Lower Extremity Sarcoma Research Articles

Evaluating Functional Outcome in Patients With Lower Extremity Sarcoma

The Short Form 36, The Toronto Extremity Salvage Score, and the 1987 and 1993 Musculoskeletal Tumor Society Rating Scales were compared as measures of functional status for patients with lower extremity sarcoma. The study included 97 patients with lower extremity sarcoma and evaluated each measure on the following measurement properties: conceptual framework; statement of the purpose; feasibility; breadth of content; depth of measurement; cross sectional and longitudinal reliability; and validity and responsiveness. The Short Form 36 represents patients' perceptions of their physical and mental health and is practical to use. However, the validity of the measure is questionable for the patients with sarcoma because the subscale structure could not be reproduced in the current data. The Toronto Extremity Salvage Score meets all standards of measurement with the exception of breadth of content as it measures only physical function. The 1987 and 1993 Musculoskeletal Tumor Society scales do not meet the standards of measurement. In choosing an outcome measure for the extremity sarcoma population, the Toronto Extremity Salvage Score has superior measurement properties when compared with the Short Form 36 or the 1987 and 1993 Musculoskeletal Tumor Society scales. The Toronto Extremity Salvage Score is a reliable and efficient measure for monitoring patients and for use in clinical trials.

Symptoms and their Relationship to Disability Following Treatment for Lower Extremity Tumours

Purpose. The aims of this study were to describe the symptoms experienced by patients in the first year following treatment for lower extremity sarcoma by limb conservation and to describe the relationship between symptoms and physical disability. Subjects. Eighty consecutive patients treated for primary bone or soft tissue sarcoma (STS) of the lower limb who were treated with limb preservation surgery. Methods. Subjects were evaluated by questionnaire at 6 weeks, and 3, 6, and 12 months post surgery. They identified whether they experienced any of the following symptoms: pain, stiffness, fatigue, weakness, limited range of motion, or swelling.The Toronto Extremity Salvage Score (TESS), a measure of physical disability, was also completed. Frequency of symptoms over time was calculated and change was evaluated using the Cochrane test. The relationship of symptoms to disability was analyzed with regression methods. Results. The mean age was 43.0, SD=20.4 with a gender ratio of 1:1. There were 38 bone tumours and 42 STS.The most frequently reported symptoms were: stiffness 48 (60%), weakness 41 (51%), fatigue 26 (33%), and pain 25 (31%) at 6 weeks. Stiffness and fatigue decreased and plateaued by 3 months. Complaints of weakness and pain continued to decrease over time. At 6 weeks, pain, stiffness, weakness and limited motion predicted disability in both univariate and multivariate analyses. At 12 months, pain, stiffness, fatigue, weakness and limited motion were significant predictors of the TESS in univariate analysis with only pain, stiffness and limited motion significant predictors in the multivariate model. Discussion. Pain, stiffness, fatigue, weakness and limited motion are common symptoms with stiffness and weakness decreasing significantly over time. The symptoms predictive of disability differ between the acute and late phases of recovery.

The Role of Free Tissue Transfer Following Oncologic Resection in the Lower Extremity

The current treatment of extremity sarcomas is multimodal, consisting of limb-sparing surgery, adjuvant radiotherapy, and/or chemotherapy. This approach has decreased the need for amputations and increased the demand for coverage of large composite defects. To date, the role of microsurgery in lower extremity reconstruction after oncologic resection has not been well defined. This study reviews a single center's experience with free tissue transfer for reconstruction of the lower extremity after oncologic resection. Fifty-nine free flaps were performed in 57 patients over a 5-year period. Forty-six patients (78%) underwent primary reconstruction and 35 patients (61%) received adjuvant therapy. Overall flap success rate was 96.6%. Most flaps were soft-tissue types including musculocutaneous (78%), skin only (11%), and muscle plus skin graft (4%). Osteocutaneous flaps were uncommon. There were major complications in 12% and minor complications in 7%. This study demonstrates that free tissue transfer for lower extremity reconstruction following oncologic resection has a high success rate that is similar to other free flap applications. It has become an integral part of lower extremity sarcoma management. Free flaps permit uninterrupted adjuvant therapy and enhance the efficacy of limb salvage surgery.

Late complications of revascularization for radiation-induced arterial disease

During a 14-year period 23 patients underwent 25 revascularizations for radiation-induced arterial obstructive disease. An average of 5000 rads was delivered, 3 to 24 (mean 9) years before arterial insufficiency, for malignancies of the following origin: gynecologic (n = 9), lymphoma (n = 7), head and neck (n = 5), testicular (n = 1), and lower extremity sarcoma (n = 1). Arterial occlusive disease occurred in the aortic arch vessels (n = 8), visceral aortic vessels (n = 1), and aortofemoral vessels (n = 16). Presenting symptoms were claudication (n = 8), rest pain or nonhealing ulcers (n = 7), transient ischemic attacks (n = 6), asymptomatic bruit (n = 1), and renal insufficiency (n = 1). Reconstructive operations included anatomic bypass (n = 10), extraanatomic bypass (n = 4), patch angioplasty (n = 5), endarterectomy (n = 3), and resection with interposition graft (n = 1). In this group of patients there were no major perioperative wound complications or other major radiation-associated morbidity. Five patients had late graft infections that manifested from 2 to 5 years after surgery. All occurred in anatomic regions where the bypass graft passed through previously irradiated tissues. Presenting symptoms of infection included a draining groin sinus (n = 3) or soft tissue abscess (n = 2). In all cases the graft had not incorporated into the surrounding tissues when passing through the irradiated area. Treatment included graft excision and extraanatomic bypass through nonirradiated tissue. One patient died of systemic sepsis. Vascular reconstructive surgery can safely be performed for radiation-induced arterial disease. We found a 21% incidence of late graft infection, all of which occurred when a bypass traversed previously irradiated tissue. Use of autologous conduits and extraanatomic bypass to avoid irradiated areas may decrease associated morbidity.

Sarcoma Therapy: Functional outcome and relationship to treatment parameters

Purpose: To systematically assess the functional outcome of patients treated with surgery and irradiation for extremity or truncal sarcomas, and to correlate this outcome with a detailed analysis of the radiation dose distribution and surgical technique. Conservative surgery and radiation therapy (RT) are known to provide excellent local control, but the relationship of technique to functional outcome requires further study. Methods and Materials: Forty-one patients were treated for lower extremity (25 patients, 61%), upper extremity (8 patients, 19.5%), and truncal (8, 19.5%) sarcomas from 1983 to 1990. Most patients had malignant fibrous histiocytoma (15), liposarcoma (8), or, aggressive fibromatosis (6). Age ranged from 13 to 85 years (median 54). All patients received RT and 39 (95%) had surgery. The mean total RT dose was 59 Gy (range 55.8–64.8 Gy). A protocol for functional assessment was devised and included a 4 point scale (0–3) for each of seven functional parameters (range of motion, fibrosis, edema, pain, skin changes, muscle strength, gait, or upper extremity performance). An aggregate score was obtained by adding the seven parameter scores and compared with both a patient and physician overall functional rating score (excellent, good, fair, poor). Based on this analysis, aggregate scores were defined as ≤ 3 = excellent, ≤ 8 = good, ≤ 13 = fair, and > 13 = poor, with 21 as the worst possible score. The same orthopaedic surgeon and radiation oncologist independently examined and rated 22 patients. An additional 17 patients were evaluated by record review. The median time from completion of radiation therapy was 30.5 months (range 7–95 months). A computerized radiation therapy dosimetric analysis was performed on 34 patients. Results: Local control was achieved in 39 patients (95%), including 6 with aggressive fibromatosis. The mean functional outcome score was 5.1 with a range of 0–16. 34 patients (83%) had good or excellent functional outcomes. The rating system demonstrated minimal interobserver variability. There was a positive relationship between volume irradiated to ≥ 55 Gy and functional score, strength, fibrosis, and skin changes. Total dose independent of volume was significantly associated with skin changes. Increasing peak dose (hot spot dose) was associated with fibrosis and skin changes. More fibrosis developed as the volume of the peak dose increased. A portion of the joint was treated in 5 33 extremity patients and the entire joint in 24 33 (mean dose 55.8 Gy, range 45–65 Gy). Neither range of motion nor total functional score was correlated with joint dose. Edema and functional score were not related to either the volume or percent of limb spared (receiving ≤ 40 Gy). The physician functional status ratings generally concurred with patient self-assessments. Conclusions: A system for functional assessment has been developed which is easily performed and provides detailed information about patient functional outcome. This system can be used to evaluate the morbidity of combined modality sarcoma therapy. Doses up to 65 Gy, even over joint spaces, are not associated with significant morbidity. Only a small volume treated to ≤ 40 Gy is required to maintain good outcome. The most important parameter appears to be the volume treated to ≥55 Gy.

The Treatment of Lower Extremity Sarcomas with Wide Excision, Radiotherapy, and Free-Flap Reconstruction

The Treatment of Lower Extremity Sarcomas with Wide Excision, Radiotherapy, and Free-Flap Reconstruction

The Treatment of Lower Extremity Sarcomas with Wide Excision, Radiotherapy, and Free-Flap Reconstruction

Treatment of extremity sarcomas has evolved into a multidisciplinary approach utilizing surgery, radiotherapy, and, in some cases, chemotherapy. Limb-sparing surgery has maintained low rates of local recurrence when supplemented with early postoperative radiotherapy (brachytherapy). Leg defects that result from resection resemble those caused by trauma and appear ideally suited to free-flap reconstruction. However, the resection site is subjected to 4500 cGy of radiation given within 2 weeks of surgery. It has not been demonstrated that free flaps can endure early postoperative radiation without adverse effects. Three patients are presented with locally recurrent leg sarcomas treated by wide excision, brachytherapy, and free-flap reconstruction. All flaps survived, and the wounds healed uneventfully. This study reviews the current multidisciplinary approach to the treatment of lower extremity sarcomas and demonstrates the durability of free-flap reconstruction in the presence of early postoperative radiation therapy.

Reconstruction Of Extensor Apparatus Of Knee By Gracilis

AbstractMarginal excision, wide excision with radieal resection, hip disarticulation and hemipelvectomy are the operative modalities in vogue for the surgical management of lower extremity sarcomas. Leiomyosarcoma of lower one third of thigh is treated by wide excision and resultant defect is filled by gracilis transposition technique.

Localized, operable soft tissue sarcoma of the lower extremity.

Recent developments in adjuvant treatment of soft tissue sarcomas of the extremities have altered the surgical approach to this disease. To assess the effects of changing management on local recurrence rates and to examine factors governing local failure, we reviewed the records of 315 adults with operable, nonmetastatic soft tissue sarcoma of the lower extremity who were treated at one institution over a ten-year period. The median follow-up was 8.2 years. One third of our patients presented with locally recurrent tumors after initial treatment elsewhere. Sixty-six percent of the lesions were above the knee, and 60% were high grade. Two thirds of the patients underwent limb-sparing surgery (LSS), which in the latter half of the study period outnumbered amputations by four to one. Local recurrence was directly related to the adequacy of the surgical margins. Adjuvant radiotherapy and chemotherapy did not significantly decrease local recurrence in patients who underwent LSS, although favorable trends were observed. A significantly increased risk of local failure was associated with age greater than 53 years, presentation with local recurrence, high tumor grade, deep location, positive nodes, and less than adequate surgical margins. Local failure also varied significantly with histologic type and was highest in patients with embryonal rhabdomyosarcoma and neurofibrosarcoma. Improved local control, particularly in patients with high-grade tumors, was observed in the latter half of the study period despite the increased use of LSS. When the data were subjected to multivariate analysis, the following variables emerged as independent predictors of local failure: age greater than 53 years, presentation with local recurrence, high grade, less than adequate margins, embryonal rhabdomyosarcoma, and neurofibrosarcoma. The key to local control of sarcomas of the extremities is resection of the tumor with adequate margins. The role of adjuvant treatment, particularly following LSS, is still being evaluated. The risk factor profile should be considered when selecting a treatment program for patients with lower extremity sarcomas.