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10.1245/ASO.2005.06.036
Annals of Surgical Oncology 12:1102-1110 (2005)
© 2005 Society of Surgical Oncology
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Original Article

The Surgical and Functional Outcome of Limb-Salvage Surgery With Vascular Reconstruction for Soft Tissue Sarcoma of the Extremity

Michelle A. Ghert, MD, FRCSC1, Aileen M. Davis, PhD2, Anthony M. Griffin, BSc1,3, Ali H. Alyami, MD, ABOS, SBOS1, Lawrence White, MD, FRCPC4, Rita A. Kandel, MD, FRCPC5, Peter Ferguson, MD, MSc, FRCSC1,3, Brian O’Sullivan, MD, FRCPC6, Charles N. Catton, MD, FRCPC6, Thomas Lindsay, MD, FRCSC7, Barry Rubin, MD, CM, PhD, FRCSC7, Robert S. Bell, MD, MSc, FRCSC1,3 and Jay S. Wunder, MD, MSc, FRCSC1,3

1 University Musculoskeletal Oncology Unit, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Suite 476E, Toronto, Ontario, Canada M6B 1H9
2 Research, Toronto Rehabilitation Institute, University of Toronto, 550 University Avenue, Toronto, Ontario, Canada M5G 2A2
3 Surgical Oncology, Princess Margaret Hospital, University of Toronto, 610 University Avenue, Toronto, Ontario, Canada M5G 2M9
4 Department of Diagnostic Imaging, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, Ontario, Canada M5G 1X5
5 Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, Ontario, Canada M5G 1X5
6 Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, 610 University Avenue, Toronto, Ontario, Canada M5G 2M9
7 Division of Vascular Surgery, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4

Correspondence: Address correspondence and reprint requests to: Jay S. Wunder, MD, MSc, FRCSC; E-mail: wunder{at}mshri.on.ca.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: This study compared the surgical, oncological, and functional outcomes of patients undergoing limb-salvage surgery for extremity soft tissue sarcoma with vascular resection and reconstruction with the outcomes of those undergoing limb-salvage without vascular reconstruction.

Methods: Nineteen patients were identified from a prospective soft-tissue sarcoma database who underwent vascular resection and reconstruction as part of their limb-salvage surgery and who were followed up for at least 1 year or until death. Each of these 19 patients was case-matched to 2 additional patients on the basis of tumor location, size, and depth; patient age; and timing of radiation. To compare functional outcome, a subset of patients was case-matched with additional criteria including wound-complication status, motor nerve sacrifice, similar preoperative function as determined by the Toronto Extremity Salvage Score, and no metastases at diagnosis or the 1-year follow-up.

Results: Patients in the vascular reconstruction group were more likely to require a muscle transfer (53% vs. 18%; P = .008), experience a wound complication (68% vs. 32%; P = .03), experience deep venous thrombosis (26% vs. 0; P = .003), experience significant limb edema (87% vs. 20%; P = .001), and ultimately require an amputation (16% vs. 3%; P = .07). Patients who underwent vascular reconstruction had only slightly lower Toronto Extremity Salvage Score scores 1 year after surgery (78.5 vs. 84.2; P = .35). There were no significant differences in local or systemic tumor relapse between the two groups.

Conclusions: Vascular reconstruction is a feasible option in limb-salvage surgery for soft tissue sarcoma but is associated with an increased risk for postoperative complications, including amputation. Although function is not significantly worse after vascular reconstruction, the results are less predictable.

Key Words: Sarcoma • Vascular reconstruction • Function • Complications • Limb salvage


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Limb-salvage surgery has become the standard of care in the surgical management of most patients with extremity soft-tissue sarcomas.1–9 With the use of adjuvant chemotherapy, radiation protocols, or both, as well as advanced imaging techniques, adequate margins can be obtained in most cases without the need for radical resection or amputation. One of the theoretical roadblocks to limb-salvage surgery is neurovascular involvement by the tumor. Reports in the literature have shown that resection of major peripheral nerves, particularly of the lower extremity, does not preclude an acceptable functional outcome.10–12 However, disabling lymphedema and ultimately amputation are frequent complications of limb-salvage procedures requiring resection of major blood vessels without vascular reconstruction.13,14 More recently, resection of major vessels followed by vascular reconstruction has been found to be technically feasible and successful, with an amputation rate of approximately 10%.15–23

The functional results of such extensive attempts at limb salvage with vascular reconstruction have not been carefully addressed in the literature. Postoperative edema, wound-healing complications, major peripheral nerve resection, and the risk of vascular graft thrombosis can all potentially increase the morbidity of limb salvage under these circumstances. 14,24–27 The purpose of this study was to review our center’s experience with vascular reconstruction for tumors invading major vascular structures and to compare the surgical, oncological, and functional outcomes with those of a case-matched control group of patients who underwent limb-salvage surgery without vascular reconstruction for a soft tissue sarcoma of the extremity.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Vascular Reconstruction Patients
A prospectively collected database of 732 patients treated at our institution between 1989 and 2000 for a primary or locally recurrent soft tissue sarcoma of the extremity was reviewed. Nineteen patients who underwent limb-salvage surgery with vascular resection and reconstruction for a sarcoma of the extremity and who were followed up for at least 1 year or until death were identified. All 19 cases involved tumors of the lower extremity. The reasons to perform vascular reconstruction included vascular invasion and/or encasement by the tumor and the need for vessel resection to obtain adequate oncological surgical margins. The demographic, treatment, and outcome parameters of these 19 patients were reviewed.

Case Matching for Surgical and Oncological Outcome
Each of these 19 patients was matched to 2 additional patients in the database who underwent limb salvage for a soft tissue sarcoma of the lower extremity without vascular reconstruction. The patients were matched by using the following criteria: (1) same tumor location based on the following anatomical specifications—inguinal canal, hip adductors, hip periarticular, popliteal fossa, quadriceps, knee quadriceps, proximal posterior compartment of the leg, proximal anterior leg, or ankle/distal leg; (2) same tumor size category (≤5, 6–10, 11–15, or >15 cm); (3) same tumor depth; (4) same patient age ±10 years; and (5) same timing of radiation treatment. The matched control group of 38 patients was compared with the treatment group of 19 vascular reconstruction patients in demographics, treatment parameters (including adjuvant therapy and the need for muscle transfer), and surgical outcomes (including wound complications, postoperative deep venous thrombosis in the operated extremity, postoperative limb edema, local recurrence, metastasis, and amputation). All patients in the control group, as well as vascular reconstruction patients treated during the early part of this study, received prophylactic anticoagulation after surgery with either low-molecular-weight heparin or warfarin. Patients who required vascular repair more recently were treated with prophylactic anticoagulation after surgery for the first 1 to 2 weeks, and then full anticoagulation with warfarin was maintained for 6 to 12 months. A wound complication was defined as a secondary operation for wound repair or prolonged deep wound packing.28 Edema was measured according to the criteria of Stern29 as follows: 0, none; 1, mild (but definite swelling); 2, moderate; 3, severe (considerable swelling); and 4, very severe (skin shiny and tight with or without skin cracking). Ratings for edema of grade ≥2 were believed to be clinically significant.

Case Matching for Functional Outcome
A separate case-control study was performed to assess functional outcomes for patients who underwent vascular reconstruction compared with patients who required no vascular procedure. In this case, the matching process was based on the following criteria: (1) all patients had preoperative functional scores in the form of the Toronto Extremity Salvage Score (TESS)30 and postoperative 1-year TESS scores, (2) preoperative TESS scores matched ±5 points, (3) no major motor nerve sacrifice, (4) same wound-complication status, (5) same tumor location as described previously in the first case matching, (6) same tumor depth, (7) same tumor size ±5 cm, (8) same patient age ±10 years, and (9) no metastases at diagnosis or 1-year follow-up. Patients in these groups were not matched for the timing of radiation because the functional outcome at 1 year after treatment has been shown to be more closely related to wound-complication status.26 Because of the large number of matching criteria, a maximum of six patients were identified in each group and compared on a one-toone basis to ensure matching adequacy. Postoperative TESS scores were compared to evaluate the difference in functional outcome between patients who underwent vascular reconstruction and those who did not. Postoperative limb edema was also compared between the two patient groups.

All statistical comparisons were performed with the use of a paired t-test for continuous variables and the {chi}2 or Fischer’s exact test for categorical variables. For functional comparison based on the preoperative and postoperative TESS scores, the Wilcoxon rank sum test was used.31 Metastasis-free survival of the initial matched patient groups was compared by using the log-rank test after exclusion of patients in each group who presented with metastases at diagnosis.32 Institutional research ethics board approval was obtained for this study.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Vascular Reconstruction Patients
The average age of the 19 patients in the vascular reconstruction group was 48.3 years (range, 20–79 years), and 63% were male (Table 1Go). The average tumor size was 10.9 cm (range, 5.5–15 cm). Most tumors were histologically grade 2 or 3, and all were deep to the investing fascia of the limb. Malignant fibrous histiocytoma and liposarcoma were the most common histological diagnoses. One patient presented with a local recurrence after being treated elsewhere. Of the six (32%) patients with metastases at the time of diagnosis, three tumors were grade 3, two were grade 2, and one was histologically grade 1. Thirty-two percent (6 of 19) of patients had undergone a previous unplanned excision elsewhere.


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  		TABLE 1. Comparison of demographic matching
 
Eleven patients had both a major artery and vein resected together en bloc with their sarcoma, seven had a major artery removed, and one required excision of only a major vein with the tumor. Vessels resected and reconstructed included the iliofemoral (n = 2), femoral (n = 11), popliteal (n = 4), and tibial/ peroneal (n = 2). Most patients (n = 12) had vascular reconstruction with a reversed saphenous vein graft for both the artery and vein (n = 8) or the artery alone (n = 4). In three cases, after resection of both vessels, the artery was reconstructed with an artificial Gore-Tex (W. L. Gore & Associates, Inc., Flagstaff, AZ) graft, and the vein was replaced with a saphenous vein graft. One patient had the femoral artery alone replaced with Gore-Tex, whereas for three patients a primary vascular repair was possible for either the femoral/popliteal artery (n = 2) or the femoral vein (n = 1).

In addition to the vascular resections in this group, three patients required resection of major motor nerves (Table 2Go). The femoral nerve was excised in two patients, one with a groin sarcoma involving the common femoral vessels and the other with a large sarcoma in the mid thigh with involvement of both the superficial and deep femoral vessels. One patient had the common peroneal nerve removed with a sarcoma in the calf that involved the peroneal and tibial vessels. Five (26%) patients developed deep venous thrombosis in the operative limb at an average of 8.2 weeks (range, 2–16 weeks) after surgery. There were 4 (33%) deep vein thromboses in 12 patients treated with prophylactic anticoagulation early in the study, compared with only 1 (14%) in 7 patients who were fully anticoagulated after vascular repair. It is interesting to note that when this last patient developed a deep vein thrombosis 3 weeks after surgery, she was found to be receiving an inadequate dose of warfarin and was not fully anticoagulated, even though she had left the hospital optimally anticoagulated 1 week earlier. After treatment for a wound complication and completion of 1 year of anticoagulation, she had only very mild extremity swelling (edema score of 1). Two deep vein thromboses occurred in the limb from which the saphenous vein had been harvested (i.e., the limb without the sarcoma), one after prophylactic and the other after full-dose anticoagulation. Clinically significant postoperative limb edema occurred in 13 (87%) of 15 assessable patients.


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  		TABLE 2. Comparison of treatment and outcomes
 
Ten (53%) of 19 patients had either local or free muscle transfers performed immediately after tumor excision and vascular reconstruction to provide adequate soft tissue coverage. Despite this, however, 13 (68%) of 19 patients developed major wound-healing complications. The limb salvage rate was 16 (84%) of 19 because 3 patients ultimately underwent amputation. One patient experienced a major wound infection despite initial local flap coverage in the distal thigh after preoperative radiation, which led to osteomyelitis and compromised function of the vascular grafts and required an above-knee amputation. One patient experienced a rupture of the iliofemoral vascular repair after repeated wound complications after preoperative radiation. Despite multiple attempts at revision of the vascular repair, including secondary local muscle coverage, hip disarticulation was required. The last patient had a local flap performed for soft tissue coverage of the proximal thigh/ inguinal region after resection of a sarcoma after preoperative radiation. A compartment syndrome developed perioperatively, likely because the saphenous vein graft used for reconstruction was too small in diameter compared with the size of the autogenous common femoral vein, thus essentially creating a relative outflow obstruction. Despite fasciotomies, severe limb swelling persisted and was followed by wound dehiscence, infection, and, finally, breakdown of the vascular anastomoses that necessitated a hip disarticulation.

There was 1 local tumor relapse in the 19 patients who underwent vascular reconstruction. This occurred in a 55-year-old patient who initially presented with metastases at diagnosis and a painful and enlarging distal thigh sarcoma involving the femoral and popliteal vessels. Despite a negative margin resection and postoperative radiation, local relapse occurred at 12 months. Because this was asymptomatic and the patient had developed progressive metastases, no further local treatment was offered, and the patient died of systemic disease at 21 months after surgery. At an average follow-up of 47 months (range, 2–128 months), 11 patients (58%) were alive without evidence of disease, 1 patient was alive with disease, 6 were dead of disease, and 1 died of unrelated causes.

Comparison of Surgical and Oncological Outcomes
The 19 patients who required vascular resection and reconstruction were well matched to the 38 patients who did not have major vessel involvement by their tumors except for disease status at presentation (Table 1Go). Six (32%) of 19 patients who underwent vascular reconstruction presented with metastatic disease, compared with only 3 (8%) of 38 in the control group (P = .02). There were no significant differences between the two study groups with respect to treatment with radiation or chemotherapy or the surgical resection margins (Table 2Go). Most patients in both groups received preoperative radiation and had their sarcomas excised with negative margins. Chemotherapy was rarely used.

There was a significant difference between the groups with respect to soft tissue management at the time of operation. Ten (53%) of 19 patients in the vascular reconstruction group required either local or free muscle transfers, compared with only 7 (18%) of 38 in the control group (P = .008). There was also a significant difference between the groups in major wound-complication rates. Thirteen (68%) of 19 vascular reconstruction patients experienced a major wound complication, compared with only 12 (32%) of 38 in the control group (P = .03). Five (26%) of 19 patients developed deep venous thrombosis after vascular reconstruction, compared with none in the control group (P = .003). Persistent postoperative limb edema was rated as moderate, severe, or very severe in 13 (87%) of 15 assessable patients after vascular reconstruction, compared with only 7 (20%) of 35 in the control group (P = .001). Limb salvage was ultimately successful in 16 (84%) of 19 vascular reconstruction patients, compared with 37 (97%) of 38 patients in the matched control group (P = .07).

The oncological outcomes of the two groups were similar (Table 2Go). Local tumor relapse occurred in only 1 of 57 patients in the entire study. Because of the high proportion of patients in the vascular reconstruction group who presented with metastatic disease (Table 1Go), systemic outcome was compared only for patients who presented without evidence of metastasis at diagnosis. The 5-year estimated disease-free survival rates were 83% for patients in the vascular reconstruction group and 74% for patients who did not require a vascular procedure (P = .7; log rank).

Comparison of Functional Outcome
The six patients in the vascular reconstruction group were similar to their individual controls on the basis of the predetermined matching criteria (i.e., similar age; similar tumor location, size, and depth; similar wound-complication status and preoperative TESS score; no motor nerve sacrifice; and no metastases at diagnosis or 1-year follow-up; Table 3Go). The mean preoperative functional TESS scores for the vascular reconstruction and control groups were 88.6 and 89.0, respectively (P = .75). The mean postoperative TESS score for the vascular reconstruction group was slightly lower but not significantly different from that of the matched control group (78.5 vs. 84.2; P = .35). On the basis of this difference of six points on the TESS score, only one vascular reconstruction patient had a higher TESS evaluation than the matched control, whereas three patients scored lower and two had similar results. Closer inspection of the individual items that make up the TESS score revealed that patients with lower TESS scores reported moderate to poor function in activities such as kneeling, walking on hills, and climbing stairs, as well as some lighter activities of daily living. Scores for work and sports were uniformly low for these patients as well.


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  		TABLE 3. Comparison of functional outcomes
 
Four of the six patient matches experienced serious wound complications requiring additional surgical management. Although 2 of the vascular reconstruction patients with wound complications (pairs 2 and 3) accounted for the lowest postoperative TESS scores in this group of 12 patients evaluated for functional outcome, 2 other vascular patients (pairs 4 and 6) had among the highest TESS scores. A greater proportion of patients who had vascular reconstruction had clinically significant limb edema (five of six vs. one of six; P = .04). However, edema scores for these patients were not directly related to the presence of wound complications or deep venous thrombosis.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In this study, we used demographic, tumor, and treatment-specific criteria to individually match our sample of 19 patients who underwent limb-salvage surgery with vascular resection and reconstruction for a soft tissue sarcoma of the extremity to 38 patients who underwent similar procedures without vascular reconstruction. We were also able to individually match six of the vascular reconstruction patients to six limb-salvage patients who did not require a vascular procedure, to compare functional outcome. We found that patients who required vascular resection and reconstruction were significantly more likely to require a muscle transfer and to experience a wound complication, deep venous thrombosis, and clinically significant limb edema; they were also at greater risk for ultimately undergoing an amputation. Although the functional outcome after vascular reconstruction was not significantly worse at 1 year after treatment, clinically significant limb edema was both more frequent and more severe.

Reports in the literature as early as 1977 described vascular resection and reconstruction in the setting of soft tissue sarcoma of the extremity.13 A review of pooled data from the literature and 2 other recent reports indicates that 10 (8.4%; range, 0%–25%) of 119 patients who underwent vascular reconstruction for a soft tissue sarcoma of the extremity ultimately required an amputation.21–23 In the current study, 3 (16%) of 19 vascular reconstruction patients required amputation, compared with only 1 (3%) of 38 in the matched limb-salvage control group; this indicates the high-risk nature of this procedure.

The higher risk for amputation in patients undergoing vascular reconstruction is multifactorial and is at least partially related to their notably higher rate of wound-associated morbidity. It is interesting to note that a higher rate of muscle flap coverage in this group of patients did not decrease the wound-complication rate. This same lack of effect of muscle flaps on decreasing wound complications after preoperative radiation for extremity sarcomas has been reported previously.28 Sixty-eight percent of the vascular reconstruction patients in this study experienced a wound complication. This was significantly higher than the control group, who had a wound-complication rate of 36%, which is similar to the preoperative radiation arm in a previously reported randomized radiation trial.28 In addition, procedures involving resection of large vessels imply the loss of more collateral vessels and disruption of lymphatic drainage channels, which further impairs wound perfusion and increases postoperative edema, as was seen in this study.

Deep venous thrombosis in vascular reconstruction patients may also be a contributing factor for limb edema and amputation. However, in the vascular repair patients who were matched for functional outcome, postoperative limb edema was not associated with the occurrence of deep venous thrombosis. A significantly greater proportion of patients in the vascular reconstruction group did develop deep venous thrombosis in this study, although the risk varied according to the postoperative anticoagulation protocol. Deep vein thrombosis was more than twice as likely to occur in patients with vascular repair if they were treated with prophylactic compared with full anticoagulation. As a result, we now treat these patients with prophylactic anticoagulation for only a short time after surgery, and then full anticoagulation is initiated. Although no complications in this study could be directly attributed to wound hematoma, it must be recognized that prophylactic and especially full-dose anticoagulation may have played a role in the high incidence of wound-healing complications, particularly in the patients who underwent vascular repair. However, the benefits of anticoagulation in minimizing thromboembolic disease likely outweigh its potential effect on wound healing.

The literature also reports a high rate of postoperative wound complications in patients undergoing vascular reconstruction. Although major wound complications have been reported to occur in 15% to 20% of these cases, a review of the pooled data in the literature for both bone and soft tissue sarcomas reported 43 complications (46%) in 92 patients; these complications included wound dehiscence, hematoma, and swelling.21,22 This may be lower than the wound-complication rate reported in our investigation because we also included complications that required prolonged nonoperative management, such as deep wound packing.28

Extensive vascular involvement by extremity sarcoma raises a major concern regarding not only the risk of local recurrence after limb salvage surgery, but also the potential increased risk for metastatic disease. In general, patients presenting with extremity sarcoma complicated by vascular involvement are at a higher risk of requiring amputation, and only a subset are eligible for limb-salvage procedures.33 However, only 1 local recurrence occurred in the 19 patients treated with vascular reconstruction in this series, and this supports the oncological safety of limb-salvage procedures for these patients. A higher proportion of patients in the vascular reconstruction group presented with systemic disease (32% vs. 8%). However, when metastasis-free survival was compared for patients presenting with localized disease, there was no difference between the two treatment groups. In the current series of 19 vascular reconstruction patients, 11 (58%) were alive without evidence of disease at a mean of 47 months’ follow-up, which is almost identical to pooled data from the literature for patients undergoing similar procedures.21

The functional outcome of patients who undergo limb-salvage surgery with vascular reconstruction has been described only briefly in the literature. Leggon et al.21 reported that for 58 patients for whom functional outcome was available from their pooled data from the literature, 76% had a "functional limb." Bonardelli et al. reported on function after vascular reconstruction by using the Musculoskeletal Tumor Society Rating Scale, a clinician-completed assessment of impairment, and reported good results in six patients and fair results in one.23,34 Koperna et al.18 found similar results in 13 patients by using the same rating system.

Our group has previously shown that the main determinants of functional outcome after limb-salvage surgery and radiotherapy for soft tissue sarcoma are tumor size, wound complications, and motor nerve sacrifice.26,27 In considering functional outcome between patients who underwent vascular reconstruction and those who did not, strict matching criteria were used, including similar tumor size, wound complications, and preoperative TESS functional scores. Patients in these groups were not matched for the timing of radiation because functional outcome at 1 year after treatment is more closely related to wound-complication status.26 In addition, none of the patients had motor nerve sacrifice so that the functional comparison would specifically address the issue of vascular reconstruction. In this study, we used the TESS, which is a reliable patient-derived measure of physical disability developed specifically for the extremity sarcoma population.30 The TESS score evaluates the patient’s perceptions of difficulty with activities of daily living, mobility, work, and recreation and has been systematically validated.

Overall, we found that patients with similar demographics, tumors, treatment, complications, and preoperative function had only slightly lower postoperative TESS scores at 1 year if vascular resection and reconstruction were performed as part of their limb-salvage surgery. Although the mean difference of six points on TESS evaluation was not statistically significant in our study, previous work has shown that this magnitude of change is likely to be clinically meaningful.35 Applying this degree of change to the individual matches (Table 3Go) suggests that one vascular reconstruction patient had better postoperative function, two had similar function, and three had worse function than patients who did not require vascular resection and repair. It is interesting that the functional difference between the two groups was not greater even though the vascular reconstruction patients had more frequent and severe limb edema after treatment. It must be emphasized that this functional comparison is based on two very closely matched patient groups. Because complications including deep venous thrombosis and limb edema are much more frequent in patients who require vascular repair, these patients are more likely to have a worse functional outcome.

Advances in adjuvant treatment protocols and improvements in imaging techniques have helped reduce the amputation rate for soft tissue sarcomas to approximately 5%.33,36–39 Moreover, improvements in operative techniques have enabled the surgical oncologist to perform successful limb-salvage surgery, even in the face of vascular invasion or encasement by tumor, as described in this study. En-bloc resection of major vascular structures with the tumor and reconstruction with reversed saphenous vein grafts or synthetic grafts has proven to be a feasible option in limb-salvage surgery. However, the surgical oncologist and patient should be aware that although overall function is only slightly worse after these procedures, individual functional results are less predictable. In addition, these procedures are associated with an increased risk of complications, including amputation.


   ACKNOWLEDGMENTS
 
A.M.D. is supported by a Health Career Award from the Canadian Institutes of Health Research. This investigation was supported by an Interdisciplinary Health Research Team Grant in Musculoskeletal Neoplasia from the Canadian Institutes of Health Research.

Received for publication June 23, 2004. Accepted for publication July 20, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Benjamin RS. Limb salvage surgery for sarcomas: a good idea receives formal blessing. JAMA 1985;254:1795–6.[Abstract/Free Full Text]
  2. Clark MA, Fisher C, Judson I, Thomas JM, Soft-tissue sarcomas in adults. N Engl J Med 2005;353:701–1.[Free Full Text]
  3. Karakousis CP, Emrich LJ, Rao U, Krishnamsetty RM. Feasibility of limb salvage and survival in soft tissue sarcomas. Cancer 1986;57:484–91.[CrossRef][Medline]
  4. Karakousis CP, Emrich LJ, Rao U, Khalil M. Selective combination of modalities in soft tissue sarcomas: limb salvage and survival. Semin Surg Oncol 1988;4:78–81.[Medline]
  5. Karakousis CP, Emrich LJ, Rao U, Khalil M. Limb salvage in soft tissue sarcomas with selective combination of modalities. Eur J Surg Oncol 1991;17:71–80.[Medline]
  6. Kraybill WG, Emami B, Lyss AP. Management of soft tissue sarcomas of the extremities. Surgery 1991;109:233–5.[Medline]
  7. Wilson AN, Davis A, Bell RS, et al. Local control of soft tissue sarcoma of the extremity: the experience of a multidisciplinary sarcoma group with definitive surgery and radiotherapy. Eur J Cancer 1994;30:746–51.
  8. Popov P, Tukiainen E, Asko-Seljaavaara S, et al. Soft tissue sarcomas of the lower extremity: surgical treatment and outcome. Eur J Surg Oncol 2000;26:679–85.[Medline]
  9. Steinau HU, Buttemeyer R, Vogt P, Hussmann J, Hebebrand D. Limb salvage and reconstructive procedures in soft tissue sarcomas of the extremities. Recent Results Cancer Res 1995;138:31–9.[Medline]
  10. Bickels J, Wittig JC, Kollender Y, et al. Sciatic nerve resection: is that truly an indication for amputation? Clin Orthop 2002;399;201–4.
  11. Fuchs B, Davis AM, Wunder JS, et al. Sciatic nerve resection in the thigh: a functional evaluation. Clin Orthop 2001;(382): 34–41.
  12. Brooks AD, Gold JS, Graham D, et al. Resection of the sciatic, peroneal, or tibial nerves: assessment of functional status. Ann Surg Oncol 2002;9:41–7.[Abstract/Free Full Text]
  13. Fortner JG, Kim DK, Shiu MH. Limb-preserving vascular surgery for malignant tumors of the lower extremity. Arch Surg 1977;112:391–4.[Abstract/Free Full Text]
  14. Matsushita M, Kuzuya A, Mano N, et al. Sequelae after limb-sparing surgery with major vascular resection for tumor of the lower extremity. J Vasc Surg 2001;33:694–9.[Medline]
  15. Imparato AM, Roses DF, Francis KC, Lewis MM. Major vascular reconstruction for limb salvage in patients with soft tissue and skeletal sarcomas of the extremities. Surg Gynecol Obstet 1978;147:891–6.[Medline]
  16. Karakousis CP, Karmpaliotis C, Driscoll DL. Major vessel resection during limb-preserving surgery for soft tissue sarcomas. World J Surg 1996;20:345–9.[Medline]
  17. Kawaii AH, Inoue H, Uchida H, San S. Vascular reconstruction in limb salvage operations for soft tissue tumours of the extremities. Clin Orthop 1996;332:215–22.
  18. Koperna T, Teleky B, Vogl S, et al. Vascular reconstruction for limb salvage in sarcoma of the lower extremity. Arch Surg Oncol 1996;131:1103–7.
  19. Nambisan RN, Karakousis CP. Vascular reconstruction for limb salvage in soft tissue sarcomas. Surgery 1987;101: 668–77.[Medline]
  20. Steed DL, Peitzman AB, Webster MW Jr, Ramasastry SS, Goodman MA. Limb sparing operations for sarcomas of the extremities involving critical arterial circulation. Surg Gynecol Obstet 1987;164:493–8.[Medline]
  21. Leggon RE, Huber TS, Scarborough MT. Limb salvage surgery with vascular reconstruction. Clin Orthop 2001;387:207–16.
  22. Hohenberger P, Allenberg JR, Schlag PM, Reichardt P. Results of surgery and multimodal therapy for patients with soft tissue sarcoma invading to vascular structures. Cancer 1999;85:396–408.[CrossRef][Medline]
  23. Bonardelli S, Nodar F, Maffeis R, et al. Limb salvage in lower-extremity sarcomas and technical details about vascular reconstruction. J Orthop Sci 2000;5:555–60.[Medline]
  24. Stinson SF, DeLaney TF, Greenberg J, et al. Acute and long-term effects on limb function of combined modality limb sparing therapy for extremity soft tissue sarcoma. Int J Radiat Oncol Biol Phys 1991;21:1493–9.[Medline]
  25. Lampert MH, Gerber LH, Glatstein E, Rosenberg SA, Danoff JV. Soft tissue sarcoma: functional outcome after wide local excision and radiation therapy. Arch Phys Med Rehabil 1984;65:477–80.[Medline]
  26. Davis AM, O’Sullivan B, Bell RS, et al. Function and health status outcomes in a randomized trial comparing preoperative and postoperative radiotherapy in extremity soft tissue sarcoma. J Clin Oncol 2002;20:4472–7.[Abstract/Free Full Text]
  27. Davis AM, Sennik S, Griffin AM, et al. Predictors of functional outcomes following limb salvage surgery for lower-extremity soft tissue sarcoma. J Surg Oncol 2000;73:206–11.[CrossRef][Medline]
  28. O’Sullivan B, Davis AM, Turcotte R, et al. Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomised trial. Lancet 2002;359:2235–41.[CrossRef][Medline]
  29. Stern TN. Clinical Examination: A Textbook for Physical Diagnosis. Chicago: Year Book Medical Publishers, 1964.
  30. Davis AM, Wright JG, Williams JI, Bombardier C, Griffin A, Bell RS. Development of a measure of physical function for patients with bone and soft tissue sarcoma. Qual Life Res 1996;5:508–16.[CrossRef][Medline]
  31. Wilcoxon F. Individual comparisons by ranking methods. Biometrics 1945;1:80–3.[CrossRef]
  32. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–81.[CrossRef]
  33. Ghert MA, Abudu A, Driver N, et al. The indications for and the prognostic significance of amputation as the primary surgical procedure for localized soft tissue sarcoma of the extremity. Ann Surg Oncol 2005;12:10–7.[Abstract/Free Full Text]
  34. Enneking WF, Dunham W, Gebhardt MC, Malawer M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop 1993;286:241–6.
  35. Davis AM, Bell RS, Badley EM, Yoshida K, Williams JI. Evaluating functional outcome in patients with lower extremity sarcoma. Clin Orthop 1999;358:90–100.
  36. Williard WC, Collin C, Casper ES, Hajdu SI, Brennan MF.The changing role of amputation for soft tissue sarcoma of the extremity in adults. Surg Gynecol Obstet 1992;175:389–96.[Medline]
  37. Vraa S, Keller J, Nielsen OS, Sneppen O, Jurik AG, Jensen OM. Prognostic factors in soft tissue sarcomas: the Aarhus experience. Eur J Cancer 1998;34:1876–82.[CrossRef][Medline]
  38. Eilber RR, Mirra JJ, Grant TT. Is amputation necessary for sarcomas. Ann Surg 1980;192:431–8.[Medline]
  39. Rosenberg SA, Tepper J, Glatstein E, et al. The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. Ann Surg 1982;196:305–15.[Medline]



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