Medline: 7922707

Cancer Investigation 12(5): 497-504, 1994.

Limb-sparing surgery for extremity sarcoma.

Marcove RC, Sheth DS, Healey J, et al.

Abstract:

This review discusses the principles and major recent advances in limb-sparing surgery, and presents the results of this approach for osteogenic sarcoma at Memorial Hospital. Patients do not accept or use upper limb prostheses readily, and although walking may be satisfactory with lower limb prostheses, recurrent infections in the stump, neuromas and chronic hidradenitis are major problems. Upper limb salvage may be very successful providing sensation can be preserved, especially in the hand, and tendon transfers and wrist fusion can add much strength. Improvements in shoulder and humeral reconstruction and in the lower limb, have made the results certainly superior to a prosthesis. The size of the tumor to be excised, and the difficulty of separating the neurovascular bundle from it present problems whose resolution depends upon thorough assessments of CT, enhanced MRI, bone scans, and arteriograms where needed. Shrinking of highly malignant sarcomas with high-dose preoperative (neoadjuvant) chemotherapy, may make the limb salvageable in osteogenic more than in Ewing's sarcoma. Other preoperative procedures include radiotherapy and cryosurgery. Metal inserts or modular prostheses are preferable, although there are problems from cement fixation; allografts have not proven satisfactory. For the problem of growth in children, expandable prostheses and conventional limb lengthening have been used, but neither are entirely satisfactory. Skipping of tumor across the joint when resection is done through a joint adjacent to tumor is a problem that resection of the joint near the ends of the bones may deal with. Memorial Hospital experience lists 199 patients (103 female) with osteogenic sarcoma who underwent limb-sparing surgery. Tumors were staged and disease evaluated by CT scan, bone scan, biplane arteriogram, and MRI. Initially the entire bone containing the tumor was removed, but later only the part of the primary involved bone with a 2-3 inch margin was removed; no intraosseous skip was found. Neurovascular bundles were freed from tumor usually from distal to proximal, and muscles were cut at a distance from the pseudocapsule. Frozen-section pathology was used to confirm bone marrow was free of tumor. Overall survival with no evidence of disease was 68% at 126 weeks median follow-up. By sites of tumor and resection, survival figures were; proximal humerus (modified Tikhoff-Linberg), 73%; proximal femur, 33%; total femur resection, 59%; distal femur and Geupar knee replacement, 77%; and tibia excision, 72%. Other methodological details, scans, and photographs are included to illustrate the procedure and results achieved. (24 Refs.)


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