Subtotal Scapulectomy Research Articles

What is the patient acceptance when only scapulectomy is possible in case of malignant tumor? A case series.

Scapulectomy is one of the surgical options in the case of malignant lesions in the scapula with an indication of surgical removal. Very few series in the literature have looked at postoperative quality of life and emotional acceptance, particularly in the case of scapulectomy without reconstruction. The objective is to assess the midterm results of scapulectomies in terms of function, quality of life, and acceptance for the patient. With a mean follow-up of 85 months (range 42 months-180 months), 11 scapulectomies for malignant tumors were performed with a mean age of 50 years: 5 partial scapulectomies, 4 total scapulectomies, and 2 subtotal scapulectomies. There were 6 chondrosarcomas, 2 high-grade osteosarcomas, 1 malignant peripheral nerve sheath tumor, and 1 low-grade atypical epithelioid sarcoma. The radio-clinical analysis was focused on functional results and mental health evaluation. The mean Musculoskeletal Tumor Society score of 11 scapulectomies was 20 ± 5 at 66% of normal, with the Disabilities of the Arm, Shoulder and Hand (DASH) score of 35 ± 26, and the Toronto Extremity Salvage Score of 76%. Patients had controlled pain (mean visual analog scale 1/10). Mobilities of the 11 scapulectomies were correct: average active anterior elevation of 89.5 ± 43 degrees, average abduction of 81 ± 42 degrees, average external rotation of 30 ± 25 degrees, and average internal rotation was at L5. Scapulectomy results in impaired physical and mental health compared with the general population (PCS-12=-9; MCS-12=-7). Partial scapulectomy, compared to total scapulectomy, gave better results: Musculoskeletal Tumor Society score (14±1 vs. 24±1 P=.0175), acceptance (45±9 vs. 92±16, P=.0184), mental health (MCS-12: 29±1 vs. 55±4, P=.0175), and Toronto Extremity Salvage Score (84±5 vs. 68±7, P=.0195). Partial and subtotal scapulectomies were better accepted (45±9 vs. 86±23, P=.0323) and tolerated (MCS-12: 29±1 vs. 52±6, P=.0099) by the patient compared to total scapulectomy. Total or partial scapulectomies without scapula reconstruction remain a disabling procedure performed with consequences on the physical and mental health of the patients. Partial or subtotal scapulectomy should be performed whenever possible because it seems to be associated with a better functional prognosis as well as less poor mental health and emotional acceptance of the patients, even though total scapulectomy may be necessary to obtain a complete curative tumor resection, which is the main goal.

Scapulectomy for Fibromatosis – Ocological and Functional Outcomes

Aggressive fibromatosis is a locally invasive tumor that does not metastasize. Only few cases of scapulectomy for fibromatosis of scapular muscles are reported in the world literature. We present two consecutive cases of scapulectomy done for fibromatosis of periscapular muscles at the Department of Surgical Oncology in our centre between 2014 and 2019. One patient underwent subtotal scapulectomy by posterior approach and the other patient underwent scapulectomy below spine of scapula by combined anterior and posterior approach. The follow-up period of both the patients was 5 years. One patient developed recurrence after 9 months of surgery dealt by re-resection followed by adjuvant radiation. The modified Musculoskeletal Tumor Society (MSTS) score for scapular surgery was 20 in the first patient and 22 in the second patient. Both of them are able to carry out normal regular activities with the compensation from the opposite upper limb. Scapulectomy for symptomatic fibromatosis of the scapular muscles gives acceptable functional results and good disease-free interval. Scapulectomy should be considered as part of resection for better tumor clearance in fibromatosis involving muscles around the scapula. Further studies are needed to evaluate and validate the need for radical surgery in this setting.

SUBTOTAL SCAPULECTOMY IN A PATIENT WITH CHONDROMA SCAPULA: A CASE REPORT

A benign chondroma (juxtacortical) is an unusual benign cartilaginous tumor. Juxtacortical chondromas, also known as periosteal chondromas, arise from the periosteum of the bones. They are thought to account for ~2% of benign bone tumors. Management of the tumor by excision in the form of total scapulectomy results in severe impairment of the upper limb function, but if all or part of the glenohumeral joint is preserved, a good function can be maintained. There is paucity in the literature about such cases. Here, we report the case of a 24-year-old male patient with chondroma of the right scapula. The patient was treated with subtotal scapulectomy and showed excellent functional outcome in terms of the range of motion of the shoulder joint.

Functional Results and Emotional Acceptance after Scapulectomy for Malignant Shoulder Tumors.

To demonstrate the functional results and emotional acceptance after scapulectomy for various malignant shoulder tumors. Eight patients with malignant shoulder tumors who had undergone scapulectomy between April 2004 and March 2014 were retrospectively reviewed. They comprised seven men and one woman their mean age was 54 years (range, 24-69 years). All patients were diagnosed by pathological examination of biopsy specimens. The tumors were metastatic in four cases, having originated from a primary carcinoma of the liver in one patient, the lung in one patient and the kidney in two patients. The other four patients had primary malignant tumors in their scapulae, specifically, two scapular malignant fibrous histiocytomas, one scapular Ewing sarcoma and one soft tissue synovial sarcoma. The four patients with metastases were staged as III, and other four were staged as IIB. Six patients underwent total and two subtotal scapulectomy. The remaining soft tissues were sutured together directly in seven of the patients. The remaining patient, who had soft tissue synovial sarcoma, required transfer of a pedicle latissimus dorsi muscle flap. The functional results and emotional acceptance were evaluated by clinician using the Musculoskeletal Tumor Society (MSTS) scoring system. The average duration of follow-up was 22.8 months. Four patients were continuously disease-free, three patients developed metastases and died of disease within 12 months of surgery and one patient with a scapular metastasis from the kidney survived with pulmonary nodules. No major complications, including infection or dislocation, occurred during or after surgery. The mean MSTS score was 16.3 (54%), which is similar to that previously reported in other studies of scapulectomy. There were no local tumor recurrences and only one patient developed pulmonary metastases. These outcomes are similar to those reported for scapular prostheses and there were fewer complications than in patients treated with allografts. The mean emotional acceptance score was 3.6 (72.5%). Performing scapulectomies on patients with malignant shoulder tumors without prostheses or allograft reconstruction achieves good functional results and emotional acceptance with a low rate of complications.

Vertical scapular osteotomy in congenital high scapula.

PurposeChildren with congenital high scapula (CHS) have a cosmetic and functional problem due to limited shoulder abduction. Treatment options include excision of the prominent superior angle, scapular relocation procedures and subtotal scapulectomy. Excision of the superomedial angle results only in cosmetic improvement. Subtotal scapulectomy and relocation procedures are associated with ugly scars, extensive bleeding and high incidence of brachial plexus injuries. Vertical scapular osteotomy (VSO) is another surgical option that provides cosmetic and functional improvement. The aim of this study is to assess medium to long term results of VSO in treatment of CHS.MethodsThis is a prospective case series study. Seven children with CHS were treated at our unit. Age ranged from 5–13 years with an average of 8.4 years. All children were females with unilateral affection. All children underwent a VSO as described by Campbell. We used the Cavendish grading system together with combined shoulder abduction for assessment. Follow up averaged 4.6 years.ResultsAll children and parents were extremely satisfied with the results of surgery. All patients experienced an improvement in global shoulder abduction with an average gain in abduction of 52.9°. All patients experienced an improvement in cosmetic appearance with better shoulder levelling. The Cavendish grade improved in all patients.ConclusionThis study emphasizes the results of previous authors demonstrating that CHS can be treated successfully with a VSO. The procedure is simple and its results are reproducible.

Factors that influence functional outcome after total or subtotal scapulectomy: Japanese Musculoskeletal Oncology Group (JMOG) study.

BackgroundScapulectomy requires not only joint resection but also wide resection of the shoulder girdle muscles. Even the significance of reconstruction has not yet been determined because of the difficulties in comparing the different conditions. The purpose of this study was to investigate factors that influence functional outcomes after scapulectomy in a multicenter study.MethodsThis retrospective study comprised 48 patients who underwent total or subtotal scapulectomy and were followed for at least one year after surgery. Patients were registered at the Japanese Musculoskeletal Oncology Group affiliated hospitals. Soft tissue reconstruction for joint stabilization was performed when there was enough remaining tissue for reconstruction of the rotator cuff and tendons. In 23 cases, humeral suspension was performed. The average follow-up period was 61.9 months. Multivariate analysis was performed using the patient’s background to determine which factors influence the Enneking functional score or active range of motion.ResultsThe average functional score was 21.1 out of 30. Active shoulder range of motion was 42.7 degree in flexion, 39.7 degree in abduction, 49.6 degree of internal rotation and 16.8 degree of external rotation. The amount of remaining bone influenced functional outcome, which means that preserving the glenoid or the acromion lead to better function compared to total scapulectomy (p<0.01). Factors that influenced each functional measure include the amount of remaining bone, soft tissue reconstruction, the length of the resected humerus and nerve resection (p<0.05).ConclusionAlthough shoulder function was almost eliminated following total or subtotal scapulectomy, minimal resection of bone, and soft tissue reconstruction should lead to better function.

Clinical outcome of 42 dogs with scapular tumors treated by scapulectomy: A Veterinary Society of Surgical Oncology (VSSO) retrospective study (1995–2010)

To report signalment, clinical signs, preoperative staging tests, histologic diagnosis, surgical, and oncologic outcomes including postoperative limb use, in dogs with scapular tumors treated by scapulectomy. Retrospective case series Dogs (n = 42) with scapular tumors. Medical records (1995-2010) from 6 hospitals were searched for dogs with scapular tumors treated by scapulectomy. Data retrieved were: signalment, weight, percentage of scapula removed, histologic diagnosis, postoperative limb use, adjunctive therapy, disease free interval (DFI), and survival time (ST). Individual variables were modeled with a Cox proportional hazard model accounting for censoring to determine risk factors for decreased DFI and ST. For categorical variables, Kaplan-Meier survival plots as well as mean and median survival times (MSTs) were calculated. Subtotal scapulectomy was performed in 18 dogs (42.9%). Osteosarcoma (OSA) was diagnosed in 27 dogs (64.3%). Limb use was evaluated immediately after surgery in 41 dogs. Information on limb use at other times (1, 2, 3, and >3 months) postoperatively was also available for some dogs and was good to excellent overall. Only adjunctive chemotherapy had a positive significant effect on DFI (P = .00011) and ST (P = .0003). Canine scapular tumors can be treated effectively by scapulectomy and limb use is fair to excellent for most dogs. OSA was the most common scapular tumor. Overall prognosis for scapular OSA is similar to appendicular OSA at other sites and use of adjunctive chemotherapy prolonged the overall DFI and MST.

A Rare Cause of Scapular Pain

A 57-year-old male patient presented to an academic sports and spine clinic with acute scapular pain and what he described as “winging” of the scapula. Three weeks before his presentation, increasingly severe pain began to develop through his left shoulder; it radiated down the upper arm, and he had pain along his left ribcage. At the same time, a significant prominence of his left scapula abruptly developed. He experienced pain when leaning on the area and upon moving the extremity, and he felt weak when lifting objects. He denied numbness or any symptoms in his other extremities. He reported a previous history of chronic neck issues and an electrocution injury involving his cervical region and left arm that resulted in persisting upper back pain radiating down his left arm and intermittent tingling in the ring and long fingers; however, these symptoms were described as distinctly different and far milder than his presenting complaints. He had no other significant medical history other than a 30-pack-year smoking history. Upon examination, the patient appeared well and was in no apparent distress. The left scapular region protruded from the chest wall at rest (Figure 1). Palpation revealed a nontender prominence following the course of the scapula, but palpation of the scapular borders was difficult. Mild tenderness to palpation at the left lateral rib cage adjacent to the lower scapula was noted. His scapula did not wing further with resisted scapular protraction or a wall push-up. He had weak shoulder external rotation and shoulder abduction to a lesser degree with minimal pain. The results of a cervical spine examination and the remainder of the neurologic examination were normal. A workup was completed, including the images provided, magnetic resonance imaging, and computed tomography angiography (Figures 2 and 3, respectively), and open biopsy pathology results confirmed pleomorphic spindle cell sarcoma with evidence of myofibroblastic differentiation, high grade (Figure 4). Soft-tissue sarcomas (STS) are the most frequent sarcomas identified, with an incidence of 10,660 cases reported in the United States in 2009. They most commonly occur in the extremities (60%). At least 50 different histologic subtypes of STS exist; pleomorphic sarcoma (malignant fibrous histiocytoma) is one of the most common, with a predilection for the shoulder/shoulder girdle [1,2]. Surgery is the standard primary treatment for most sarcomas. Limb-sparing surgery is recommended for extremity STS to achieve local tumor control with minimal morbidity [1]. High-grade extremity sarcomas are at high risk for local recurrence and metastasis, and thus many patients are treated with radiation therapy and chemotherapy preoperatively or postoperatively [1,2]. Factors associated with decreased overall survival and local recurrence in patients are tumor characteristics, including stage, grade, size, depth, and anatomic location [3]. In a Mayo clinic study of 248 cases of intermediateor high-grade surgically treated STS of the extremities diagnosed between 1995 and 2008, the 5-year incidence of local recurrence was 4.1% [3]. Patients who had positive surgical margins or margins of less than 2 mm had 5-year survival rates of 47% versus 72% in patients with wide margins [3]. Cases of STS in the infraspinatus muscle itself are rare. Four previous cases of sarcoma located in the infraspinatus muscle were found in a review of the literature. The first case, published in 1897, was in an 8-year-old child who underwent excision of the scapula [4]. A second case published in 1938 described a 17-year-old male patient who underwent surgical excision of the tumor, as well as at least part of the scapula [5]. A more recent publication describes a 28-year-old Japanese woman who underwent surgical excision of the infraspinatus muscle, part of the teres minor and teres major, and near-complete resection of the scapular periosteum [2]. The fourth case was noted in a study of function after a subtotal scapulectomy for bony or soft-tissue tumors among patients presenting to a university musculoskeletal oncology unit

Total scapulectomy for the treatment of chondrosarcoma in a cat

A 10-year-old neutered male domestic shorthair cat was admitted for treatment of a mass affecting the right scapula. A firm soft tissue mass located over the craniolateral aspect of the right scapula was evident during palpation. The mass extended close to the shoulder joint but did not cause lameness of the affected limb. Examination of a biopsy specimen obtained from the mass indicated chondrosarcoma. Total scapulectomy was performed to allow wide excision of the tumor. Weight bearing on the operated limb was tolerated 12 hours after surgery. Six months after surgery, limb function was assessed and considered excellent. The owner reported that the cat had its typical amount of activity and was able to jump and play normally. No recurrence of the tumor was evident 6 months after surgery. On the basis of the functional outcome after surgery, total scapulectomy may be a viable limb-sparing technique for the treatment of local neoplasms in cats. Subtotal scapulectomy has been reported previously, with a good to excellent clinical outcome expected. Total scapulectomy associated with only a fair clinical outcome has been reported previously, which has led to the general recommendation that scapulectomy be performed with preservation of the shoulder joint. The information provided in this report revealed that total scapulectomy can be associated with an excellent outcome in a cat.

Alveolar rhabdomyosarcoma arising from the infraspinatus muscle in a child treated with subtotal scapulectomy and chemoradiotherapy: A case study

Alveolar rhabdomyosarcoma arising from the infraspinatus muscle in a child treated with subtotal scapulectomy and chemoradiotherapy: A case study

Subtotal scapulectomy as the treatment for scapular tumour in the dog: a report of six cases

The medical records of six dogs treated by sub-total scapulectomy for tumours involving the scapula were reviewed. The mean age of dogs in this study was 8 years and 4 months. Clinical signs on presentation included lameness of the affected forelimb and a palpable mass over the scapular area on physical examination. Pre-operative chest and affected forelimb radiographs were taken in most cases in addition to a biopsy. Subtotal scapulectomy was performed, ensuring margins clear of neoplastic tissue of at least 2 cm, preservation of the glenoid cavity and thus retention of the scapulo-humeral joint. On histopathological examination the tumours where diagnosed as chondrosarcoma (one), haemangiosarcoma (two), anaplastic malignant neoplasia (one) and osteosarcoma (one). Limb function was found to be good in all cases postoperatively. Prognosis was related to histopathological diagnosis of the tumour, favourable with chondrosarcoma and poor with the other tumour types.

From the editors

From the editors

Function after subtotal scapulectomy for neoplasm of bone and soft tissue

We describe the functional results in 14 patients (7 men, 7 women) after subtotal scapulectomy for primary bone and soft-tissue tumours at a specialist musculoskeletal oncology unit. Eight had chondrosarcomas, two Ewing’s sarcomas, one aggressive fibromatosis and three soft-tissue sarcomas. The mean follow-up was 52 months (6 to 120). Analysis of residual symptoms and of range and strength of movement by physicians used the Musculoskeletal Tumour Society rating scale (MSTS). Physical disability was measured by the patients using the Toronto Extremity Salvage Score (TESS). All 14 patients are still alive, two with systemic disease. Nine had more than 80% of their scapula resected but the glenohumeral joint was preserved in all cases. Eight had full movement and another two achieved 90° of flexion. The mean functional results were good to excellent in all except three patients (mean MSTS = 71.6 and TESS = 79.9). Two of these three patients had considerable pain as a result of brachial neuropathy. Scapulectomy gives an excellent functional result if the glenohumeral joint is preserved. The rotator cuff could be removed without a severe functional deficit provided that the deltoid was reattached to the scapular remnant and the trapezius.

Function after subtotal scapulectomy for neoplasm of bone and soft tissue.

We describe the functional results in 14 patients (7 men, 7 women) after subtotal scapulectomy for primary bone and soft-tissue tumours at a specialist musculoskeletal oncology unit. Eight had chondrosarcomas, two Ewing's sarcomas, one aggressive fibromatosis and three soft-tissue sarcomas. The mean follow-up was 52 months (6 to 120). Analysis of residual symptoms and of range and strength of movement by physicians used the Musculoskeletal Tumour Society rating scale (MSTS). Physical disability was measured by the patients using the Toronto Extremity Salvage Score (TESS). All 14 patients are still alive, two with systemic disease. Nine had more than 80% of their scapula resected but the glenohumeral joint was preserved in all cases. Eight had full movement and another two achieved 90 degrees of flexion. The mean functional results were good to excellent in all except three patients (mean MSTS = 71.6 and TESS = 79.9). Two of these three patients had considerable pain as a result of brachial neuropathy. Scapulectomy gives an excellent functional result if the glenohumeral joint is preserved. The rotator cuff could be removed without a severe functional deficit provided that the deltoid was reattached to the scapular remnant and the trapezius.

Thoracoglenoid fusion after subtotal scapulectomy

Three cases of malignant tumors involving the scapula were treated primarily with a radical subtotal scapulectomy. Humeral head stabilization was achieved by fusion of the preserved neck of both the scapula and the glenoid to the chest wall, with good functional and cosmetic results.

Scapulectomy with Latissimus Dorsi Musculocutaneous Flap in the Treatment of Sarcoma of the Upper Back

We present a patient in whom scapulectomy was performed to treat a huge malignant fibrous hystiocytoma of the back. Computed tomographic examination showed the tumor to have invaded the musculature of the upper back and about the scapula. To achieve adequate surgical excision, a major portion of the skin and soft tissue of the upper back was excised in conjunction with subtotal scapulectomy. The defect, with exposed vertebral spines and transected scapula, was covered with an ipsilateral latissimus dorsi musculocutaneous flap. Now, four years postoperatively, the patient has no evidence of recurrent disease and has good use of his arm. Total or partial excision of the scapula is rarely performed and poses unique problems. As our case demonstrates, scapulectomy (combined with musculocutaneous flap) is well tolerated, and surgeons should not be discouraged from using it when appropriate.

Scapulectomy for malignant tumor. Function and shoulder strength in five patients.

Function and muscular strength were studied in five patients who had undergone either total or subtotal scapulectomy for malignant tumor. We found a striking difference in the functional impairment between the two patients with total and the three patients with subtotal scapulectomy. The latter three patients were able to handle light objects with their hands over their heads, and reached or nearly reached the horizontal plane in flexion and abduction of the shoulder. The two patients with total scapulectomy had a flexion and abduction range between 40 and 50 degrees. The mean isometric muscle strength in flexion relative to the non-operated side was 17 and 37 per cent for patients with total and subtotal scapulectomy, respectively, and the abduction strength 14 and 44 per cent, respectively. After scapulectomy, a reasonably good function can be expected, especially if it is possible to preserve the glenoid fossa and/or the acromion.