Amputation for Extremity Sarcoma: Indications and Outcomes

Factors Influencing Long-Term Local Recurrence, Distant Metastasis, and Survival in Patients with Soft Tissue Sarcoma of the Extremities Treated with Radiotherapy

INTRODUCTION

The prognostic factors for extremity soft-tissue sarcomas (ESTSs) treated with multimodal surgery and radiotherapy (RT) remain a subject of debate across diverse and heterogeneous studies.

METHODS

We retrospectively analyzed nonmetastatic ESTS patients treated with RT between 2007 and 2020 in Strasbourg, France. We assessed local control (LC), distant control (DC), overall survival (OS), and complications.

RESULTS

A total of 169 patients diagnosed with localized ESTS were included. The median age was 64 years (range 21-94 years). ESTS primarily occurred proximally (74.6%) and in the lower limbs (71%). Most tumors were grade 2-3 (71.1%), deep-seated (86.4%), and had R0 margins (63.9%). Most patients were treated with helical tomotherapy (79.3%). The median biologically effective dose (BED) prescribed was 75 BEDGy4 (range 45.0-109.9). The median follow-up was 5.5 years. The 5- and 10-year LC, DC, and OS rates were 91.7%, 76.8%, and 83.8% and 84.2%, 74.1%, and 77.6%, respectively. According to the univariate analysis, LC was worse for patients who received less than 75 BEDGy4 (p = 0.015). Deep tumors were associated with worse OS (p < 0.05), and grade 2-3 and undifferentiated pleomorphic sarcoma (UPS) were linked to both shorter DC and shorter OS (p < 0.05). IMRT was associated with longer LC than 3DRT (p = 0.018). Multivariate analysis revealed that patients with liposarcoma had better OS (p < 0.05) and that patients with distant relapse had shorter OS (p < 0.0001).

CONCLUSION

RT associated with surgical resection was well tolerated and was associated with excellent long-term rates of LC, DC, and OS. Compared with 3DRT, IMRT improved local control. Liposarcoma was a favorable prognostic factor for OS. Intermediate- and high-grade tumors and deep tumors were associated with lower DC and OS.

Limb Amputations in Cancer: Modern Perspectives, Outcomes, and Alternatives

PURPOSE OF REVIEW

This review summarizes current findings regarding limb amputation within the context of cancer, especially in osteosarcomas and other bony malignancies. We seek to answer the question of how amputation is utilized in the contemporary management of cancer as well as explore current advances in limb-sparing techniques.

RECENT FINDINGS

The latest research on amputation has been sparse given its extensive history and application. However, new research has shown that rotationplasty, osseointegration, targeted muscle reinnervation (TMR), and regenerative peripheral nerve interfaces (RPNI) can provide patients with better functional outcomes than traditional amputation. While limb-sparing surgeries are the mainstay for managing musculoskeletal malignancies, limb amputation is useful as a palliative technique or as a primary treatment modality for more complex cancers. Currently, rotationplasty and osseointegration have been valuable limb-sparing techniques with osseointegration continuing to develop in recent years. TMR and RPNI have also been of interest in the modern management of patients requiring full or partial amputations, allowing for better control over myoelectric prostheses.

Foot and Ankle Soft Tissue Sarcomas-Treatment and Oncologic Outcomes: A Systematic Review of the Literature

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.

Prognostic Factors in Extremity Soft Tissue Sarcomas Treated with Radiotherapy: Systematic Review of the Literature

Soft tissue sarcomas of the extremities are rare tumors with various prognostic factors. Their management is debatable due to their inconsistent results within the literature and the lack of large prospective studies. The objective of this systematic review is to analyze the available scientific data on prognostic factors concerning the characteristics of the patients, the disease and the treatments performed, as well as their potential complications, on studies with a median follow-up of 5 years at minimum. A search of articles following the "PRISMA method" and using the PubMed search engine was conducted to select the most relevant studies. Twenty-five articles were selected, according to preestablished criteria. This review provides a better understanding of the prognosis and disease outcome of these tumors. Many factors were described comparing the frequency of occurrence according to the studies, which remain heterogeneous between them. Significant factors that could orient patients to radiotherapy were highlighted. These positive prognostic factors provide valuable insight to optimize radiotherapy treatments for patients treated for soft tissue sarcoma of the extremities.

Limb-salvage surgery versus extremity amputation for early-stage bone cancer in the extremities: a population-based study

Background

Many attempts have been made to induce limb salvage as an alternative to amputation for primary bone cancer in the extremities, but efforts to establish its benefits over amputation yielded inconsistent results with regard to outcomes and functional recovery. This study aimed to investigate the prevalence and therapeutic efficiency of limb-salvage tumor resection in patients with primary bone cancer in the extremities, and to compare it with extremity amputation.

Methods

Patients diagnosed with T1-T2/N0/M0 primary bone cancer in the extremities between 2004 and 2019 were retrospectively identified from the Surveillance, Epidemiology, and End Results program database. Cox regression models were used to test for statistical differences between overall survival (OS) and disease-specific survival (DSS). The cumulative mortality rates (CMRs) for non-cancer comorbidities were also estimated. The evidence level in this study was Level IV.

Results

A total of 2,852 patients with primary bone cancer in the extremities were included in this study, among which 707 died during the study period. Of the patients, 72.6% and 20.4% underwent limb-salvage resection and extremity amputation, respectively. In patients with T1/T2-stage bone tumors in the extremities, limb-salvage resection was associated with significantly better OS and DSS than extremity amputation (OS: adjusted HR, 0.63; 95% confidence interval [CI], 0.55-0.77; p < 0.001; DSS: adjusted HR, 0.70; 95% CI, 0.58-0.84; p < 0.001). Limb-salvage resection was associated with significantly better OS and DSS than extremity amputation for patients with limb osteosarcoma (OS: adjusted HR, 0.69; 95% CI, 0.55-0.87; p = 0.001; DSS: adjusted HR, 0.73; 95% CI, 0.57-0.94; p = 0.01). Mortality from cardiovascular diseases and external injuries was remarkably declined in primary bone cancer in the extremities patients who underwent limb-salvage resection (cardiovascular diseases, p = 0.005; external injuries, p = 0.009).

Conclusion

Limb-salvage resection exhibited excellent oncological superiority for T1/2-stage primary bone tumors in the extremities. We recommend that patients with resectable primary bone tumors in the extremities undergo limb-salvage surgery as the first choice of treatment.

Two simple-to-use web-based nomograms to predict overall survival and cancer-specific survival in patients with extremity fibrosarcoma

Background

Fibrosarcoma is a rare sarcoma of the soft tissue in adults, occurring most commonly in the extremities. This study aimed to construct two web-based nomograms to predict overall survival (OS) and cancer-specific survival (CSS) in patients with extremity fibrosarcoma (EF) and validate it with multicenter data from the Asian/Chinese population.

Method

Patients with EF in the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015 were included in this study and were randomly divided into a training cohort and a verification cohort. The nomogram was developed based on the independent prognostic factors determined by univariate and multivariate Cox proportional hazard regression analyses. The predictive accuracy of the nomogram was validated with the Harrell's concordance index (C-index), receiver operating curve, and calibration curve. Decision curve analysis (DCA) was utilized to compare the clinical usefulness between the novel model and the existing staging system.

Result

A total of 931 patients finally were obtained in our study. Multivariate Cox analysis determined five independent prognostic factors for OS and CSS, namely, age, M stage, tumor size, grade, and surgery. The nomogram and the corresponding web-based calculator were developed to predict OS (https://orthosurgery.shinyapps.io/osnomogram/) and CSS (https://orthosurgery.shinyapps.io/cssnomogram/) probability at 24, 36, and 48 months. The C-index of the nomogram was 0.784 in the training cohort and 0.825 in the verification cohort for OS and 0.798 in the training cohort and 0.813 in the verification cohort for CSS, respectively, indicating excellent predictive performance. The calibration curves showed excellent agreement between the prediction by the nomogram and actual outcomes. Additionally, the results of DCA showed that the newly proposed nomogram was significantly better than the conventional staging system with more clinical net benefits. The Kaplan-Meier survival curves showed that patients assigned into the low-risk group had a more satisfactory survival outcome than the high-risk group.

Conclusion

In this study, we constructed two nomograms and web-based survival calculators including five independent prognostic factors for the survival prediction of patients with EF, which could help clinicians make personalized clinical decisions.

How much is a leg worth following radical tumor resection in bone sarcomas? Literature review

Bone sarcomas of the lower extremities are rare malignancies occurring mostly amongst adolescents and young adults. Necessarily, the therapy conducted in sarcoma centers is multimodal and multidisciplinary. In certain cases, in a metastasis free situation with adequate therapy, an overall survival rate of 90% can be achieved. Two principal surgical procedures exit for the local control of the malignancy: 1. Limb salvage with biological with/or endoprosthetic reconstruction; and, 2. amputation with restoration of the function with exoprosthesis or endo-exoprosthesis. Currently, limb salvage procedures are performed in up to 95% of cases. In contrast, amputation is performed when the disease has reached an advanced stage or limb salvage has failed. Both of the surgical options have their risks and possible complications. According to the literature, there should be no significant difference between limb salvage and amputation with respect to long-term overall survival, overall quality of life, psycho-socio-economic outcomes, or patient satisfaction. An important advantage of limb salvage is greater everyday functionality. With the expanded indication of limb salvage and great survival rates, the cases of late complications in patients expecting to maintain their own leg continues to increase. In some cases, it requires multiple interventions, ranging from minor up to the most complex revisions, to maintain the functionality of the extremity. Despite the great costs, personal effort, and the possible complications, limb salvage could be a suitable method to achieve functionally beneficial outcomes and patient satisfaction in bone sarcomas of the lower extremities over the long-term even in cases involving complications.

Intraoperative Evaluation of Soft Tissue Sarcoma Surgical Margins with Indocyanine Green Fluorescence Imaging

Soft tissue sarcomas (STS) are rare malignant tumors often associated with poor outcomes and high local recurrence rates. Current tools for intraoperative and definitive margin assessment include intraoperative frozen section and permanent pathology, respectively. Indocyanine green dye (ICG) is a historically safe fluorophore dye that has demonstrated efficacy for intraoperative margin assessment in the surgical management of both breast and gastrointestinal cancers. The utility of ICG in the surgical management of sarcoma surgery has primarily been studied in pre-clinical mouse models and warrants further investigation as a potential adjunct to achieving negative margins. This study is a prospective, non-randomized clinical study conducted on patients with confirmed or suspected STS. Patients younger than 18 years, with a prior adverse reaction to iodine or fluorescein, or with renal disease were excluded from the study. Intravenous ICG was infused approximately three hours prior to surgery at a dosage of 2.0-2.5 mg/kg, and following tumor resection, the excised tumor and tumor bed were imaged for fluorescence intensity. When scanning the tumor bed, a threshold of 77% calibrated to the region of maximum intensity in the resected tumor was defined as a positive ICG margin, according to published protocols from the breast cancer literature. ICG results were then compared with the surgeon's clinical impression of margin status and permanent pathology results. Out of 26 subjects recruited for the original study, 18 soft tissue sarcomas (STS) were included for analysis. Three subjects were excluded for having bone sarcomas, and five subjects were excluded due to final pathology, which was ultimately inconsistent with sarcoma. The average age of patients was 64.1 years old (range: 28-83), with an average ICG dose of 201.8 mg. In 56% (10/18) of patients, ICG margins were consistent with the permanent pathology margins, with 89% specificity. The use of ICG as an intraoperative adjunct to obtaining negative margins in soft tissue sarcoma surgery is promising. However, studies with larger sample sizes are warranted to further delineate the accuracy, optimal dosage, timing, and types of sarcoma in which this diagnostic tool may be most useful.

Contemporary role of amputation for patients with extremity soft tissue sarcoma

INTRODUCTION

limb-sparing surgery is the mainstream treatment for primary extremity soft tissue sarcoma (ESTS) at referral centers, following advances in surgical reconstructions and multimodal management. However, amputation is still needed in selected patients and has not yet been described for a ESTS cohort in a contemporary scenario.

MATERIAL AND METHODS

consecutive patients who underwent surgery for primary ESTS from 2006 to 2018 were extracted from a prospectively collected database at our reference center. Patients receiving amputation for either primary tumor or local recurrence (LR) after limb-sparing surgery were selected for analysis.

RESULTS

Among 1628 primary ESTS, 29 patients underwent primary amputation (1.8%), 22/1159 (1.9%) for upper limb and 7/469 (1.5%) for lower limb ESTS. Patients were mainly affected by grade III FNCLCC (89.6%) of notable dimension (median size 16 cm, IQR 10-24). 65.5% of patients received preoperative treatments (systemic or regional chemotherapy, radiotherapy or chemo-radiation). Secondary amputation for LR was performed after a median of 23 months in 16/1599 patients (1%). Median survival time was 16.2 and 29.6 months after primary or secondary amputation respectively. Factors prompting the need for a primary amputation were most often a combination of multifocal disease, bone invasion and pain or neurovascular bundle involvement and relevant comorbidities, mainly for grade III tumors in elderly patients.

CONCLUSION

Contemporary rate of amputation for ESTS at a reference center is extremely low. Still, amputation is required in selected cases with advanced presentations, especially in elderly, frail patients.

Impact of Limb Salvage on Prognosis of Patients Diagnosed With Extremity Bone and Soft Tissue Sarcomas

Background

Although clinicians and patients with extremity bone and soft tissue (EBST) are increasingly interested in limb salvage surgery (LSS), because of the minimal damage to physical appearance and function, however, there is still a lack of large-scale population studies on whether LSS improves the prognosis of patients.

Purpose

The aim of this study was to compare the survival of patients with EBST sarcomas after receiving LSS and amputation.

Methods

To conduct the population-based study, we identified 6,717 patients with a histologically diagnosed bone sarcoma and 24,378 patients with a histologically diagnosed soft tissue sarcoma from the Surveillance, Epidemiology, and End Results database. We analyzed overall survival (OS), cancer-specific survival (CSS), and non-sarcoma survival (NSS) using the Kaplan-Meier method, log-rank test or Gray test, Cox regression model, propensity score-matched analysis, and landmark analysis.

Results

LSS could improve the prognosis in patients with most EBST subtypes, except for Ewing sarcomas and MPNST. However, in the subgroup without distant metastases, limb salvage increased CSS only for patients with osteosarcoma, Ewing sarcoma, and leiomyosarcoma, as well as NSS for patients with chondrosarcoma and synovial sarcoma. Landmark analysis further demonstrated that sarcoma survivors surviving <10 years could benefit from LSS but not for long-term survivors ≥10 years. Moreover, for patients with distant metastases, LSS could improve survival of osteosarcoma patients but worsen CSS among patients with MPNST. Landmark analysis further demonstrated that LSS improved survival among osteosarcomas patients with distant metastases only within 1 year after surgery. Moreover, patients receiving LSS and those receiving amputation had a high risk of dying from different non-sarcoma diseases during the postoperative follow-up.

Conclusions

The impact of limb salvage on the prognosis of patients depends on the pathological subtype and stage of EBST sarcomas.