Vascular reconstruction after retroperitoneal and lower extremity sarcoma resection

Purpose

Soft tissue sarcomas (STS) of the retroperitoneum and the lower limb with invasion of major blood vessels are very rare malignancies. This study analyses the outcome of patients with vascular replacement during resection of STS of the retroperitoneum and the lower extremity with either arterial or concomitant arterial and venous infiltration.

Equal quality of life after limb-sparing or ablative surgery for lower extremity sarcomas

This study investigated quality of life (QoL) and function of 124 patients with lower extremity sarcoma who underwent either amputation or limb-salvage surgery (LSS) in order to assess potential differences in subjective treatment outcome. The results reflect similar QoL in both treatment groups. However, in contrast to patients with LSS, who described QoL in terms of a high physical performance status with sports and recreational activities, amputees' QoL was strongly associated with their social acceptability. High QoL in amputees brings into question the expectations held with time-consuming advanced technical skills for LSS by physicians.     

Results of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma in the lower extremity: comparison between only arterial and arterovenous reconstruction

BACKGROUND: Reports on vascular reconstruction in conjunction with limb salvage techniques for soft tissue sarcomas in the lower extremity have been published. The aim of this study was to investigate the necessity for venous reconstruction by comparing the results of arterial reconstruction alone and those of arteriovenous reconstruction. METHODS: Twenty-five (6.7%) of 373 patients underwent vascular resections for lower limb soft tissue sarcomas. Only arterial reconstruction was performed for 12 patients. Arteriovenous reconstruction was performed for 13 patients. The clinical results, complications, and postoperative function were compared between only arterial reconstruction group and arteriovenous reconstruction group. RESULTS: Limb salvage was achieved in 92% of all cases. No local recurrence has been observed. Nineteen patients (76%) are continuously free of disease. Histopathologic examination of the specimens showed that blood vessels had been infiltrated in 24%. The mean Musculoskeletal Tumor Society score was 70%. There were no significant differences in complication rate and postoperative function between two groups. CONCLUSIONS: Wide resection with vascular reconstruction for patients of soft tissue sarcomas involving major vessels in the lower limb provide long term local control and limb salvage. This study could not indicate the usefulness of additional venous reconstruction after vascular resection in the lower extremity.     

Case of epithelioid sarcoma of the lower extremity

A 26-year-old woman with epithelioid sarcoma is reported. An 8 X 4 cm mass was present in the pretibial region of the right leg. The operative specimen revealed a solid mass with necrosis and hemorrhage. Histologically, the tumor consisted of large round or oval cells with rich and eosinophilic cytoplasm and many vascular invasions. Electron-microscopically, the tumor was composed of light and dark cells. The dark cells showed abundant microfibrils in their cytoplasm compared to the light cells. We posit that the tumor was of synovial cell origin because of the presence of cytoplasmic microfibrils, pinocytotic vesicles and filopodias or microvilli-like structures.     

康复护理对下肢骨肿瘤微波灭活保肢术后患者疗效和生活质量的影响

目的探讨康复护理对下肢骨肿瘤微波灭活保肢术后患者疗效和生活质量的影响。方法选取2012年5月至2013年5月间青岛市市立医院收治的74例下肢骨肿瘤患者,采用等距随机抽样法分为观察组和对照组,每组37例。观察组患者采用康复护理模式,对照组患者采用常规护理模式,对比两组患者护理前后的视觉模拟评分(VAS)和生活质量评分,及护理后的肢体功能、并发症发生率和生存率。结果护理前,两组患者的VAS和生活质量评分比较,差异无统计学意义(P>0.05)。护理后观察组患者各时间段VAS评分均低于对照组患者,生活质量评分均高于对照组患者,差异均有统计学意义(均P<0.05)。护理后,观察组患者的生存率和肢体功能优良率分别为89.2%和94.6%,均明显高于对照组的64.9%和78.4%,差异均有统计学意义(均P<0.05)。观察组患者并发症发生率为8.1%,明显低于对照组的29.7%,差异有统计学意义(P<0.05)。结论康复护理可有效提高微波灭活保肢手术治疗下肢骨肿瘤患者的生活质量,缓解疼痛症状,降低并发症发生率,对肢体功能的恢复产生积极影响,宜广泛推广。     

介入化疗与保肢手术治疗软组织肉瘤

目的研究术前动脉介入化疗与手术治疗肢体软组织肉瘤。方法21例肢体软组织肉瘤，其中13例(62％)术前影像学显示肿瘤邻近大血管或骨骼侵犯，采用股动脉及肱动脉插管，化疗2—3周后，施行肿瘤切除及保留肢体功能的手术。结果介入化疗后病理检查，肿瘤有不同程度的坏死，体积缩小，周围水肿浸润带减少，肿瘤与邻近组织术中易分离，术后随访6—62个月，患肢功能基本正常。结论对四肢软组织肉瘤侵犯大血管、骨骼者，术前动脉介入化疗可提高切除率，降低局部复发及保存患肢。     

Function and quality-of-life of survivors of pelvic and lower extremity osteosarcoma and Ewing's sarcoma: the Childhood Cancer Survivor Study

Limb-sparing surgeries have been performed more frequently than amputation based on the belief that limb-sparing surgeries provide improved function and quality-of-life (QOL). However, this has not been extensively studied in the paediatric population, which has unique characteristics that have implications for function and QOL. Using the Childhood Cancer Survivor Study, 528 adult long-term survivors of pediatric lower extremity bone tumours, diagnosed between 1970 and 1986, were contacted and completed questionnaries assessing function and QOL. Survivors were an average of 21 years from diagnosis with an average age of 35 years. Overall they reported excellent function and QOL. Compared to those who had a limb-sparing procedure, amputees were not more likely to have lower function and QOL scores and self-perception of disability included general health status, lower educational attainment, older age and female gender. Findings from this study suggest that, over time, amputees do as well as those who underwent limb-sparing surgeries between 1970 and 1986. However, female gender, lower educational attainment and older current age appear to influence function, QOL and disability.     

软组织肉瘤动脉灌注新辅助化疗后的保肢治疗

目的探讨术前动脉内灌注化疗对软组织肉瘤的疗效及在保肢治疗中的意义。方法28例肢体软组织肉瘤,其中恶性纤维组织细胞瘤18例,滑膜肉瘤3例,脂肪肉瘤6例,原始神经外胚层肿瘤（PNET）1例。术前均给予选择性肿瘤供血动脉灌注化疗2-3周期,化疗药物为阿霉素／顺铂和异环磷酰胺。化疗后均行保肢手术治疗。结果28例术前化疗后均有疼痛缓解、皮温降低、肿胀减轻、瘤体不同程度缩小、边缘变清楚及关节活动度增加。化疗后均行肿瘤广泛切除术,术中获得良好的外科切除界限。随访6-46个月,平均25个月。2例死亡,1例局部复发行截肢术。术后12个月后采用MSTS93评分系统评分为24-29分,平均为27分。28例3年生存率为92.9％,初次保肢率100％,最终保肢率89.3％。结论肢体软组织肉瘤术前动脉灌注新辅助化疗是一种有效的保肢治疗方法。     

Ewing's sarcoma of a lower extremity in an infant. A therapeutic dilemma

A 5.5-month-old infant with Ewing's sarcoma of the left femur is described. The clinical and the pathologic features in this infant are presented in detail, and the dilemma faced in diagnosis and therapy of Ewing's sarcoma in infants is discussed. It is suggested that Ewing's sarcoma in an infant with a lower extremity lesion may be adequately managed without primary amputation.     

关节置换术治疗下肢骨肿瘤的临床疗效及安全性分析

目的探讨关节置换术治疗下肢骨肿瘤的临床疗效及安全性。方法选取2016年3月至2018年3月间榆林市第三医院收治的62例下肢骨肿瘤患者,采用随机数字表法分为观察组和对照组,每组31例。对照组患者采用常规手术治疗,观察组患者采用人工关节置换术,术后随访1年,比较两组患者的临床疗效及并发症发生情况。结果两组患者术中出血量和手术时间比较,差异无统计学意义(P> 0. 05);观察组患者住院天数少于对照组,差异有统计学意义(P <0. 05)。术前,两组患者Harris和NHP评分比较,差异均无统计学意义(P> 0. 05)。术后1年,两组患者Harris评分均高于术前,且观察组高于对照组,两组患者NHP评分均低于术前,且观察组低于对照组,差异均有统计学意义(均P <0. 05)。术后随访1年,观察组患者并发症发生率为6. 5%,低于对照组的25. 8%,组间比较,差异有统计学意义(P <0. 05)。结论人工关节置换术治疗下肢骨肿瘤临床疗效较好,且安全性可靠,值得临床运用。     

The significance of a marginal excision after preoperative radiation therapy for soft tissue sarcoma of the extremity

BACKGROUND:

Marginal excision of soft tissue sarcoma (STS), defined as resection through the tumor pseudocapsule or surrounding reactive tissue, increases the likelihood of local recurrence and necessitates re‐excision or postoperative radiation. However, its impact after preoperative radiation therapy (RT) remains unclear. This study therefore investigated the significance of marginal margins in patients treated with preoperative RT for extremity STS, reporting long‐term local control and limb preservation endpoints.

METHODS:

The records of 317 adults at the University of Florida with nonmetastatic extremity STS treated from 1980 to 2008 with preoperative RT as part of a limb conservation strategy were reviewed. The median follow‐up was 4.7 years (8.3 years for living patients). The median tumor size was 10 cm (range, 2‐36 cm), and 86% were high grade. The median RT dose was 50.4 Gy (range, 12.5‐57.6 Gy). Margins were classified as wide/radical (n = 105), marginal (n = 179), contaminated (n = 15), positive (n = 17), or unknown (n = 1). Endpoints were local control (LC), amputation‐free survival (AFS), cause‐specific survival (CSS), and overall survival (OS).

RESULTS:

Five‐year CSS and OS rates were 62% and 59%, respectively. Five‐year LC and AFS was 93% and 89%, respectively. AFS by margin status was 64%, 83%, 97%, and 92% for positive, contaminated, marginal, and wide/radical margins, respectively (P<.005). Marginal excision following preoperative RT resulted in equivalent LC and AFS compared with wide/radical margins.

CONCLUSIONS:

Marginal resection after preoperative RT does not compromise LC or AFS in extremity STS. This finding may be related to radiosterilization of tumor cells within the reactive zone following preoperative RT. Cancer 2012;118: 3199–207. © 2011 American Cancer Society.     

Palliative percutaneous stabilization of lower extremity for bone metastasis using flexible nails and bone cement

ObjectivePercutaneous stabilization (PS; percutaneous flexible nailing and intramedullary bone cement injection) was performed at lower extremity long bones in patients with multiple bone metastases with short life expectancy to get mechanical stability and local tumor control. We evaluated the usefulness of PS by clinical status, F-18-FDG PET-CT and bone scintigraphy (BS).MethodsPatients comprised 15 patients (total 20 sites) who had undergone PS for the metastatic bone tumors of lower extremity long bones (femur and tibia). After percutaneous flexible nailing, bone cement was injected (mean amount = 15.5 ± 6.4 ml). Patients' clinical status was evaluated by visual analog scale (VAS). Qualitative assessment of PET-CT and BS was categorized by improved, stable and aggravated states of PS lesion. Quantitative assessment of PET-CT was performed by maximum and mean standardized uptake value (SUVmax and SUVmean).ResultsPS was performed in all of the patients without complication, and showed significant pain improvement of VAS (7.2 ± 0.2 vs. 2.8 ± 0.3, P < 0.001). PS lesion showed improved state in 65% (13/20) and stable state in 35% (7/20). However, naive bony metastatic lesion showed mostly aggravated state in 90% (19/20) in the same patients, which was significantly different compared with PS lesion (P < 0.001). In PS lesion, SUVmax (10.1 ± 6.9 vs. 7.1 ± 5.2, P = 0.008) and SUVmean (6.2 ± 4.8 vs. 4.6 ± 3.7, P = 0.008) showed significantly decreased uptake after PS.ConclusionBy PS in lower extremity long bones, patients can reduce regional pain, and has the possibility of local tumor control. PS can be performed for lower extremity bone metastasis in poor general condition to perform conventional intramedullary nailing.     

Optimizing radiation therapy and post-treatment function in the management of extremity soft tissue sarcoma

Opinion statement When treating soft tissue sarcomas (STS) of the extremities, the major therapeutic goals are survival, local tumor control, optimal function, and minimal morbidity. Surgical resection of the primary tumor is the essential component of treatment for virtually all patients. However, local control by surgery alone is poor for the majority of patients with extremity lesions unless the procedure removes large volumes of grossly normal tissue (ie, widely negative margins are attained, because sarcomas tend to infiltrate normal tissue adjacent to the evident lesion). Thus, removal of the gross lesion by a simple excision alone is followed by local recurrence in 60% to 90% of patients. Radical resections reduce the local recurrence rate to 10% to 30%, but may compromise limb function. The combination of function-sparing surgery and radiation achieves better outcomes than either treatment alone for nearly all patients with STS. Because both surgical and radiation technique are critically important for optimizing local control of tumor and functional outcome, it is important to manage these patients in dedicated multispecialty clinics comprised of physicians with expertise in sarcomas, including orthopedic and general oncologic surgeons, radiation oncologists, medical oncologists, sarcoma pathologists, and bone and soft tissue diagnostic radiologists. Radiation therapy can be given by external beam radiation therapy (EBRT) or brachytherapy (BRT) or combination thereof. External beam radiation can be given either preoperatively or postoperatively. The clinical considerations and the outcome data that must be considered in choosing the most appropriate treatment technique for the individual patient are discussed.     

巨大腹膜后肿瘤的术前评估和手术策略

腹膜后肿瘤（retroperitoneal tumor,RPT）发病较为隐匿,出现症状时肿瘤往往体积较大,多侵犯周围组织与脏器,尤其是腹腔重要血管,是RPT手术主要难点。累及大血管RPT的处理常被很多外科医生视为禁区,但手术仍是目前治疗该病唯一有效的方法,累及大血管RPT的处理决策是提高肿瘤手术切除率的关键。因此,术前对肿瘤累及血管程度的评估,术中对血管重建技术的应用对于肿瘤完整切除至关重要。术前应用影像学检查了解RPT与腹腔大血管之间的关系、浸润情况,手术中良好的术野为处理和控制血管出血创造了有利条件;累及大血管RPT在完整切除时,需要对一些重要的血管进行修复与重建,自体血管的使用技术已日益成熟,人工血管和补片的应用也为手术创造了条件。术前评估、手术策略、术后管理对肿瘤外科医生在累及大血管RPT的患者治疗过程中起着至关重要的作用。