS Data about patient demographics, clinical und histopathological characteristics, tumor response, morbidity and oncological outcome of all patients with STS, who underwent an ILP at our institution in a 10-year period, were retrospectively detected and analyzed. RESULTS The cohort comprised 30 patients. Two patients were treated with ILP for palliative tumor control, 13 patients because of a local recurrent soft tissue sarcoma (rSTS) and 15 patients because of primarily unresectable soft tissue sarcoma (puSTS). 25 of the 28 patients with curative intention received surgery after ILP (11 pts with rSTS and 14 pts with puSTS). Histopathologically we observed complete response in 6 patients (24%) and partial responses in 19 patients (76%) with a significant better remission in patients with puSTS (p = 0,043). Limb salvage rate was 75%. Mean follow-up was 69 months [range 13-142 months]. Seven (7/11; 64%) patients with rSTS and one (1/14; 7%) patient with puSTS developed local recurrence after ILP and surgery, whereas eight (8/13; 62%) rSTS patients and seven (7/15; 47%) puSTS patients developed distant metastasis. During follow-up, eight patients (28.5%) died of disease (5/13; 38%) rSTS and 3/15 (20%) puSTS. ILP in the group of previously irradiated sarcoma patients (n = 13) resulted in a limb salvage rate of 69% and was not associated in an increased risk for adverse events. DISCUSSION ILP for advanced extremity STS is a treatment option for both puSTS and rSTS resulting in good local control and should be considered in multimodal management. ILP is also a good option for patients after radiation history.
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Affiliation(s)
- N Vassos
- Division of Surgical Oncology and Thoracic Surgery, Department of Surgery, Mannheim University Medical Centre, University of Heidelberg, Mannheim, Germany; Department of Surgery, University Hospital Erlangen, Erlangen, Germany.
| | - M Brunner
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - A Perrakis
- Department of Surgery, University Hospital Magdeburg, Magdeburg, Germany
| | - J Göhl
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - R Grützmann
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - W Hohenberger
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - R S Croner
- Department of Surgery, University Hospital Magdeburg, Magdeburg, Germany
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30
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Chodyla M, Demircioglu A, Schaarschmidt BM, Bertram S, Bruckmann NM, Haferkamp J, Li Y, Bauer S, Podleska L, Rischpler C, Forsting M, Herrmann K, Umutlu L, Grueneisen J. Evaluation of 18F-FDG PET and DWI Datasets for Predicting Therapy Response of Soft-Tissue Sarcomas Under Neoadjuvant Isolated Limb Perfusion. J Nucl Med 2020; 62:348-353. [PMID: 32737246 DOI: 10.2967/jnumed.120.248260] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/26/2020] [Indexed: 01/16/2023] Open
Abstract
Our purpose was to evaluate and compare the clinical utility of simultaneously obtained quantitative 18F-FDG PET and diffusion-weighted MRI datasets for predicting the histopathologic response of soft-tissue sarcoma (STS) to neoadjuvant isolated limb perfusion (ILP). Methods: In total, 37 patients with a confirmed STS of the extremities underwent 18F-FDG PET/MRI before and after ILP with melphalan and tumor necrosis factor-α. For each patient, the maximum tumor size, metabolic activity (SUV), and diffusion restriction (apparent diffusion coefficient, ADC) were determined in pre- and posttherapeutic examinations, and percentage changes during treatment were calculated. Mann-Whitney U testing and receiver-operating-characteristic analysis were used to compare the results of the different quantitative parameters to predict the histopathologic response to therapy. Results from histopathologic analysis after tumor resection served as the reference standard, and patients were defined as responders or nonresponders based on the grading scale by Salzer-Kuntschik. Results: Histopathologic analysis categorized 22 (59%) patients as responders (grades I-III) and 15 (41%) as nonresponders (grades IV-VI). Under treatment, tumors in responders showed a mean reduction in size (-9.7%) and metabolic activity (SUVpeak, -51.9%; SUVmean, -43.8%), as well as an increase of the ADC values (ADCmin, +29.4%; ADCmean, +32.8%). The percentage changes in nonresponders were -6.2% in tumor size, -17.3% in SUVpeak, -13.9% in SUVmean, +15.3% in ADCmin, and +14.6% in ADCmean Changes in SUV and ADCmean significantly differed between responders and nonresponders (<0.01), whereas differences in tumor size and ADCmin did not (>0.05). The corresponding AUCs were 0.63 for tumor size, 0.87 for SUVpeak, 0.82 for SUVmean, 0.63 for ADCmin, 0.84 for ADCmean, and 0.89 for ratio of ADCmean to SUVpeak Conclusion: PET- and MRI-derived quantitative parameters (SUV and ADCmean) and their combination performed well in predicting the histopathologic therapy response of STS to neoadjuvant ILP. Therefore, integrated PET/MRI could serve as a valuable tool for pretherapeutic assessment as well as monitoring of neoadjuvant treatment strategies of STS.
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Affiliation(s)
- Michal Chodyla
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Aydin Demircioglu
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Benedikt M Schaarschmidt
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Stefanie Bertram
- Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nils Martin Bruckmann
- Department of Diagnostic and Interventional Radiology, University Hospital Dusseldorf, University of Dusseldorf, Dusseldorf, Germany
| | - Jennifer Haferkamp
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Yan Li
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sebastian Bauer
- Sarcoma Center, Western German Cancer Center, University of Duisburg-Essen, Essen, Germany
| | - Lars Podleska
- Sarcoma Surgery Division, Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; and
| | - Christoph Rischpler
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Michael Forsting
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Lale Umutlu
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Johannes Grueneisen
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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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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Abstract
Pediatric musculoskeletal tumors can arise in both bone and soft tissues. The overwhelming majority of these are benign; however, rarely, malignant neoplasms do occur. These are collectively termed sarcomas, indicating their mesenchymal origin. Sarcoma management requires careful adherence to the well-described tenets of tumor management. This article summarizes the basic principles and recent advances in the management of soft tissue and bone tumors.
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Affiliation(s)
- Amit Singla
- Department of Orthopaedic Surgery, Montefiore Medical Center, 3400 Bainbridge Avenue, 6th Floor, Bronx, NY 10467, USA.
| | - David S Geller
- Department of Orthopaedic Surgery, Montefiore Medical Center, 3400 Bainbridge Avenue, 6th Floor, Bronx, NY 10467, USA
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Zeller J, Kiefer J, Braig D, Winninger O, Dovi-Akue D, Herget GW, Stark GB, Eisenhardt SU. Efficacy and Safety of Microsurgery in Interdisciplinary Treatment of Sarcoma Affecting the Bone. Front Oncol 2019; 9:1300. [PMID: 31850204 PMCID: PMC6901986 DOI: 10.3389/fonc.2019.01300] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/11/2019] [Indexed: 01/08/2023] Open
Abstract
Background: Sarcomas are tumors of mesenchymal origin with high variation in anatomical localization. Sarcomas affecting the bone often require an interdisciplinary resection and reconstruction approach. However, it is critical that microsurgical reconstruction strategies do not negatively impact tumor safety and overall survival, as limb salvage is only the secondary goal of tumor surgery. Here, we analyzed the efficacy and safety of microsurgery in interdisciplinary treatment of sarcoma affecting the bone. Patients and Methods: We performed a retrospective chart review of all patients treated for soft-tissue and bone sarcoma at the senior author's institution with a focus on bone affection and microsurgical reconstruction between 2000 and 2019. This particular subgroup was further investigated for tumor resection status, 5-year survival rate, length of hospital stay, as well as overall complication and amputation rates. Results: Between 2000 and 2019, 803 patients were operated for sarcoma resection and reconstruction by the Department of Plastic and Hand Surgery. Of these, 212 patients presented with sarcoma of the extremity affecting the bone. Within this subgroup, 40 patients required microsurgical reconstruction for limb salvage, which was possible in 38 cases. R0 resection was achieved in 93.8%. The 5-year survival was 96.7%, and the overall complication rate was 25%, of which 40% were microsurgery associated complications. Conclusion: Safe and function-preserving treatment of soft-tissue and bone sarcoma is challenging. Primary reconstruction with microsurgical techniques of sarcoma-related defects enables limb-sparing and adequate oncosurgical cancer treatment without increasing the risk for local recurrence or prolonged hospital stay. The treatment of sarcoma patients should be reserved to high-volume centers with experienced plastic surgeon embedded in a comprehensive treatment concept.
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Affiliation(s)
- Johannes Zeller
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Jurij Kiefer
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - David Braig
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany.,Plastic and Reconstructive Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Oscar Winninger
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - David Dovi-Akue
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Georg W Herget
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - G B Stark
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany
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Risk factors for postoperative wound complications after extremity soft tissue sarcoma resection: A systematic review and meta-analyses. J Plast Reconstr Aesthet Surg 2019; 72:1449-1464. [DOI: 10.1016/j.bjps.2019.05.041] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/28/2019] [Accepted: 05/16/2019] [Indexed: 12/18/2022]
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Abstract
Tumour endoprostheses have facilitated limb-salvage procedures in primary bone and soft tissue sarcomas, and are increasingly being used in symptomatic metastases of the long bones. The objective of the present review was to analyse articles published over the last three years on tumour endoprostheses and to summarize current knowledge on this topic. The NCBI PubMed webpage was used to identify original articles published between January 2015 and April 2018 in journals with an impact factor in the top 25.9% of the respective category (orthopaedics, multidisciplinary sciences). The following search-terms were used: tumour endoprosthesis, advances tumour endoprosthesis, tumour megaprosthesis, prosthetic reconstruction AND tumour. We identified 347 original articles, of which 53 complied with the abovementioned criteria. Articles were categorized into (1) tumour endoprostheses in the shoulder girdle, (2) tumour endoprostheses in the proximal femur, (3) tumour endoprostheses of the knee region, (4) tumour endoprostheses in the pelvis, (5) (expandable) prostheses in children and (6) long-term results of tumour endoprostheses. The topics of interest covered by the selected studies largely matched with the main research questions stated at a consensus meeting, with survival outcome of orthopaedic implants being the most commonly raised research question. As many studies reported on the risk of deep infections, research in the future should also focus on potential preventive methods in endoprosthetic tumour reconstruction.
Cite this article: EFORT Open Rev 2019;4:445-459. DOI: 10.1302/2058-5241.4.180081
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Affiliation(s)
- Maria A Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Austria
| | - Dimosthenis Andreou
- Department of General Orthopaedics and Tumour Orthopaedics, University Hospital Muenster, Germany
| | - Per-Ulf Tunn
- Tumour Orthopaedics, HELIOS Klinikum Berlin-Buch, Germany
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Austria
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Shimatani A, Aono M, Hoshi M, Oebisu N, Iwai T, Takada N, Nakamura H. Two case reports of fair lower limb function after sciatic nerve sacrifice for the treatment of a malignant peripheral nerve sheath tumor. Int Cancer Conf J 2019; 7:137-141. [PMID: 31149533 DOI: 10.1007/s13691-018-0338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022] Open
Abstract
Wide resection for malignant soft tissue tumors may require resection of a major nerve. When a limb salvage procedure is selected in these cases, the anticipated functional outcome of the procedure must be clearly discussed with the patient, as recovery of normal function cannot be expected. In this report, we describe our surgical management of two cases of malignant peripheral nerve sheath tumor, a 58-year-old man and a 10-year-old girl, requiring a limb salvage procedure with sacrifice of the sciatic nerve. Although both patients required a short-leg brace for walking, because of a drop foot, both patients reported satisfactory functional results and were able to perform their activities of daily living with only slight difficulties. Based on our experience, limb salvage surgery can be considered for the treatment of malignancies involving the sciatic nerve, with fair functional outcomes expected.
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Affiliation(s)
- Akiyoshi Shimatani
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Masanari Aono
- 2Department of Orthopedic Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021 Japan
| | - Manabu Hoshi
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Naoto Oebisu
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Tadashi Iwai
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Naoki Takada
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
| | - Hiroaki Nakamura
- 1Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-ku, Osaka, 545-8585 Japan
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Grueneisen J, Schaarschmidt B, Demircioglu A, Chodyla M, Martin O, Bertram S, Wetter A, Bauer S, Fendler WP, Podleska L, Forsting M, Herrmann K, Umutlu L. 18F-FDG PET/MRI for Therapy Response Assessment of Isolated Limb Perfusion in Patients with Soft-Tissue Sarcomas. J Nucl Med 2019; 60:1537-1542. [DOI: 10.2967/jnumed.119.226761] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/13/2019] [Indexed: 12/15/2022] Open
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Erstad DJ. ASO Author Reflections: Amputation for Extremity Sarcoma. Ann Surg Oncol 2018; 26:548. [PMID: 30556115 DOI: 10.1245/s10434-018-7069-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Derek J Erstad
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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39
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Florou V, Nascimento AG, Gulia A, de Lima Lopes G. Global Health Perspective in Sarcomas and Other Rare Cancers. Am Soc Clin Oncol Educ Book 2018; 38:916-924. [PMID: 30231406 DOI: 10.1200/edbk_200589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Sarcomas, rare and heterogenous malignancies that comprise less than 1% of all cancers, have poor outcomes in the metastatic and refractory setting. Their management requires a multidisciplinary approach that consists of medical and surgical oncologists, radiation oncologists, and pathologists as well as ancillary support. In addition to systemic treatments, most patients will require surgical resection and radiation therapy, which mandates the use of the latest technologies and specialized expertise. Management guidelines have been developed in high-income countries, but their applicability in low-income countries, where resources may be limited, remains a challenge. In this article, we propose the best possible evidence-based practices specifically for income-constrained settings to overcome this challenge. In addition, we review the different methods that can be used in low-income countries to access new and expensive treatments, which often times carry prohibitive costs for these areas.
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Affiliation(s)
- Vaia Florou
- From the Sylvester Comprehensive Cancer Center at the University of Miami, Miami, FL; AC Camargo Cancer Center, Sao Paulo, Brazil; Tata Memorial Hospital, New Delhi, India
| | - Antonio G Nascimento
- From the Sylvester Comprehensive Cancer Center at the University of Miami, Miami, FL; AC Camargo Cancer Center, Sao Paulo, Brazil; Tata Memorial Hospital, New Delhi, India
| | - Ashish Gulia
- From the Sylvester Comprehensive Cancer Center at the University of Miami, Miami, FL; AC Camargo Cancer Center, Sao Paulo, Brazil; Tata Memorial Hospital, New Delhi, India
| | - Gilberto de Lima Lopes
- From the Sylvester Comprehensive Cancer Center at the University of Miami, Miami, FL; AC Camargo Cancer Center, Sao Paulo, Brazil; Tata Memorial Hospital, New Delhi, India
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40
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Milgrom DP, Sehdev A, Kays JK, Koniaris LG. Integrating therapies for surgical adult soft tissue sarcoma patients. Transl Gastroenterol Hepatol 2018; 3:88. [PMID: 30603724 PMCID: PMC6286915 DOI: 10.21037/tgh.2018.10.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 10/22/2018] [Indexed: 12/25/2022] Open
Abstract
Sarcomas are an uncommon group of over 50 different individual histological malignancies arising from mesenchymal (non-epithelial or connective) tissues. Overall, they constitute 1% of human malignancies with an annual incidence rate of fewer than 5 patients per million. Sarcoma may arise from any mesenchymal cell lineages including fat, muscle, or other connective tissues. Due to the rarity of these groups of malignancies, many subtypes were, and still today, are managed as a single entity. This review focused on soft tissue sarcomas with an emphasis on how to integrate therapies for patients with this rare disorder. The role for surgical resection in cure and palliation as well as the relative benefits of adjuvant therapies such as chemotherapy and radiation therapy are discussed.
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Affiliation(s)
- Daniel P. Milgrom
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Amikar Sehdev
- Division of Medical Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Joshua K. Kays
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Leonidas G. Koniaris
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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41
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Awad N, Lackman R, McMackin K, Kim TW, Lombardi J, Caputo F. Multidisciplinary Approach to Treatment of Soft Tissue Sarcomas Requiring Complex Oncologic Resections. Ann Vasc Surg 2018; 53:212-216. [DOI: 10.1016/j.avsg.2018.04.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 04/14/2018] [Accepted: 04/19/2018] [Indexed: 11/27/2022]
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Park D, Cho S, Han A, Choi C, Ahn S, Min SI, Ha J, Min SK. Outcomes after Arterial or Venous Reconstructions in Limb Salvage Surgery for Extremity Soft Tissue Sarcoma. J Korean Med Sci 2018; 33:e265. [PMID: 30275808 PMCID: PMC6159105 DOI: 10.3346/jkms.2018.33.e265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 06/04/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Limb salvage surgery with vascular reconstruction is currently considered as the standard treatment for extremity soft tissue sarcoma (STS), showing equivalent oncologic outcome compared with amputation. In this retrospective study, the surgical and functional outcomes after arterial or venous reconstruction in limb salvage surgery for STS were analyzed. METHODS Consecutive patients who underwent vascular resection and reconstruction as part of limb salvage surgery for extremity STS from July 2009 to June 2015 were included in this study. Incidence of surgical complication, graft patency, and patients' functional outcome were reviewed. RESULTS During the study period, 14 arteries and 13 veins were reconstructed in 17 patients (artery only in 4, vein only in 3, artery and vein in 10). Autologous great saphenous vein (GSV) was the most commonly used vascular conduit in both arterial and venous reconstruction (78.6% and 77.0%). The patency of synthetic graft was significantly lower than that of the autologous vein conduit (log rank test, P = 0.001). Among 15 patients with tumors in lower extremity, 13 were ambulatory after limb salvage surgery. During median follow up of 23.3 months (interquartile range 39.9 months), 2 patients (11.7%) needed amputation of the initially salvaged limb due to local recurrence. CONCLUSION Limb salvage surgery of soft tissue tumor combined with vascular reconstruction showed favorable functional outcome with good local control. Autologous vein conduit is preferred over synthetic graft both in arterial and venous reconstruction.
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Affiliation(s)
- Daedo Park
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sungsin Cho
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ahram Han
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chanjoong Choi
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sanghyun Ahn
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-il Min
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Jakob J, Smith HG, Wilkinson MJ, Pencavel T, Miah AB, Thomas JM, Tunn PU, Pilz LR, Strauss DC, Hohenberger P, Hayes AJ. Regional chemotherapy by isolated limb perfusion prior to surgery compared with surgery and post-operative radiotherapy for primary, locally advanced extremity sarcoma: a comparison of matched cohorts. Clin Sarcoma Res 2018; 8:12. [PMID: 29988594 PMCID: PMC6027577 DOI: 10.1186/s13569-018-0098-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 03/17/2018] [Indexed: 11/10/2022] Open
Abstract
Background Induction chemotherapy by isolated limb perfusion (ILP) with melphalan and tumour necrosis factor-α is an effective strategy to facilitate limb-conserving surgery in locally advanced extremity sarcoma. In a comparison of cohorts matched for grade, size and surgical resectability, we compared the outcome of patients undergoing induction ILP prior to limb-conserving surgery and selective post-operative radiotherapy with patients undergoing limb-conserving surgery and routine post-operative radiotherapy. Methods Patients with primary, grade 2/3 sarcomas of the lower limbs over 10 cm in size were identified from prospectively maintained databases at 3 centres. Patients treated at a UK centre underwent limb-conserving surgery and post-operative radiotherapy (Standard cohort). Patients at two German centres underwent induction ILP, limb-conserving surgery and selective post-operative radiotherapy (ILP cohort). Results The Standard cohort comprised 80 patients and the ILP cohort 44 patients. Both cohorts were closely matched in terms of tumour size, grade, histological subtype and surgical resectability. The median age was greater in the Standard vs the ILP cohort (60.5 years vs 56 years, p = 0.033). The median size was 13 cm in both cohorts. 5-year local-recurrence (ILP 12.2%, Standard 20.1%, p = 0.375) and distant metastases-free survival rates (ILP 49.6%, Standard 46.0% p = 0.821) did not differ significantly between cohorts. Fewer patients received post-operative radiotherapy in the ILP cohort compared with the Standard cohort (27% vs 82%, p < 0.001). Conclusion In comparative cohorts, the outcomes of patients undergoing induction ILP prior to surgery did not differ from those undergoing standard management, although induction ILP was associated with a reduced need for adjuvant radiation.
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Affiliation(s)
- Jens Jakob
- 1Department of Surgery, Division of Surgical Oncology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Henry G Smith
- 2Sarcoma Unit, Department of Academic Surgery, Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Michelle J Wilkinson
- 2Sarcoma Unit, Department of Academic Surgery, Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Tim Pencavel
- 2Sarcoma Unit, Department of Academic Surgery, Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Aisha B Miah
- 2Sarcoma Unit, Department of Academic Surgery, Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Joseph M Thomas
- 2Sarcoma Unit, Department of Academic Surgery, Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Per-Ulf Tunn
- 3Department of Orthopedic Oncology, Helios Klinikum Berlin-Buch, Sarcoma Center Berlin-Brandenburg, Berlin, Germany
| | - Lothar R Pilz
- 4Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Dirk C Strauss
- 2Sarcoma Unit, Department of Academic Surgery, Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | - Peter Hohenberger
- 5Department of Surgery, Division of Surgical Oncology and Thoracic Surgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Andrew J Hayes
- 2Sarcoma Unit, Department of Academic Surgery, Royal Marsden Hospital NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
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Limb-Salvage Surgery of Soft Tissue Sarcoma with Sciatic Nerve Involvement. Sarcoma 2018; 2018:6483579. [PMID: 29692655 PMCID: PMC5859890 DOI: 10.1155/2018/6483579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 02/08/2018] [Indexed: 12/20/2022] Open
Abstract
Background The surgical resection of soft tissue sarcomas (STS) with sciatic nerve involvement presents a significant surgical and oncological challenge. Current treatment strategies pursue a multimodal approach with the aim of limb preservation. We aim to evaluate the outcomes of limb-sparing surgery of STS in a patient cohort and to propose a classification for STS with sciatic nerve involvement. Methods Patients receiving limb-preserving resections for STS with sciatic nerve involvement between 01/2010 and 01/2017 were included. Clinical and oncological data were prospectively collected in a computerized database and retrospectively analyzed. Sciatic nerve involvement in STS was classified preoperatively as follows: type A for nerve encasement; type B for nerve contact; and type C for no nerve involvement. Results A total of 364 patients with STS were treated, of which 27 patients had STS with sciatic nerve involvement. Eight patients with type A tumors (29.6%) underwent sciatic nerve resection, and 19 patients with type B tumors (70.4%) received epineural dissections. Disease progression was observed in 8 patients (29.6%) with a local recurrence of 11.1% and distant metastasis in 29.6%. The type of nerve resection significantly influenced leg function but had no impact on disease recurrence or overall survival. Conclusion In a cohort of carefully selected patients with STS and sciatic nerve involvement, the extent of sciatic nerve resection had no significant impact on disease recurrence or survival. Precise classification of neural involvement may therefore be useful in selecting the appropriate degree of nerve resection, without compromising oncological outcome or unnecessarily sacrificing leg function.
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45
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Does an Algorithmic Approach to Using Brachytherapy and External Beam Radiation Result in Good Function, Local Control Rates, and Low Morbidity in Patients With Extremity Soft Tissue Sarcoma? Clin Orthop Relat Res 2018; 476:634-644. [PMID: 29443850 PMCID: PMC6260030 DOI: 10.1007/s11999.0000000000000079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND High-dose-rate brachytherapy (HDR-BT) and external-beam radiation therapy (EBRT) are two modalities used in the treatment of soft tissue sarcoma. Previous work at our institution showed early complications and outcomes for patients treated with HDR-BT, EBRT, or a combination of both radiation therapy modalities. As the general indications for each of these approaches to radiation therapy differ, it is important to evaluate the use of each in an algorithmic way, reflecting how they are used in contemporary practice at sites that use these treatments. QUESTION/PURPOSES: (1) To determine the proportions of intermediate- and long-term complications associated with the use of brachytherapy in the treatment of primary high-grade extremity soft tissue sarcomas; (2), to characterize the long-term morbidity of the three radiation treatment groups using the Radiation Therapy Oncology Group/ European Organization for Research and Treatment of Cancer (RTOG/EORTC) Late Radiation Morbidity Scoring Scheme; (3) to determine whether treatment with HDR-BT, EBRT, and HDR-BT+EBRT therapy, in combination with limb-salvage surgery, results in acceptable local control in this high-risk group of sarcomas. METHODS We retrospectively studied data from 171 patients with a diagnosis of high-grade extremity soft tissue sarcoma treated with limb-sparing surgery and radiation therapy between 1990 and 2012 at our institution, with a mean followup of 72 months. Of the 171 patients, 33 (20%) were treated with HDR-BT, 128 (75%) with EBRT, and 10 (6%) with HDR-BT+EBRT. We excluded 265 patients with soft tissue sarcomas owing to axial tumor location, previous radiation to the affected extremity, incomplete patient records, patients receiving primary amputation, recurrent tumors, pediatric patients, low- and intermediate-grade tumors, and rhabdoid histology. Fifteen patients (9%) were lost to followup for any reason including died of disease or other causes during the first 12 months postoperatively. This included four patients who received HDR-BT (12%), 11 who received EBRT (9%), and none who received HDR-BT+EBRT (0%) with less than 12 months followup. Determination of radiation therapy technique for each patient was individualized in a multidisciplinary forum of sarcoma specialists. Anticipated close or positive surgical margins and a low likelihood of complex soft tissue procedures were factors that encouraged use of brachytherapy, whereas the anticipated need for secondary procedures and/or soft tissue coverage encouraged use of EBRT alone. Combination therapy was used when the treatment volume exceeded the treatment field of the brachytherapy catheters or when the catheters were used to boost a close or positive surgical margin. Local recurrence, complications, and morbidity outcomes scores (RTOG) were calculated based on chart review. Between-group comparisons pertaining to the proportion of patients experiencing complications, morbidity outcomes scores, and local recurrence rates were not performed because of dissimilarities among the patients in each group at baseline. RESULTS The HDR-BT treatment group showed a high incidence of intermediate-term complications, with the three most common being: deep infection (33%, 11 of 33); dehiscence and delayed wound healing (24%, eight of 33); and seroma and hematoma (21%, seven of 33). The EBRT group showed a high incidence of intermediate- and long-term complications with the three most common being: chronic radiation dermatitis (35%, 45 of 128); fibrosis (27%, 35 of 128); and chronic pain and neuritis (13%, 16 of 128). The RTOG scores for each treatment group were: HDR-BT 0.8 ± SD 1.2; EBRT 1.9 ± 2.0; and HDR-BT+EBRT 1.7 ± 1.7. Overall, 142 of 169 (84%) patients were free from local recurrence: 27 (82%) in the HDR-BT group, 108 (86%) in the EBRT group, and seven (70%) in the combination therapy group. CONCLUSIONS In this single-institution study, an algorithmic approach to using HDR-BT and EBRT in the treatment of patients with high-grade soft tissue sarcomas can yield acceptable complication rates, good morbidity outcome scores, and a high degree of local control. Based on these results, we believe HDR-BT is best for patients with an anticipated close margin, a positive surgical margin, and for patients who are unlikely to receive a complex soft tissue procedure. Conversely, if a secondary procedure and/or soft tissue coverage are likely to be used, EBRT alone may be reasonable. Finally, combination therapy might be considered when the treatment volume exceeded the treatment field capacity for HDR-BT or when the catheters were used to boost a close or positive surgical margin. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Tringale KR, Pang J, Nguyen QT. Image-guided surgery in cancer: A strategy to reduce incidence of positive surgical margins. WILEY INTERDISCIPLINARY REVIEWS-SYSTEMS BIOLOGY AND MEDICINE 2018; 10:e1412. [PMID: 29474004 DOI: 10.1002/wsbm.1412] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/13/2017] [Accepted: 11/03/2017] [Indexed: 12/16/2022]
Abstract
Primary treatment for many solid cancers includes surgical excision or radiation therapy, with or without the use of adjuvant therapy. This can include the addition of radiation and chemotherapy after primary surgical therapy, or the addition of chemotherapy and salvage surgery to primary radiation therapy. Both primary therapies, surgery and radiation, require precise anatomic localization of tumor. If tumor is not targeted adequately with initial treatment, disease recurrence may ensue, and if targeting is too broad, unnecessary morbidity may occur to nearby structures or remaining normal tissue. Fluorescence imaging using intraoperative contrast agents is a rapidly growing field for improving visualization in cancer surgery to facilitate resection in order to obtain negative margins. There are multiple strategies for tumor visualization based on antibodies against surface markers or ligands for receptors preferentially expressed in cancer. In this article, we review the incidence and clinical implications of positive surgical margins for some of the most common solid tumors. Within this context, we present the ongoing clinical and preclinical studies focused on the use of intraoperative contrast agents to improve surgical margins. This article is categorized under: Laboratory Methods and Technologies > Imaging.
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Affiliation(s)
- Kathryn R Tringale
- Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California
| | - John Pang
- Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California
| | - Quyen T Nguyen
- Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California.,Department of Pharmacology, University of California, San Diego, La Jolla, California.,Moores Cancer Center, University of California, San Diego, La Jolla, California
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Harati K, Lehnhardt M. The changing paradigm of resection margins in sarcoma resection. Innov Surg Sci 2017; 2:165-170. [PMID: 31579750 PMCID: PMC6754025 DOI: 10.1515/iss-2017-0043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 11/15/2022] Open
Abstract
Soft tissue sarcomas (STS) are a heterogeneous group of rare mesenchymal tumors that account for approximately 1% of all adult malignancies. They can arise throughout the body due to their mesenchymal origin, although 60% of all STS occur in the extremities. Locally advanced STS can lead to significant functional morbidity and tend to local recurrences despite surgical resection. About 30% of all STS patients develop distant metastases with a median overall survival of less than 15 months. The treatment of choice in patients with localized disease is still surgical resection with negative margins. However, there has been a paradigm shift in the last few decades. Large retrospective analyses could not establish a strong association between radical resections and improved local control or survival. Previous radical concepts in STS surgery have been gradually replaced by more moderate approaches with function- and limb-sparing resections combined with radiotherapy. Here, the margin status appears to be of prognostic significance. However, several large retrospective analyses have presented inconsistent results, questioning the independent prognostic impact of surgical margins. This article reviews the literature critically, focusing on the changing role of surgical margins in STS surgery.
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Affiliation(s)
- Kamran Harati
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, Bochum, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG-University Hospital Bergmannsheil, Bochum, Germany
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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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Neuwirth MG, Song Y, Sinnamon AJ, Fraker DL, Zager JS, Karakousis GC. Isolated Limb Perfusion and Infusion for Extremity Soft Tissue Sarcoma: A Contemporary Systematic Review and Meta-Analysis. Ann Surg Oncol 2017; 24:3803-3810. [PMID: 29022281 DOI: 10.1245/s10434-017-6109-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Isolated limb perfusion (ILP) and isolated limb infusion (ILI) have been variably used in recent years for the treatment of locally advanced or marginally resectable extremity soft tissue sarcomas (STSs). We performed a systematic review and meta-analysis of contemporary studies to further characterize treatment patterns and outcomes. METHODS PubMed was queried for articles published in or after the year 2000, in the English language, with > 10 patients, and with adequate outcome data following ILP/ILI. Descriptive aggregate statistics were performed. RESULTS Nineteen studies that met the inclusion criteria were identified, with a total of 1288 patients. Weighted mean patient age was 55.9 years and 52% were male. The majority underwent ILP (88%) versus 12% for ILI, and chemotherapeutic regimens used were as follows: (1) melphalan with tumor necrosis factor (TNF)-α (78%), (2) melphalan ± actinomycin (10%), and (3) other regimens (12%). Most common histologies treated were malignant fibrous histiocytoma (21%), liposarcoma (16%), synovial (11%) and leiomyosarcoma (7%). Aggregate overall response rate (ORR) post-procedure was 73.3%, with 25.8% demonstrating a complete response (CR). Similar unadjusted ORRs were noted in the melphalan treatment groups with and without TNFα (72.0 and 67.0%, respectively; p = 0.27). Grade III toxicity was observed in 15.4% of patients, and grade IV/V toxicity was observed in 6.0% of patients. Overall limb salvage rate was 73.8% and median time to local (in-field) progression ranged from 4 to 28 months (weighted median 22.1 months). CONCLUSION ILP and ILI for extremity STS can be safely performed with appreciable response rates and significant limb salvage rates. Further study is needed to identify optimal treatment regimens by histology.
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Affiliation(s)
- Madalyn G Neuwirth
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew J Sinnamon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan S Zager
- Departments of Cutaneous Oncology and Sarcoma, Moffitt Cancer Center, Tampa, FL, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Eckert F, Braun LH, Traub F, Kopp HG, Sipos B, Lamprecht U, Müller AC, Paulsen F, Zips D. Radiotherapy and hyperthermia with curative intent in recurrent high risk soft tissue sarcomas. Int J Hyperthermia 2017; 34:980-987. [PMID: 28826283 DOI: 10.1080/02656736.2017.1369174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Radiotherapy before or after resection is one of the pillars of treatment for localised high risk soft tissue sarcomas. Treatment intensification has been described with concurrent chemotherapy and hyperthermia. The aim of this study is to assess local control after multimodal treatment, focussing on the treatment of local recurrences after surgery only. PATIENTS AND METHODS Of 42 patients treated in a prospective protocol with radiotherapy and hyperthermia, nine were treated for isolated local recurrences without metastatic spread. Most patients were treated with trimodal therapy including chemotherapy with ifosfamide and underwent resection whenever possible. Median follow-up was 1.4 years. RESULTS The treatment was well tolerated. Estimated disease free survival, distant metastases free survival and local control for the whole cohort after 1.5 years were 66, 73 and 88%, respectively. Neoadjuvant vs. adjuvant treatment influenced local control with a trend to statistical significance. Resection status did not influence local control. The cohort of patients treated for local recurrence after surgery alone had a significantly impaired local control compared to multimodal treatment at primary diagnosis (100 vs. 52%, p < 0.001). CONCLUSIONS With multimodal therapy including radiotherapy and hyperthermia local tumour control is achievable even in locally recurrent tumours. The clear-cut difference of the treatment of local recurrence in contrast to primary diagnosis might either reflect difficulties in diagnosis and treatment of local recurrences or biological aggressiveness of recurrent tumours. However, we recommend to consider multimodal treatment at primary diagnosis of high risk soft tissue sarcomas.
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Affiliation(s)
- Franziska Eckert
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Lore Helene Braun
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Frank Traub
- b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,c Department of Orthopaedic Surgery , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Hans-Georg Kopp
- b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,d Department of Medical Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Bence Sipos
- b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,e Institute for Pathology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Ulf Lamprecht
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Arndt-Christian Müller
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Frank Paulsen
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany.,b Center for Soft Tissue Sarcoma, GIST and bone tumors , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
| | - Daniel Zips
- a Department of Radiation Oncology , Eberhard-Karls-University Tuebingen , Tuebingen , Germany
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