The influence of anatomic location on functional outcome in lower-extremity soft-tissue sarcoma

Twenty-five years of experience with patient-reported outcome measures in soft-tissue sarcoma patients: a systematic review

PURPOSE

As the importance of the patient's perspective on treatment outcome is becoming increasingly clear, the availability of patient-reported outcome measures (PROMs) has grown accordingly. There remains insufficient information regarding the quality of PROMs in patients with soft-tissue sarcomas (STSs). The objectives of this systematic review were (1) to identify all PROMs used in STS patients and (2) to critically appraise the methodological quality of these PROMs.

METHODS

Literature searches were performed in MEDLINE and Embase on April 22, 2024. PROMs were identified by including all studies that evaluate (an aspect of) health-related quality of life in STS patients by using a PROM. Second, studies that assessed measurement properties of the PROMs utilized in STS patients were included. Quality of PROMs was evaluated by performing a COSMIN analysis.

RESULTS

In 59 studies, 39 PROMs were identified, with the Toronto Extremity Salvage Score (TESS) being the most frequently utilized. Three studies evaluated methodological quality of PROMs in the STS population. Measurement properties of the TESS, Quick Disability of the Arm, Shoulder and Hand (QuickDASH) and European Organization for Research and Treatment for Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) were reported. None of the PROMs utilized in the STS population can be recommended for use based on the current evidence and COSMIN analysis.

CONCLUSION

To ensure collection of reliable outcomes, PROMs require methodological evaluation prior to utilization in the STS population. Research should prioritize on determining relevant content and subsequently selecting the most suitable PROM for assessment.

Evaluation of clinical factors associated with early postoperative physical function and lower extremity functional impairment in patients with soft tissue sarcoma

PURPOSE

This study aimed to investigate the relationship between various clinical factors and physical function in the early postoperative period in patients with soft tissue sarcomas (STSs) by subjective and objective evaluations.

MATERIALS AND METHODS

The 90 patients enrolled in this study were classified into five groups according to tumor location: retroperitoneal, gluteal, groin, thigh, and lower leg. The Musculoskeletal Tumor Society (MSTS) score was evaluated at discharge; the timed up-and-go test (TUGT) was performed preoperatively and at discharge. Group comparisons by tumor location were performed. To identify significant factors associated with physical dysfunction, multivariate analysis was performed using an MSTS score of <80% and a change in pre and postoperative TUGT score.

RESULTS

There were no significant differences between the tumor location and physical function. The change in pre- and postoperative TUGT scores was significantly associated with an MSTS score of <80%. Quadriceps and tibialis anterior muscle resections were significantly associated with the change in pre- and post-operative TUGT scores.

CONCLUSIONS

The quadriceps and tibialis anterior muscles may affect physical dysfunction after surgery for STSs. Early postoperative rehabilitation should include the identification of resected muscles and functional improvement of residual muscles, possibly with orthotic support for knee extension and ankle dorsiflexion.

Factors associated with physical function in patients after surgery for soft tissue sarcoma in the thigh

PURPOSE

This study aimed to examine the validity of the timed up and go test (TUGT), which is a representative, objective, and functional assessment that can evaluate walking speed, strength, and balance, and determine the significant factors associated with physical dysfunction in the early postoperative period in patients with soft tissue sarcomas (STSs).

METHODS

This retrospective, single-center, observational study conducted at the National Cancer Center Hospital included 54 patients with STSs in the thigh who underwent surgery. The Musculoskeletal Tumor Society (MSTS) score, which subjectively evaluates the affected limb, was evaluated at discharge, and TUGT was performed preoperatively and at discharge. Higher scores indicated good limb function in the MSTS score and poor performance in the TUGT. Spearman's correlation analysis was performed to identify the relationship between the MSTS score and TUGT. A receiver operating characteristic curve was used to calculate the cut-off value of the change in pre- and postoperative TUGT for an MSTS score of ≥ 80%. To examine the significant factors associated with physical dysfunction, multivariate regression analysis was performed using the change in pre- and postoperative TUGT as the dependent variable.

RESULTS

Postoperative TUGT and the change in pre- and postoperative TUGT were significantly associated with the MSTS score. The cut-off value for the change in pre- and postoperative TUGT for acceptable affected lower-limb function was 3.7 s. Furthermore, quadriceps muscle resection was significantly associated with the change in pre- and postoperative TUGT in the early postoperative period.

CONCLUSIONS

TUGT could be a useful objective evaluation tool for postoperative patients with STSs. The cut-off value for the change in TUGT can be used to monitor postoperative recovery. If recovery is prolonged, a rehabilitation program can be designed according to the severity of the functional impairment in muscle strength, balance, or gait. In addition, sufficient information should be obtained regarding the presence or absence of quadriceps resection, which has a significant impact on postoperative performance.

Muscle strength and functional recovery for soft-tissue sarcoma of the thigh: a prospective study

BACKGROUND

This study aimed to investigate changes in muscle strength and functional outcome before and after surgery for soft-tissue sarcoma of the thigh and to examine the timing of recovery.

METHODS

From 2014 to 2019, 15 patients who underwent multiple resections of the thigh muscle for soft-tissue sarcoma of the thigh were included in this study. The muscle strength was measured with an isokinetic dynamometer for the knee joint and with a hand-held dynamometer for the hip joint. The functional outcome assessment was based on the Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D), and maximum walking speed (MWS). All measurements were conducted preoperatively and at 3, 6, 12, 18, and 24 months postoperatively, and the ratio of postoperative to preoperative value was used. A repeated-measures analysis of variance was performed to compare changes over time and to investigate the recovery plateau. Correlations between changes in muscle strength and functional outcomes were also examined.

RESULTS

The muscle strength of the affected limb, MSTS score, TESS, EQ-5D, and MWS were significantly decreased at 3 months postoperatively. The recovery plateau was subsequently reached at 12 months postoperatively. The changes in muscle strength of the affected limb and functional outcome showed a significant correlation.

CONCLUSIONS

The estimated postoperative recovery for soft-tissue sarcoma of the thigh is 12 months after surgery.

Venous Reconstruction in Extremity Soft Tissue Sarcoma Is Not Essential

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.

Functional outcomes after single quadriceps muscle resection in patients with soft tissue sarcoma of the anterior compartment of the thigh

BACKGROUND

Soft tissue sarcoma (STS) occurs most commonly in the anterior compartment of the thigh. Limb salvage surgery is the mainstay of treatment, however, resections frequently involve muscle sacrifice. This study determines the impact of a single quadriceps muscle sacrifice on daily living functions. This is to assist clinical decision-making relating to when a functional reconstruction should be offered over simple soft tissue coverage for these defects.

METHODS

Patients who underwent single quadriceps resection as part of the management of STS between 2010 and 2020 were selected. Three functional tests were performed: Time Up and Go (TUG), Timed Up and Down Stairs (TUDS) and Toronto Extremity Salvage Score (TESS). The results were compared with age/sex matched healthy reference values and literature cohorts of lower limb STS patients. Correlations between the tests and age and follow-up duration were determined by the Spearman's test.

RESULTS

The mean TESS, TUG and TUDS results of the 13 patients were 89.6%, 9.8 and 1.01 s/step, respectively. These scores were either similar or significantly better than the comparator values. The TESS score showed no statistical significance compared with patients with no muscle resection. TUG and TUDS scores showed significant positive correlation with each other (ρ = 0.885, P = <0.01) and with age (ρ = 0.646, P = 0.017 and ρ = 0.567, P = 0.043, respectively).

CONCLUSION

This is the largest documented case series of single quadriceps resection for STS. The study suggests that this group of patients does not show a functional deficit and therefore does not require functional reconstruction.

Personalized Surgical Planning for Soft Tissue Sarcoma of the Popliteal Fossa with a Novel 3D Imaging Technique

OBJECTIVE

Soft tissue sarcomas (STSs) arising from the popliteal fossa pose surgical challenges due to their proximity to critical neurovascular structures. This study aimed to investigate whether a novel 3D imaging technique highlighting these key anatomical structures could facilitate preoperative planning and improve surgical outcomes in STS.

METHODS

This was a prospective, observational, pilot study. Between November 2019 and December 2020, 27 patients with STS of the popliteal fossa undergoing limb-sparing procedures were enrolled and assigned to either a control or intervention group. Control patients underwent traditional preoperative planning with separate computed tomography angiography, magnetic resonance imaging, and magnetic resonance hydrography. In the intervention group, 3D images were generated from these images, the tumor and skeletomuscular and neurovascular structures were revealed in three dimensions, and this was visualized on the surgeon's smartphone or computer. Primary endpoints were surgical margins and complications. Secondary endpoints included operative time, blood loss, serum C-reactive protein and interleukin-6, length of in-hospital stay, and limb function. Comparisons between groups were made using independent-sample t-tests for continuous data and the Mann-Whitney U and Fisher's exact tests for categorical data.

RESULTS

There was a lower but not significantly different inadvertent positive margin rate (1/15 vs. 3/12, P = 0.294), significantly shorter hospital stay (P = 0.049), and less numbers ≥75th percentile of operative time (P = 0.037) and blood loss (P = 0.024) in the intervention group. Differences in surgical complications, operative time, blood loss, C-reactive protein and interleukin-6 levels on the second postoperative day, and limb functional scores were statistically insignificant.

CONCLUSIONS

The novel 3D imaging technique facilitates complex preoperative planning and limb-salvage surgical procedures for patients with STS of the popliteal fossa, and this may affect how surgical planning is performed in the future.

Influence of the adductor compartment resection on muscle strength and postoperative function in soft-tissue sarcoma of the thigh

OBJECTIVE

To predict the muscle strength and postoperative function for soft-tissue sarcoma arising from the adductor compartment of the thigh.

METHODS

Between 2003 and 2019, 17 cases that underwent resection of the adductor muscle group (adductor longus, adductor magnus, adductor brevis, gracilis and pectineus) for soft-tissue sarcoma in the adductor compartment of the thigh were included. The muscle strength was measured with an isokinetic dynamometer for the knee joint and with a hand-held dynamometer for the hip joint (ratio of affected to unaffected side). The Musculoskeletal Tumor Society score, Toronto Extremity Salvage Score, European Quality of Life-5 Dimensions and maximum walking speed were used to assess postoperative function and examine correlations with muscle strength.

RESULTS

In 13 cases that underwent an isolated resection of the adductor compartment, reduced adduction strength correlated with increased number of resected muscles in the adductor muscle group (P < 0.001). Postoperative function was maintained, showing no correlations with adduction strength. In four cases that underwent combined resections of other compartments, a decrease was observed in adduction strength as well as the muscle strength of other resected muscles, in addition to a decline in postoperative function. In the 4 or 5 adductor muscle resection group, the comparison between isolated and combined resection revealed comparable results for adduction strength but a significant decrease in postoperative function for the combined resection group.

CONCLUSIONS

Postoperative function can be preserved for isolated adductor compartment resection. Combined resections of multiple muscles in other compartments and most adductor muscles may result in decreased postoperative function.

Neoplastic Elbow Diseases and Mimickers

Tumors around the elbow are infrequent, and delayed diagnosis is a common theme because of the low incidence and lack of familiarity. However, just like any other site, the radiologic work-up of musculoskeletal tumors around the elbow remains the same, with plain films the first investigation in a patient with a suspected bone tumor and ultrasound the first modality to evaluate a soft tissue lump. The management of both bone and soft tissue tumors around the elbow is unique because of a large number of important structures in an anatomically confined space and little normal tissue to spare without severely compromising the joint's function. Many benign nonneoplastic entities can mimic bone and soft tissue tumors on imaging. It is important to keep the characteristic imaging appearance in mind while formulating a differential diagnosis to avoid an unnecessary additional work-up. This article reviews the most common benign and malignant bone and soft tissue tumors around the elbow, mimickers, imaging features, and current therapeutic concepts.

PROMIS scores of patients undergoing neoadjuvant and adjuvant radiation therapy for surgically excised soft tissue sarcoma

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First to evaluate PROMIS for patients undergoing radiotherapy and surgery for sarcoma.

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Patients exhibited meaningful change in PROMIS scores throughout the treatment.

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Analyses show PROMIS scores were similar between pre- and post-operative radiotherapy.

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Wound complications were associated with increases in anxiety and decreases in function.

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These data should be considered when selecting ideal therapy.

Introduction

Few recent studies have examined patient reported outcomes (PROs) during pre- or post-operative radiation therapy (RT) for soft tissue sarcoma (STS), and none have used PROMIS. This study aims to examine PROMIS scores across peri-operative time points for patients receiving pre- or post-operative RT.

Methods

Anxiety, depression, pain interference, and physical function PROMIS domains were collected at the pre-operative (1), immediate post-operative (2), and post-treatment completion (3) timepoints for patients undergoing surgery and either pre-operative or post-operative RT. Median scores were compared between groups using the Kruskal-Wallis test. The reliable change index was used to determine minimum important change in PROMIS scores and to compare scores between timepoints.

Results

95 patients were included (19 pre-operative, 76 post-operative). Both groups had significant decreases in function during treatment. Patients with wound complications were more likely to have significant increases in anxiety (36.4% vs. 8.3%; p = 0.020) and decreases in physical function (57.1% vs. 16.2%; p = 0.011) independent of RT timing.

Conclusions

This study demonstrates minimum significant change thresholds to detect PROMIS changes in STS patients undergoing pre- and post-operative radiotherapy. As expected, more patients with pre-operative RT than post-operative RT had wound complications (p = 0.06), but patients with complications in both groups had worse anxiety and function at the completion of treatment compared with those that did not. The association of wound complications with worse anxiety and physical function at completion of treatment should be considered when making individualized treatment recommendations regarding the timing of RT.

Unravelling the heterogeneity of soft tissue and bone sarcoma patients' health-related quality of life: a systematic literature review with focus on tumour location

Patients with sarcoma experience many physical and psychological symptoms, adversely affecting their health-related quality of life (HRQoL). HRQoL assessment is challenging due to the diversity of the disease. This review aims to unravel the heterogeneity of HRQoL of patients with sarcoma with regard to tumour location and to summarise the used measures in research. English-language literature from four databases published between January 2000 and April 2019 was reviewed. Studies that described adult sarcoma HRQoL outcomes were included and classified according to primary sarcoma location. Eighty-seven articles met the inclusion criteria covering sarcoma of the extremities (n=35), pelvis and axial skeleton (n=9), pelvis and extremities (n=5), head and neck (n=4), retroperitoneum (n=2) and multiple sarcoma locations (n=33), respectively. Urogenital and thoracic sarcoma were lacking. Fifty-four different questionnaires were used, most often cancer-generic or generic HRQoL questionnaires. Patients with sarcoma reported lower HRQoL than the general population. Distinctive patterns of HRQoL outcomes according to tumour location regarding symptoms, physical functioning, disability and psychosocial well-being were identified. In metastatic sarcoma, mostly constitutional symptoms were present. To comprehensively assess HRQoL, a sarcoma-specific measurement strategy should be developed and used covering the heterogeneity of sarcoma including location-specific issues to improve personalised HRQoL assessment in future research and clinical practice.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The need for improved patient reported outcome measures in patients with extremity sarcoma: A narrative review

BACKGROUND

Extremity sarcoma causes impairments to functionality and quality of life. Patient-reported outcome measures (PROMS) assess patient perspectives relating to domains of health and quality of life.

METHODS

To describe PROMs utilised in extremity sarcoma, the available literature was screened for studies that utilised PROMs to evaluate outcomes in extremity sarcoma following surgery.

RESULTS

Seventy articles met eligibility criteria; six PROMs were identified. The Toronto Extremity Salvage Score, The Short-Form 36, The EORTC QLQ-C30, The Disabilities of the Arm, Shoulder and Hand questionnaire, the Reintegration to Normal Living index and the Patient-Reported Outcomes Measurement Information System. Most sarcoma patients score well in these tools, with bone sarcoma, and extent of resection being predictors of poor outcomes.

CONCLUSION

TESS is the only sarcoma-specific PROM, and though a valid assessment of functionality, it has difficulty differentiating patients with minor functional impairments. The absence of a disease-specific measure of health is concerning, as generic tools do not account for the unique experiences sarcoma patients face and may impair their accuracy in analysing intervention effectiveness.

Osteofibrous dysplasia and adamantinoma: A summary of diagnostic challenges and surgical techniques

Osteofibrous dysplasia is an indolent benign fibro-osseous tumor, while adamantinoma is a locally aggressive biphasic malignancy with epithelial and fibro-osseous components. Predominantly arising in the tibial diaphysis of children and young adults, both tumors are resistant to chemotherapy and radiation. Wide surgical resection is regarded as the mainstay of therapy for adamantinoma, and limb-salvage reconstructive procedures can achieve good functional outcomes, albeit with non-negligible rates of complications. This review discusses emerging advances in the pathogenesis, histogenesis, and diagnosis of these entities and presents advantages and limitations of the most common surgical techniques used for their management.

Excision and Reconstruction of Alveolar Rhabdomyosarcoma Involving the Achilles Tendon in a Pediatric Patient: A Case Report

CASE

We describe a case of a 9-year-old boy who presented with a left calf mass consistent with alveolar rhabdomyosarcoma involving the Achilles tendon. The patient underwent radical resection of the Achilles tendon and Achilles tendon allograft reconstruction. At 2.5-year follow-up, the child had full ankle range of motion and strength and no signs of disease.

CONCLUSIONS

Radical resection of Achilles tendon in the setting of malignancy and reconstruction with allograft is a rare procedure that has not been previously described in the pediatric population. Orthopaedic oncologists can consider this option for the rare malignancies involving the Achilles tendon.

Soft Tissue Sarcoma of Lower Extremity: Functional Outcome and Quality of Life

Background

Few studies have focused on patient-related factors in analyzing long-term functional outcome and health-related quality of life (HRQoL) in patients with postoperative lower extremity soft tissue sarcoma (STS).

Objective

The purpose of this study was to investigate factors associated with postoperative functional outcome and HRQoL in patients with lower extremity STS.

Methods

This cross-sectional study was performed in a tertiary referral center using the Toronto Extremity Salvage Score (TESS), Quality-of-Life Questionnaire (QLQ)-C30 and 15 Dimension (15D) measures. Functional outcome and HRQoL data were collected prospectively. All patients were treated by a multidisciplinary team according to a written treatment protocol.

Results

A total of 141 patients who had undergone limb-salvage surgery were included. Depending on the outcome measure used, 19–51% of patients were completely asymptomatic and 13–14% of patients had an unimpaired HRQoL. The mean score for TESS, 15D mobility score, and QLQ-C30 Physical Functioning scale were 86, 0.83, and 75, respectively, while the mean score for 15D was 0.88, and 73 for QLQ-C30 QoL. Lower functional outcome was statistically significantly associated with higher age, higher body mass index (BMI), and the need for reconstructive surgery and radiotherapy, while lower HRQoL was statistically significantly associated with higher age, higher BMI, and reconstructive surgery.

Conclusion

Functional outcome and HRQoL were generally high in this cross-sectional study of patients with STS in the lower extremity. Both tumor- and treatment-related factors had an impact but patient-related factors such as age and BMI were the major determinants of both functional outcome and HRQoL.

Supplementary Information

The online version of this article (10.1245/s10434-021-09774-6) contains supplementary material, which is available to authorized users.

Microvascular tissue transfer after the resection of soft tissue sarcomas

BACKGROUND

Microvascular tissue transfer enables the oncological resection of soft tissue sarcomas of the extremities and the trunk by covering the resulting tissue defects that are often extensive. This study was performed to investigate the long-term survival and functional outcome of patients treated with free flaps after sarcoma resection.

METHODS

A total of 78 sarcoma patients received microvascular tissue transfer in our institution between March 2003 and January 2013. In a retrospective analysis, we investigated data such as tumor characteristics as well as survival time and disease-free survival. In a prospective analysis, we assessed the functional outcome and the health-associated quality of life with the TESS and SF-36 questionnaire, respectively.

RESULTS

Seventy patients qualified for disease-free survival after tumor resection, 41 patients remained disease free for over 5 years. Forty-five patients reached a survival time of more than 5 years. The functional results experienced by our patients were good with a mean score of 82.6% in the TESS. The physical health-related quality was lower than in the German norm sample and patients suffering from chronical illnesses or cancer, whereas the mental health was only slightly lower than in the norm sample and higher than in the groups with chronic illnesses or cancer (SF-36).

CONCLUSION

Microvascular tissue transfer enables tumor resection and limb salvage through the coverage of the resulting defects without impairing patients' prognosis. The long survival times after tumor resection emphasizes the need for good functional results as well as quality of life.

Complications after thigh sarcoma resection

BACKGROUND AND OBJECTIVES

Standard treatment for extremity sarcoma is limb-sparing surgery often with radiation, but complications occur frequently. We sought to determine factors predictive of wound complications after thigh sarcoma resection and reconstruction while analyzing trends over time.

METHODS

We reviewed all thigh defects requiring plastic surgeon reconstruction following sarcoma resection at our institution from 1997 to 2014. Patient demographics, comorbidities, operative characteristics, multi-modality therapies, and complications were analyzed. Wound complications were: infection, dehiscence, seroma, hematoma, or partial/total flap loss.

RESULTS

There were 159 thigh reconstructions followed for 30 months on average. Eighty-seven percent of patients underwent radiation and 42% had chemotherapy. Almost half (49.1%) had a complication. The most common wound complication was surgical site infection (23.3%) followed by dehiscence (19.5%), and seroma (10.7%). Less common were partial (2.5%) or total flap loss (0.6%). Reoperation was required in 21 patients (13.2%). Tobacco use, older patient age, cardiac disease, and higher body mass index were independently associated with wound complications. Complications trended towards decreasing over time, but this was not statistically significant.

CONCLUSIONS

Tobacco use, cardiac disease, and higher body mass index, but not the timing of reconstruction, appear to increase the risk of wound complications after thigh soft tissue sarcomas resection and plastic surgery reconstruction.

A systematic review of functional outcomes after nerve reconstruction in extremity soft tissue sarcomas: A need for general implementation in the armamentarium

Resection of nerves in extremity soft tissue sarcomas (STS) can lead to large functional deficits. Nerve reconstructions are rarely performed and little is known on their outcomes and indications for their use, even though they are essential in restoring sensation in limb salvage procedures. This study investigated current knowledge on functional outcomes and considerations to be taken before performing such reconstructions after sarcoma resection. A systematic search was performed in July 2018 in PubMed and Embase databases according to PRISMA guidelines. Search terms related to "soft tissue sarcoma" and "nerve reconstruction" were used. Studies evaluating functional outcomes after nerve grafting or nerve transfers in extremity STS were included. Qualitative synthesis was performed on all studies. Nineteen studies were included after full-text screening, describing 26 patients. The majority of patients had a nerve reconstruction in the upper extremity (65%). Perioperative radiotherapy was administered in 67% and perioperative chemotherapy in 29% of patients. Nerve grafting was most commonly performed (n = 23) and nerve transfers were performed in six patients. A wide variety of outcome measures were used. Most patients recovered at least some motor function and sensation, but success rates were higher after upper than lower extremity defects. Multimodal treatment did not preclude successful reconstructions. Nerve reconstructions in extremity STS allow the restoration of sensation in limb salvation, even motor nerve function can be restored with satisfactory function. The use of multimodal therapy does not seem to interfere with success. Nerve reconstructions should therefore be considered in STS patients.

Functional and oncological outcomes of limb-salvage surgery for foot and ankle tumors

BACKGROUND

Limb-salvage surgery has become the backbone treatment for musculoskeletal tumors in the last decades. However, limb-salvage with safe margins for tumors of the foot and ankle is challenging, due to the complex anatomy of this region. This study aimed to evaluate functional and oncological outcomes, complications, and local recurrence of limb-salvage procedures for tumors of the foot and ankle.

METHODS

This study was a retrospective review of 18 patients with primary tumors of the foot and ankle who underwent limb-salvage surgery between 1996 and 2015, with a minimum follow-up of 2 years. Clinical presentations, radiological and histopathological investigations, surgical procedures, functional and oncological outcomes, complications and local recurrences were analyzed. The Musculoskeletal Tumor Society (MSTS) scoring system was utilized for evaluation of the functional outcome.

RESULTS

With a mean follow-up period of 44.2 months, 7 males and 11 females with a mean age of 29.2 years were included. Nine patients were presented as recurrent cases. The most common location was forefoot in 7 patients. Synovial sarcoma was the histopathologic diagnosis in 7 patients. The final surgical margins were wide in 15 patients, wide-contaminated in one patient, and marginal in two patients. After resection, soft tissue reconstruction and wound coverage were done by soft tissue flaps in 4 patients. The mean MSTS score was 27.5. Four patients developed local recurrence, all of them were recurrent cases.

CONCLUSION

Limb-salvage surgery for foot and ankle tumors is an effective treatment option with good functional outcome.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Functional Outcome Measurement in Patients with Lower-Extremity Soft Tissue Sarcoma: A Systematic Literature Review

Background

The importance of functional outcome (FO) in the treatment of patients with extremity soft tissue sarcoma (STS) has been increasingly recognized in the last three decades. This systematic review aimed to investigate how FO is measured in surgically treated lower-extremity STS patients.

Methods

A systematic search of PubMed, Web of Science, and Scopus was performed based on the PRISMA guidelines. The methodologic quality of the publications was measured using the MINORS tool. The results from the included studies examining measurement types, measures, and time of FO measurement were compiled. The FO pooled mean and standard deviation were calculated as a weighted average for the groups. The validity of the applied measures is reported.

Results

The literature search found 3461 publications, 37 of which met the inclusion criteria. The measurement types used were clinician-reported outcomes (n = 27), patient-reported outcomes (n = 20), and observer-reported outcomes (n = 2). The most frequently used measures were the Toronto Extremity Salvage Score (TESS) (n = 16) and the Musculoskeletal Tumor Society (MSTS) score 1993 (n = 12). The postoperative FO was relatively good. The pooled mean TESS and MSTS 1993 scores were respectively 83.3 and 86.2 (out of 100). Of the 10 previously reported measures, 3 provide validated FO scores. The methodologic quality of publications was generally low.

Conclusions

Based on this systematic review, several different methods exist for assessing FO in patients with lower-extremity sarcoma. The most frequently used measure is a validated TESS. The postoperative FO of patients with lower-extremity STS seems to increase to the preoperative baseline level during long-term follow-up evaluation.

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

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

Using the Barthel Index to Assess Activities of Daily Living after Musculoskeletal Tumour Surgery: A Single-centre Observational Study

Objective

The objective of the current study was to find the factors affecting the activities of daily living, as evaluated by the Barthel Index, at the end of rehabilitation after musculoskeletal tumour surgery. Further, we evaluated whether the Barthel Index correlates with functional scores that are specific to musculoskeletal tumours at final follow-up.

Methods

The activities of daily living of 190 patients who underwent postoperative rehabilitation after surgery to treat musculoskeletal tumours were evaluated at the end of the program using the Barthel Index. Functional evaluation at the time of final follow-up observation was evaluated using the Musculoskeletal Tumour Society Score and the Toronto Extremity Salvage Score.

Results

The post-rehabilitation Barthel Index was significantly lower in elderly patients aged more than 60 years and in those with malignant tumours and tumours larger than 10 cm. Malignancy and large tumour size were risk factors for a low Barthel Index. There was significant correlation between the Musculoskeletal Tumour Society Score/Toronto Extremity Salvage Score at final functional evaluation and the Barthel Index at the end of rehabilitation.

Conclusion

The Barthel Index is a simple method to assess the activities of daily living and can potentially predict disease-specific health-related quality of life at final functional evaluation after musculoskeletal tumour surgery.

A Longitudinal Study of Functional Outcomes in Patients with Limb Salvage Surgery for Soft Tissue Sarcoma

Background

Many studies have reported on the surgical outcomes of soft tissue sarcoma. However, there was no longitudinal cohort study. Because time is the most valuable factor for functional recovery, adjusting time value was the key for finding the causal relationship between other risk factors and postoperative function. Therefore, existing cross-sectional studies can neither fully explain the causal relationship between the risk factors and the functional score nor predict functional recovery. The aim of this study was to determine important predictive factors that affect postoperative functional outcomes and longitudinal changes in functional outcomes in patients who had undergone limb-sparing surgery (LSS) for soft tissue sarcoma (STS).

Methods

Between January 2008 and December 2014, we retrospectively enrolled 150 patients who had undergone LSS for STS and had been assessed for postoperative functional outcomes with questionnaires. To evaluate functional outcomes, we used the Musculoskeletal Tumor Society (MSTS) score and Toronto Extremity Salvage Score (TESS). Multivariate generalized estimating equation (GEE) analysis was used to identify the predictive factors, including size, stage, and anatomic location of tumor, bone resection, flap reconstruction, age, and time after surgery. Each continuous variable such as age and time after surgery was explored for statistically significant cutoff points using the Wilcoxon rank sum test.

Results

Functional scores significantly improved until the second year after surgery and plateaued for the rest of the 5-year period. Age (p < 0.0001), bone resection (p=0.0004), and time after surgery (p < 0.0001) were identified as significant predictive factors. The functional score was significantly higher in patients younger than 47 years old.

Conclusions

Functional outcomes can improve until the second year after surgery. Patients who were older than 47 and underwent bone resection may have poor final functional outcomes.

Prediction of muscle strength and postoperative function after knee flexor muscle resection for soft tissue sarcoma of the lower limbs

INTRODUCTION

Oncological margins and prognosis are the most important factors for operative planning of soft tissue sarcomas, but prediction of postoperative function is also necessary. The purpose of this study was to predict the knee flexion strength and postoperative function after knee flexor muscle resection for soft tissue sarcoma of the lower limbs.

MATERIALS AND METHODS

Seventeen patients underwent knee flexor muscle resection for soft tissue sarcoma of the lower limbs between 1991 and 2015. The type of resected muscles was surveyed, knee flexion strength (ratio of affected to unaffected side) was evaluated using the Biodex System isokinetic dynamometer, and differences between the type of resected muscles were examined. The Musculoskeletal Tumor Society (MSTS) score, Toronto Extremity Salvage Score (TESS), European Quality of Life-5 Dimensions (EQ-5D), and Short Form 8 (SF-8) were used to assess postoperative function and examine correlations with flexion strength. The cutoff value for flexion strength to predict good postoperative results was calculated by a receiver operating characteristic (ROC) curve and Fisher's exact test.

RESULTS

Median flexion strength decreased in the resection of sartorius (97.8%), gracilis (95.4%), gastrocnemius (85.2%; interquartile range (IQR): 85.0-86.2), medial hamstrings (semimembranosus and semitendinosus, 76.2%; IQR: 73.3-78.0), lateral hamstrings (long and short head of biceps femoris, 66.1%; IQR: 65.9-70.4), and bilateral hamstrings (27.3%; IQR: 26.6-31.5). A significant difference was observed between lateral and bilateral hamstrings resection (P=0.049). Flexion strength was associated with lower functional scales (MSTS score, P=0.021; TESS, P=0.008; EQ-5D, P=0.034). Satisfactory function was obtained at a flexion strength cutoff value of 65.7%, and strength remained above the cutoff value up to unilateral hamstrings resection.

DISCUSSION

Greater knee flexor muscles resection can result in functional deficits that are associated with decreased flexion strength. If continuity of unilateral hamstrings is maintained, good postoperative results can be expected.

LEVEL OF EVIDENCE

IV, retrospective study.

Reconstructive Surgery in Soft Tissue Sarcomas—Long-Term Outcome and Quality of Life

The long-term oncological and functional outcome including quality of life should be evaluated in soft tissue sarcomas (STS). The need for reconstructive surgery with possible influence on the results should also be analyzed. Tumor stage mainly influences the prognosis of STS. Advances in reconstructive surgery mostly allow limb salvage. Limited information exists about functional outcome and life quality. A total of 86 patients (51 men, 35 women, mean age 50.5 years) with a minimum follow-up of 10 years were analyzed. We determined the oncological outcome (local recurrences, metastases, overall survival) of tumors at varying stages: stage I (n = 30), stage II (n = 52), and stage III (n = 4). Functional outcome and quality of life of the survivors were measured using the Musculoskeletal Tumor Society (MSTS) criteria and the EORTC-QLQ-C-30 (European Organisation for Research and Treatment of Cancer-Quality of Life-Questionnaire-Core-30 module) questionnaire. Tumor stage influenced the survival and the development of metastases. Survival rates were 89.5 and 88% after 5 and 10 years in stage I, and 56.5 and 49% in stage II tumors. Surgical margin influenced the development of local recurrence. Reconstructive procedures were necessary in 27 patients. After a median follow-up of 144 months, 36 patients were dead: 29 of their malignancy and 7 of other diseases. Fifty long-term survivors presented good results for MSTS (mean score: 82.4) and EORTC-QLQ-C-30 (mean score: 79.8), the results were independent on the need of reconstructive surgery. In stage II STS, the survival drops even after 5 years. The surgical treatment of STS requires the knowledge of different reconstructive techniques; functional results and quality of life are not compromised by the need for reconstructive surgery.

Management of soft-tissue sarcomas; treatment strategies, staging, and outcomes

Soft-tissue sarcomas (STS) are a rare group of malignant tumors which can affect any age group. For the majority of patients who present with a localized STS, treatment involves a multidisciplinary team decision-making approach ultimately relying on surgical resection with or without adjuvant radiation for successful limb salvage. The goals of treatment are to provide the patient with a functional extremity without local tumor relapse. The purpose of this article is to review the treatment of extremity STS, with a focus on staging, treatment options, and outcomes.

Factors associated with reduced functional outcome and quality of life in patients having limb-sparing surgery for soft tissue sarcomas - a national multicenter study of 128 patients

BACKGROUND

Limb-sparing surgery for sarcomas has become possible in most cases. However, the impact of the procedure on the functional outcome has only been investigated in a few studies. The aim of this study has been to identify tumor- and patient-related factors associated with reduced functional outcome and quality of life after limb-sparing surgery in soft tissue sarcoma patients.

MATERIAL AND METHODS

In total, 128 patients (mean age = 58, female/male = 54/74) who were treated with limb-sparing surgery without bone resection for soft tissue sarcomas in Denmark during the period 1 January 2009 to 31 December 2011 were included. Patients were asked to participate at least one year after surgery, and patients who had experienced local recurrence or metastatic disease were excluded. The Toronto Extremity Salvage Score (TESS) measured functional disability, while the Musculoskeletal Tumor Society Score (MSTS) measured functional impairment. European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 measured quality of life. Tumor- and patient-related factors (age, gender, tumor depth, tumor size, malignancy, comorbidity, location, and radiotherapy) were extracted from the Danish National Sarcoma Database. Wilcoxon rank-sum test and Kruskal-Wallis were used for univariable analysis. Adjusted odds ratios were estimated by using multiple logistic regression models.

RESULTS

In the multiple regression analysis, it was found that female gender (p = 0.03), lower extremity tumors (p < 0.01) and radiotherapy (p = 0.02) resulted in an increased risk of a lower TESS score. Initial reduced postoperative function was found to be associated with a lower functional outcome. Patients with reduced functional outcome have increased risk for reduced quality of life (p < 0.01).

CONCLUSION

The results of this study show that patient- and tumor-related factors have an important role in the functional outcome.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Peripheral nerve tractography in soft tissue tumors: a preliminary 3-tesla diffusion tensor magnetic resonance imaging study

INTRODUCTION

This diffusion tensor magnetic resonance imaging (DTI) study aimed to clarify the relationship of peripheral nerves and soft tissue tumors (STTs) in 3D to optimize subsequent treatment.

METHODS

Twenty-six consecutive STT patients (histologically malignant, n=10; intermediate, n=3; and benign, n=13) underwent 3-Tesla MRI using an echoplanar DTI sequence. Deterministic tractography was performed. Fractional anisotropy (FA) values were measured within peritumoral and distant regions of interest.

RESULTS

Tractography depicted the 3D course of the sciatic (n=12), femoral (n=2), tibial (n=7), fibular (n=2), median (n=1), musculocutaneous (n=1), and ulnar (n=1) nerves in a regular (n=8 of 18, 44.4%) or thinned (n=7 of 18, 38.9%) fashion. The lowest peritumoral FA values, abrupt thinning, and/or complete discontinuity of trajectories were found in 2 cases with histologically proven tumoral nerve infiltration.

CONCLUSIONS

DTI clarifies the 3D topography between major peripheral nerves and STTs and may be helpful in the assessment of peripheral nerve infiltration by malignant tumors.

Skin elasticity as a measure of radiation fibrosis: is it reproducible and does it correlate with patient and physician-reported measures?

Current means of measuring RT-induced fibrosis are subjective. We evaluated the DermaLab suction cup system to measure objectively skin deflection as a surrogate for fibrosis. Sixty-nine patients with E-STS were treated with limb-sparing surgery and 50-66 Grays (Gy) of RT. Using a “scleroderma” DermaLab Suction Cup, the skin stiffness was measured by two clinicians. The National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) scale, the Musculoskeletal Tumor Rating Scale (MSTS) and Toronto Extremity Salvage Score (TESS) questionnaires were completed for each patient. Levels of agreement between measurers were estimated using the Kappa (κ) coefficient and the concordance correlation coefficient (CCC). All sixty-nine patients were included. The level of agreement between measurers for NCI-CTCAE grading was moderate (range κ = 0.41-0.59). The CCC for the elasticity measurements were higher, with CCC = 0.82 for fibrotic skin and CCC = 0.84 for normal skin. The elasticity measurements were significantly higher when MSTS scores were <30 and or TESS scores were <90. Suction Cup measurement of skin elasticity is more reproducible than CTCAE grading and shows promise in generating reproducible measurements for radiation-induced skin fibrosis. Furthermore, it correlates well with the MSTS and TESS.

Functional outcome following upper limb soft tissue sarcoma resection with flap reconstruction

BACKGROUND

Upper limb preservation after soft tissue sarcoma resection often requires flap reconstruction. The aim of this study was to compare pre- and post-operative upper limb function following shoulder, elbow or wrist/hand sarcoma resection and soft tissue reconstruction with a pedicled or free flap.

PATIENTS

Between 1989 and 2008, 113 patients underwent resection of an upper limb soft tissue sarcoma and required flap reconstruction. Perioperative morbidity, mortality and flap loss were studied. Functional outcome was assessed pre and postoperatively using the Toronto Extremity Salvage Score (TESS), a measure of disability, and the Musculoskeletal Tumour Society Rating Scale (MSTS), a measure of impairment. Statistical analyses were performed to evaluate the relationship between flap type and functional outcome scores.

RESULTS

Patients underwent soft tissue sarcoma excision in the shoulder (n = 64), elbow (n = 27) or wrist/hand (n = 22) region with soft tissue reconstruction using either a pedicled (n = 76) or free flap (n = 37). Comparison of the post-operative MSTS (n = 88) and TESS (n = 84) revealed no significant differences between the free and pedicled flap groups. A significant pre- to post-operative difference was identified in MSTS 87 scores for patients in both the pedicled (p < 0.02) and free flap groups (p < 0.04). Comparison of the pre- and post-operative MSTS 93 scores also revealed a significant difference (p < 0.01) but this was limited to the free flap group. The most notable post-operative score reductions in these patients were due to major joint, nerve, tendon or muscle group resection.

CONCLUSION

Reconstruction of the soft tissue defect following sarcoma resection in the upper limb maintains a similar satisfactory level of upper limb activity with either pedicled or free flap reconstructions. Based on TESS scores, patients rated themselves as having better function compared to impairment measures such as MSTS.

Analysis of immediate vascular reconstruction for lower-limb salvage in patients with lower-limb bone and soft-tissue sarcoma

BACKGROUND

Limb amputation has historically been the first choice of treatment for patients with bone or soft-tissue sarcomas involving major blood vessels. However, recent advances in surgical technique have allowed limb-salvage surgery. We reviewed our experiences with limb-salvage surgery and immediate vascular reconstruction following en bloc resection of bone or soft-tissue sarcomas of the lower extremity.

MATERIALS AND METHOD

We reviewed 23 patients (15 male and eight female; mean age, 43.6 years) who underwent limb-salvage surgery and immediate vascular reconstruction. Details of surgical factors and postoperative complications were evaluated.

RESULTS

Reconstructed vessels remained patent in 21 cases. The rate of limb oedema was higher in patients who underwent only arterial reconstruction after arteriovenous resection. Twenty patients could walk well without crutches a few months after reconstructive surgery. All patients avoided amputation. Two patients died of disseminated disease within 3 years after surgery.

CONCLUSION

The high rate of limb oedema suggests that venous reconstruction is necessary after arteriovenous resection. Vascular reconstruction and musculocutaneous flap techniques are useful in limb-salvage surgery and are indicated for patients who have achieved good disease control. Evidence Rating Scale for Therapeutic Studies: Level III.

The toronto extremity salvage score in unoperated controls: an age, gender, and country comparison

The Toronto Extremity Salvage Score (TESS) is widely used for the functional assessment of patients following surgery for musculoskeletal tumours. The aim of this study was to determine if there are gender and/or age-specific changes, unrelated to surgery, that may influence this score and the appropriateness of the questions. The TESS for lower limb was carried out in two different countries to see if there was variation between them. There were no statistically significant differences between the scores obtained between the respondents from Australia or Britain either in total or between the corresponding age groups. There were statistically significant differences in the TESS obtained between age groups with a lower score at older age groups but there was no difference between the sexes. Patients in the age group 70+ were more likely to record activities as "not applicable" and also have a lower score. This study has shown that age is the major factor in determining the TESS in both an Australian and British populations of otherwise healthy people. As there were no differences between the two populations, it supports the TESS as an international scoring system. There may be also an argument for age-specific questions.

Functional reconstruction of sarcoma defects utilising innervated free flaps

Soft-tissue reconstruction following preoperative radiotherapy and wide resection of soft tissue sarcoma remains a challenge. Pedicled and free tissue transfers are an essential part of limb sparing surgery. We report 22 cases of sarcoma treated with radiotherapy and wide excision followed by one-stage innervated free or pedicled musculocutaneous flap transfers. The resection involved the upper limb in 3 cases, the lower limb in 17, and the abdominal wall in 2. The flaps used for the reconstruction were mainly latissimus dorsi and gracilis. The range of motion was restored fully in 14 patients. The muscle strength of the compartment reconstructed was of grades 4 and 5 in all patients except one. The overall function was excellent in all the cases with functional scores of 71.2% in the upper limb and 84% in the lower limb. The only 2 major complications were flap necrosis, both revised with another flap, one of which was innervated with restoration of function. Innervated flaps are valuable alternatives for reconstruction after sarcoma resection in the extremity and in the abdominal wall. The excellent functional results are encouraging, and we believe that innervated muscle reconstruction should be encouraged in the treatment of sarcoma after radiotherapy and wide resection.

Can the Toronto Extremity Salvage Score produce reliable results when used online?

BACKGROUND

Web-based questionnaires have become popular, however, access to the Internet can be biased regarding age, gender, and education, among other factors. Therefore, it is unknown whether this is a reasonable avenue to administer a questionnaire to patients or whether Web-based can be a reliable alternative to paper-based.

QUESTIONS/PURPOSES

We determined whether the Internet version of the Toronto Extremity Salvage Score is reproducible compared with the paper-based version and the compliance and completion rates.

PATIENTS AND METHODS

The study population consisted of 81 adults who had had surgery for a musculoskeletal tumor of the lower extremity more than 12 months earlier. The Toronto Extremity Salvage Score was administered by paper at a baseline interview and then readministered via Internet 7 to 14 days later to those with access.

RESULTS

Sixty of the 81 patients (74%) were able to use the Internet. Increasing age and lower education levels were correlated with a lower likelihood of using the Internet. Questionnaires were done online and on paper by 56 patients but 10 were excluded because of self-reported change in circumstances. The mean TESS was 85.7 (range, 41.1-100; SD, 17.26) for the paper-based questionnaire and 85.2 (range, 42.5-100; SD, 17.47) for the Internet-based questionnaire. The intraclass correlation coefficient was 0.97.

CONCLUSIONS

The questionnaire can be transferred successfully to the Internet and can be used reliably instead of a paper-based instrument. Recruitment to use an Internet-based questionnaire is limited only by the percentage of patients able to access and use the Internet.

Radiotherapy for soft tissue sarcoma of the proximal lower extremity

Soft-tissue sarcoma (STS) is a histopathologically diverse group of tumors accounting for approximately 10,000 new malignancies in the US each year. The proximal lower extremity is the most common site for STS, accounting for approximately one-third of all cases. Coordinated multimodality management in the form of surgery and radiation is often critical to local control, limb preservation, and functional outcome. Based on a review of currently available Medline literature and professional experience, this paper provides an overview of the treatment of STS of the lower extremity with a particular focus on the modern role of radiotherapy.

Sarcomas in the groin and inguinal canal--often missed and difficult to manage

INTRODUCTION

This is a 7-year retrospective review summarising the North of England Bone and Soft Tissue Tumour Service's experience of managing 13 cases of groin sarcoma requiring soft tissue flap reconstruction. This study was performed to try to identify where national referral guidelines in sarcoma management had been followed and reasons for any delays. The study also includes outcome data relating to these patients.

PATIENTS AND METHODS

A retrospective, case-note review was undertaken using the local sarcoma database to identify appropriate patients.

RESULTS

In nine patients, national referral guidelines were not followed. This resulted in a mean delay of presentation to the multidisciplinary team of 4.4 months. Ten patients had unplanned excision or exploration of tumours before referral. There were no lower limb amputations. All patients with narrow margins or high grade tumours were referred for radiotherapy. Four patients died; three as a result of distant metastases and one as a result of local recurrence.

CONCLUSIONS

Despite delays in referral, treatment by wide excision and plastic surgical reconstruction allowed for local control of these tumours with functional limb salvage. Implementation of National Institute for Health and Clinical Excellence (NICE) guidelines and local strategies could improve the expedient management of these patients.

Limb salvage for soft-tissue sarcomas of the foot and ankle

We evaluated the oncological and functional outcome of 27 patients who had limb salvage for a soft-tissue sarcoma of the foot or ankle between 1992 and 2007, with a mean follow-up of 7.5 years (1.05 to 16.2). There were 12 men and 15 women, with a mean age at presentation of 47 years (12 to 84). Referrals came from other hospitals for 16 patients who had previous biopsy or unplanned excision, and 11 presented de novo. There were 18 tumours located in the foot and nine around the ankle. Synovial sarcoma was the most frequent histological diagnosis. Excision was performed in all cases, with 16 patients requiring plastic surgical reconstruction with 13 free and three local flaps. Adjuvant treatment was undertaken in 20 patients, 18 with radiotherapy and two by chemotherapy. Limb salvage was successful in 26 of the 27 patients. There have been two local recurrences and two mesenchymal metastases. Four patients have died of their sarcoma and two of other causes.

Function was evaluated with the Toronto Extremity Salvage Score and a mean overall score of 89.40 (52.1 to 100) was obtained. A questionnaire revealed that all surviving patients are able to wear normal shoes and none require a walking aid.

Limb salvage can achieve good oncological and functional results with additional treatment.

Limb salvage in malignant tumors

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