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The Influence of Anatomic Location on Functional Outcome in Lower-Extremity Soft-Tissue Sarcoma

From the University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto and Princess Margaret Hospital, Toronto, Canada.

Correspondence: Address correspondence and reprint requests to: A. M. Davis, PhD, Room 1119, Toronto Rehabilitation Institute, 550 University Avenue, Toronto, Ontario, Canada M5G 2A2; Fax: 416-597-3031; e-mail: davis.aileen{at}torontorehab.on.ca

	ABSTRACT

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Background: The purpose of this study was to explore the relationship between the anatomical location of lower-extremity soft-tissue sarcoma and functional outcome.

Methods: Function was evaluated with the Musculoskeletal Tumor Society (MSTS 1993) score and Toronto Extremity Salvage Score (TESS); 207 patients (median age, 54 years) were eligible. The median maximum tumor diameter was 8.0 cm; 58 tumors were superficial and 149 were deep. Nine locations based on anatomical compartments were defined: 6 tumors were in the groin/femoral triangle; 8, the buttock; 52, the anterior thigh; 22, the medial thigh; 20, the posterior thigh; 10, the popliteal fossa; 13, the posterior calf; 11, the anterolateral leg; and 7, the foot or ankle.

Results: Treatment of superficial tumors did not lead to significant changes in MSTS score (mean, 90.6% preoperatively vs. 93.0% postoperatively; P = .566) or TESS (mean, 86.4% preoperatively vs. 90.9% postoperatively; P = .059). Treatment of deep tumors lead to significant reductions in MSTS score and TESS (mean MSTS, 86.9% preoperatively vs. 83.0% postoperatively; P = .001; and mean TESS, 83.0% preoperatively vs. 79.4% postoperatively; P = .015). Anatomical location was not a significant predictor of aggregated MSTS and TESS evaluations. Exploratory analysis showed variation in MSTS pain and gait handicap or limp items and TESS dressing, sitting, bending, and bathing items by anatomical location.

Conclusions: The treatment of superficial tumors does not lead to significant changes in MSTS score or TESS. Anatomical location is not a significant predictor of aggregated MSTS and TESS evaluations. However, there is variation in MSTS and TESS item scores across anatomical locations.

Key Words: Lower extremity • Soft-tissue sarcoma • Anatomical site • Functional outcome

	INTRODUCTION

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The function of patients after treatment is an important consideration in the management of extremity soft-tissue sarcoma. In this context, function has been conceptualized in a variety of ways. Some authors have used clinical measures such as range of motion and muscle strength^1,2 or activities of daily living.¹ The Musculoskeletal Tumor Society Rating Scale (MSTS 1987) combines symptoms and clinical measures,³ and the revised MSTS (1993) includes scores for symptoms, mobility, and the use of assistive devices.⁴ Other studies have used generic health measures, such as the Sickness Impact Profile.⁵ We have previously used the World Health Organization definitions of impairment, disability, and handicap as a guide to the assessment of function.^6,7 The Toronto Extremity Salvage Score (TESS) was based upon the World Health Organization definition of disability as "any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being."⁶ The TESS evaluation has demonstrated reliability, validity, and responsiveness in the extremity sarcoma population.^8,9 The MSTS scores are closest to the WHO definition of impairments as "any loss or abnormality of psychological, physiological, or anatomical structure or function."⁶

We have previously analyzed factors that predict functional outcome after treatment of lower-extremity soft-tissue sarcoma as measured by the MSTS and TESS rating systems.⁷ We showed that large tumor size, resection of bone, resection of major motor nerves, and complications of surgery predicted lower MSTS 1987 and 1993 scores and that patients with large, high-grade tumors who required motor nerve resection had lower TESS values.⁷ Although anatomical location as defined as proximity to the nearest major joint (hip, knee, ankle) was not a significant predictor of functional scores in this study, we hypothesized that the anatomical location of a tumor is nevertheless important in determining functional outcome. For example, function after treatment of a buttock tumor is likely to differ from function after treatment of a tumor in the foot or ankle by virtue of anatomical location alone. The purpose of this study therefore was to further examine the influence of anatomical location on functional scores in patients with lower-extremity soft-tissue sarcoma.

	PATIENTS AND METHODS

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Patients were eligible for this study if they underwent limb-sparing surgery in our center for lower-extremity soft-tissue sarcoma and had a minimum follow-up of 1 year for functional evaluation, at which point functional scores are known to plateau.¹⁰ Two measures were used to assess function. The MSTS (1993) is completed by the clinician and consists of six items: pain, overall function, emotional acceptance, walking ability, walking aids, and gait handicap or limp.⁴ Each item is rated on a scale of 1 to 5. The total score is calculated from a sum of the individual items and expressed as a percentage. The TESS questionnaire is completed by the patient and comprises 30 items in which the patient indicates the difficulty experienced in performing a range of everyday activities, such as dressing, grooming, mobility, work, sports, and leisure.⁸ Each item is rated on a scale of 1 to 5 and the total is expressed as a percentage. The TESS was first used in April 1994, and therefore patients treated before this date were excluded. Patients were also excluded if they had metastases at presentation, had a local or systemic relapse before functional assessment at 1 year, or underwent chemotherapy. The lower extremity was defined as commencing at the pelvic brim.

We did not use the MSTS (1987) system because it is site-specific and therefore not suitable for this analysis. We did not use the generic general health status measure Short-Form 36 (SF-36) because we have shown that it is not sensitive to local treatment factors.⁷

A prospectively collected database was used to identify suitable patients and the following data were extracted from it: age, gender, type of surgery, metastases at presentation (yes/no [Y/N]), presentation with a local recurrence (Y/N), chemotherapy (Y/N), radiotherapy (Y/N), unplanned excision before referral (Y/N), histological type and grade, maximum tumor diameter in centimeters, resection of bone (Y/N), resection of major motor nerve (Y/N), and complications of surgery (Y/N). Complications of surgery were defined as major wound dehiscence, infection, or fracture.

Anatomical Definitions
The anatomical location of the tumor was determined by review of the operating note and imaging. One author (CG) assigned tumors to anatomical regions as described below. These regions were based upon the concept of anatomical compartments developed by Enneking because these were thought to have both oncological and functional significance.¹¹ A tumor involving more than one region was assigned to the region that was most involved. Tumors superficial to and not involving the deep investing fascia of the limb were classified as superficial and others as deep. To minimize errors, data relating to anatomical location were entered twice into a spreadsheet (Excel 97, Microsoft, Redmond, WA) and checked for compatibility with the preexisting anatomical classification, in which tumors were grouped by their proximity to the nearest major joint.

Groin/Femoral Triangle
This triangle comprises proximally the inguinal ligament, posteriorly the iliopsoas and anterior hip capsule, and laterally the tendon of rectus femoris, as well as the proximal extent of the femoral artery, vein, nerve, and inguinal nodes.

Buttock
The buttock comprises proximally the posterior brim of pelvis, medially the sacrum, anteriorly the posterior border of tensor fascia lata, the anterior border of gluteus medius, and as the deep boundary, the outer table of pelvis. It also contains the gluteus maximus, minimus, medius, quadratus femoris, and the proximal extent of the sciatic nerve.

Anterior Thigh
This comprises proximally the brim of pelvis, distally the patella, and laterally the intermuscular septum. It also contains the quadriceps, including patella and patellar tendon, sartorius, tensor fascia lata, femoral artery, vein, and nerve.

Medial Thigh
This comprises proximally the pubic rami and ischial tuberosity, anterolaterally the adductor canal and medial intermuscular septum, posteriorly the posterior surface of adductor magnus, and distally the pes anserinus. It also contains the gracilis, adductors brevis, longus, magnus, pectineus, and profunda femoris vessels.

Posterior Thigh
This comprises laterally the intermuscular septum, medially the adductor magnus fascia, proximally the ischial tuberosity, distally the musculotendinous junctions of the hamstring muscles, anteriorly the linea aspera, and the posterior face of femur. It also contains the semimembranosus, semitendinosus, and biceps femoris.

Popliteal Fossa
This comprises superficially the deep fascia, anteriorly the posterior capsule of knee joint and the heads of gastrocnemius, distally the confluence of gastrocnemius, and proximally the musculotendinous junctions of hamstrings. It also contains the sciatic nerve, popliteal vessels, and lymph nodes.

Posterior Calf
This comprises anteriorly the posterior surface of the tibia, interosseous membrane, posterior aspect of fibula, and posterior intermuscular septum; posteriorly the deep fascia of the calf; superiorly the confluence of gastrocnemius; distally the commencement of the tendo Achilles. It also contains the gastrocnemius, plantaris, soleus, popliteus, flexor digitorum longus, flexor hallucis longus and tibialis posterior, and the posterior tibial vessels and nerve.

Anterolateral Leg
This comprises anteriorly the deep fascia of the leg; posteriorly the lateral surface of the tibia, the interosseous membrane, the fibula, and the posterior intermuscular septum; proximally the proximal extent of the insertion of tibialis anterior into the tibia; and distally the superior extensor retinaculum of the ankle. It also contains the peroneus longus and brevis, peroneus tertius, extensor digitorum longus, extensor hallucis longus, tibialis anterior, the anterior tibial vessels, and the deep peroneal nerve.

Foot and Ankle
Proximally this space in bounded by the superior extensor retinaculum anteriorly and the commencement of the tendo Achilles posteriorly.

Analysis
Initially, descriptive variables were calculated for the whole group of eligible patients. Recognizing that treatment of tumors located superficial to the investing fascia of the limb was likely to have little impact on the function of the underlying compartment, these superficial tumors were analyzed as a separate group. Next, variables for the anatomical location of deep tumors were added to factors already recognized to have an influence on MSTS (1993) score and TESS in multiple linear regression models. Finally, an exploratory analysis was performed in which individual MSTS and TESS items for deep tumors were compared by anatomical location.

Statistical Notes
Differences in mean values between two groups were compared with use of independent-samples t-tests and between multiple groups with one-way analysis of variance (ANOVA) and the Tukey post-test. Differences in proportions were compared with the Pearson ² test. MSTS scores and TESS values are not normally distributed. Therefore, when comparing scores between two groups, we used the nonparametric Mann-Whitney test. When comparing scores before and after treatment, we used the Wilcoxon test for paired samples, and we used the Kruskal-Wallis test to compare scores across more than two groups. Results with a P value of < .05 were taken to be significant (SPSS software for Windows, release 10.0.5, 1999; SPSS, Chicago).

	RESULTS

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Between April 1994 and March 1999, data relating to 397 patients were collected. Ninety-seven patients had upper-extremity tumors and 17 had an amputation. The following patients were also excluded: 22 with metastases at presentation, 32 who developed metastases, 2 who died of other causes, 3 with a local recurrence in the first year, and 10 who received chemotherapy. For seven patients there were no functional data available. Therefore, 207 patients remained in the study.

Completeness of Function Data
Preoperative MSTS results were available for 203, and 1- or 2-year MSTS results were available for 189 patients. Preoperative TESS results were available for 172 and 1- or 2-year TESS results were available for 155 patients. Of the patients for whom 1- or 2-year TESS results were not available, 20 did not speak English, 11 were lost to follow-up, 7 were infirm and unable to complete the questionnaire, and 14 had no data available for other reasons.

Characteristics of the Whole Group
There were 106 females (51.2%) and 101 males (48.8%), of median age 54 (15 to 89) years. Twelve patients (5.8%) presented with a local recurrence after treatment elsewhere. Seventy-six patients (36.7%) had been treated by unplanned excision before referral. The distribution of histological types was similar to that in other series, with malignant fibrous histiocytoma in 48 (23.2%), liposarcoma otherwise undesignated in 49 (23.7%), and myxoid liposarcoma in 28 (13.5%). Tumors were grade 1 in 40 cases (19.3%), grade 2 in 76 (36.7%), and grade 3 in 91 (44.0%). The median maximum tumor diameter was 8.0 cm (0.3 to 36.0).

A tissue transfer or split-thickness skin graft was used for wound closure in 40 cases (19.3%), and 170 patients (82.1%) received adjuvant radiotherapy. Resection of bone was required in 12 cases (5.8%), and resection of a major motor nerve in 12 cases (5.8%). Forty-eight patients (23.2%) had a wound complication and 3 (1.4%) had a fracture.

After anatomical classification there were 58 superficial tumors (28.0%) and 149 deep tumors (72.0%). Superficial tumors were significantly smaller than deep tumors (4.6 vs. 11.2 cm; P < .0001). Of the deep tumors, 6 were located in the groin/femoral triangle, 8 in the buttock, 52 in the anterior thigh, 22 in the medial thigh, 20 in the posterior thigh, 10 in the popliteal fossa, 13 in the posterior calf, 11 in the anterolateral leg, and 7 in the foot and ankle (Table 2). Of the deep tumors, 119 (79.9%) involved one site only, 28 (18.8%) involved two sites, and 2 (1.3%) involved three sites.

A multiple regression model for postoperative TESS was constructed in the same fashion with use of variables previously identified as predictive (tumor diameter, grade, and motor nerve resection). Once more, resection of a motor nerve was the only variable to reach significance in this model (P = .002).

Comparison of MSTS and TESS Items by Anatomical Location
An exploratory analysis of item variation by anatomical location was performed with use of the nonparametric Kruskal-Wallis test. Items in which there was significant variation by anatomical location were further examined. There was significant variation by anatomical location for the pain and gait handicap or limp items of the preoperative MSTS (Table 3). Tumors in the groin/femoral triangle were associated with more preoperative pain than those in other locations. Preoperatively all patients with tumors in the groin/femoral triangle required analgesia, with most requiring narcotic analgesia. The lowest preoperative mean score for the gait handicap or limp item was for tumors in the groin/femoral triangle, followed by the posterior calf, the foot and ankle, and the anterolateral leg (Table 3).

In the preoperative TESS, the exploratory statistical analysis did not identify any items with significant variation by anatomical location, although the item score for sitting approached significance. Patients with tumors in the groin/femoral triangle, buttock, and posterior thigh had the greatest difficulty with sitting (Table 4).

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
The purpose of this study was to examine the influence of anatomical factors on impairment as measured by MSTS (1993) score and disability as measured by TESS. We have shown a difference in MSTS and TESS when superficial and deep tumors are compared and that although there does not appear to be significant variation in the MSTS and TESS for deep tumors by anatomical location, some items do vary with anatomical location.

Our study shows that unlike deep tumors, the treatment of superficial tumors is not associated with a significant decrease in MSTS and TESS values. In fact, mean scores for superficial tumors increase slightly after treatment, whereas those for deep tumors decrease after treatment. Higher MSTS (1993) and TESS values for superficial tumors likely reflect their smaller size and the fact that surgery does not involve major muscle, motor nerve, or bone resection.

We could not demonstrate that the variables for anatomical location made a significant contribution to total postoperative MSTS score and TESS in the regression model, and it may be that our study was not sufficiently powered to detect this. However, the exploratory analysis suggests that most of the variability with anatomical location lies at the item level, rather than in aggregated scores. Although the number of patients in the group was small, it was of interest that tumors in the groin/femoral triangle were associated with more preoperative pain, as measured by the MSTS item for pain, than those in other locations. This may be related to the relatively high rate of major nerve involvement in this location (two of six patients required major motor nerve resection). Other than those in the groin, tumors located below the knee appeared to be associated with the lowest preoperative gait handicap or limp item scores. Postoperatively tumors in the groin/femoral triangle were associated with the lowest mean MSTS gait handicap or limp item scores. This may have been because one patient had a major femoral nerve resection and scored zero for the gait handicap or limp item postoperatively.

The TESS evaluation contains a greater number of items than the MSTS, and some items, such as the ability to sit, are likely to have a clear relationship with anatomical location. We found that tumors in the buttock and posterior thigh were associated with greater difficulty in sitting than those in other locations, which may reflect the discomfort experienced when sitting directly on the tumor. Patients with tumors in the groin/femoral triangle also have difficulty sitting normally, likely because of restriction of normal hip flexion. The postoperative TESS evaluation confirms that after treatment, patients with tumors in the groin/femoral triangle continue to score lower for the items putting on socks, getting out of the bath, and bending to pick up, all of which involve hip flexion.

To conclude, we have shown that when considering the function of a patient after treatment of lower-extremity soft-tissue sarcoma, anatomical location is important. The treatment of superficial tumors is not associated with a significant decrease in functional scores, whereas the treatment of deep tumors is. Although the contribution of the anatomical location of deep tumors to aggregated MSTS (1993) and TESS values does not appear to be significant, there is variation in score items with anatomical location. This information may be of value in counseling patients about their likely disability and impairment after treatment.

	ACKNOWLEDGMENTS

 
Mr. Gerrand’s fellowship was supported by the Wishbone Trust, Ethicon, Depuy UK, Stryker, and Howmedica. Dr. Wunder holds the University of Toronto/Mount Sinai Hospital Rubinoff-Gross Chair in Orthopaedic Oncology. Dr. Davis is supported by a Health Career Award from the Canadian Institutes of Health Research.

	FOOTNOTES

 
The influence of lower-extremity anatomical location on functional outcome following limb preservation for soft-tissue sarcoma was evaluated. Anatomical location is not a significant predictor of aggregated impairment or disability scores, but score items do vary by anatomical location.

Received for publication July 25, 2003. Accepted for publication January 12, 2004.

	REFERENCES

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