Diagnostik und Therapie von Weichteilsarkomen der Extremitäten

The diagnosis of unclear soft tissue tumors represents a common problem in everyday clinical practice. Magnetic resonance imaging often reveals some first information about soft tissue tumors; however, clarification of the dignity can only be achieved by histopathological examination. Most of the lesions are benign but should be treated as a malignant tumor until this can be excluded as unnecessary surgery or biopsies can complicate treatment and worsen the prognosis. These aspects in particular are summarized and discussed in this article.     

Die Bedeutung von Referenzzentren in Diagnose und Therapie von Weichgewebssarkomen der Extremitäten

Correct histopathologic diagnosis is essential for adequate treatment of soft tissue sarcomas. Due to the disorder’s rarity, multitude of subgroups, sometimes varying histopathologic appearance, and occasionally inadequate biopsy specimens, diagnosis and grading are challenging. The records of 603 patients with soft tissue tumors of the extremities were reviewed concerning mismatches in primary and definite diagnoses relating to entity, evaluation of primary or recurrent tumor specimens, and the diagnosing pathology institution. For second opinions we referred to the Institute of Pathology of the Ruhr University at the Bergmannsheil Hospital in Bochum, Germany, and to the Pathology Institute of the University of Jena, also in Germany. Liposarcoma and malignant fibrous histiocytoma were the most often diagnosed subgroups at 24% and 22.6%, respectively. In the eight most frequent sarcoma types, malignant peripheral nerve sheath tumors and leiomyosarcoma had the highest rates of false primary diagnosis, 78.4% and 74.2% of cases, respectively. The diagnostic error ratio for nonspecialized pathologists in practice, community hospital pathologists, and academic medical centers was over 60%. For optimal treatment of soft tissue sarcomas, we suggest obtaining expert second opinion to ensure adequate surgical therapy and precise indications for radiation and chemotherapy.     

Bildgebung und Interventionen bei Weichteilsarkomen der Extremitäten

Background

Soft tissue sarcomas are rare tumors comprising approximately 1% of all adult malignancies. The long-term outcome as well as the success of local and systemic therapeutic methods crucially depends on the correct local staging of the primary tumor as well as the tumor extent using whole body staging.

Principles

In addition to classical projection radiographic techniques and ultrasound, magnetic resonance imaging (MRI) plays a leading role in local staging of soft tissue sarcomas. Due to the high soft tissue contrast as well as the lack of ionizing radiation, it is the ideal method for evaluation and therapy monitoring after treatment of soft tissue sarcomas. Due to the metastatic pattern of soft tissue sarcomas, whole body staging is recommended. A sensitive method is available with computed tomography (CT). The combination with metabolic methods, such as positron emission tomography (PET) in terms of PET/CT, allows a further increase in the sensitivity for pathological findings. Interventional methods, e.g. biopsy and embolization for preoperative preparation, are also used to optimize the outcome.

Conclusion

Only through the targeted use of modern imaging techniques is it now possible to ensure correct local and systemic staging of soft tissue sarcomas to ensure adequate long-term survival. In interdisciplinary cooperation in a sarcoma center, the selection of methods and the use of interventional procedures should be decided based on the individual patient situation in order to ensure optimal treatment success up to long-term freedom from tumors.

     

Weichteilsarkome der Extremitäten

Whereas amputation was regularly carried out as a curative treatment strategy for soft tissue sarcomas of the extremities three decades ago, limb salvage procedures are nowadays preferred. In combination with adjuvant irradiation these procedures do not lead to higher recurrence rates.Limb salvage procedures are only considered if tumor-free resection margins and superior function can be achieved by extremity preservation compared with amputation. The modularity is a specific feature of tumor prostheses and forms the basis for the extensive flexibility of the surgeon and comprehensive possibilities for bone and joint reconstruction. The success of the development of modular tumor prostheses must be considered against the background of high rates of complications and revision.Studies of megaprostheses of the lower extremities show an implant survival of 77–100% after 10 years and a failure rate of 22% over 10 years. Due to a lower mechanical stress the results are better for the upper extremities. Infection rates for proximal humeral replacement are low. In contrast infection rates after proximal or distal femoral or proximal tibial replacement can be as high as 20–25%. After bone and joint replacement of the lower extremities and in particular after proximal tibial replacement, significant functional deficits are to be expected. Better results are reported after proximal femoral replacement and reconstructive procedures of the upper extremities.Studies on the quality of life after extremity preservation by means of tumor prostheses should include evaluation of complication and revision rates and aspects of postoperative function. An overall analysis of these factors is required for conclusive statements about amputation vs. reconstruction in individual cases.     

Analyse und Korrektur von Beindeformitäten

Die Unfallchirurgie -     

Resektionsmethodik und funktionelle Wiederherstellung bei Weichgewebesarkomen der Extremitäten

Zusammenfassung. Bei Weichgewebesarkomen der Extremit?ten stellt die weite Excision in sano (R0) den wichtigsten Parameter zur Verhütung eines Lokalrezidivs dar. Es werden die taktischen und technischen Parameter beschrieben und diskutiert, die bei Biopsie und definitiver Tumorresektion die lokalen Komplikationsraten senken. Plastisch rekonstruktive Methoden erlauben dabei die Deckung ausgedehnter onkologischer Defekte, und reduzieren Infekt- sowie radiogene Sch?den. In der Extremit?tenperipherie gelingt die Gliedma?enerhaltung in mehr als der H?lfte der F?lle nur mit Hilfe dieser Techniken.      

Zur Systematik der Weichteilsarkome der Extremitäten und des Stammes

Ohne Zusammenfassung Mit 8 Textabbildungen     

Untersuchungen über die spontane Gangrän der Extremitäten und ihre Abhängigkeit von Gefässerkrankungen

Ohne Zusammenfassung Aus der chirurg. Abtheilung des Hrn. Docent W. Zoege v. Manteuffel im Dorpater Bezirkshospital und aus seiner Privatpraxis (Mit 2 Abbildungen.) [Fortsetzung aus Bd. XXXIX.]     

Vollhauttransplantate bei Verbrennungsschäden und Hautmißbildungen an Extremitäten

Ohne ZusammenfassungMit 3 Textabbildungen in 6 Einzeldarstellungen     

Operative Interdisziplinarität. Extremitäten

From the perspective of trauma and orthopedic surgery interdisciplinary reconstructive surgery of the extremities encompasses different indications ranging from IIIB/Copen fractures with major segmental loss of bone and soft tissue, to arterial vessel in-jury necessitating vascular repair and to biological, plastic reconstructions following resections of musculoskeletal tumors. The interdisciplinary treatment concept including trauma-orthopedic surgery combined with vascular, plastic and neuro- as well as microsurgery has significantly decreased amputation rates and functional deficits thereby improving quality of life and long-term oncological outcome The multisdisciplinary management of both complex trauma and malignant bone/ soft tissue sarcoma of the extremity is an integral task of the surgical trauma or tumor center. Close interdisciplinary communication and expierence are the precondition for performance of a priority-adapted therapeutic strategy, low complication rates and improvement of overall prognosis.     

Ueber die von mir angewandten Behandlungsmethoden von Fracturen der grossen Knochen der Extremitäten und Gelenkresectionen und die dabei erzielten Resultate

Ohne Zusammenfassung     

Offener Latissimus-dorsi-Transfer – Indikation und Technik

In cases of irreparable posterosuperior rotator cuff tears, patients suffer from pain and loss of shoulder function particularly in outer rotation. Latissimus dorsi transfer can lead to improvement in overall shoulder pain and function. Open or arthroscopy-assisted tendon transfer is possible but correct indication for successful treatment is essential. Definite results and outcome after latissimus dorsi transfer can be expected two years after surgery. Progression of cuff tear arthropathy is possible but successful tendon transfer of latissimus dorsi might delay need for a prosthesis especially in young patients.     

Verhütung und Behandlung von Zirkulationsstörungen an den Extremitäten Unfall- und Kriegs-Verletzter durch elastische Klebe-Kompressionsverbände

Zusammenfassung Die elastischen Klebe-Kompressionsverb?nde haben sich bei der Prophylaxe und der Behandlung von Zirkulationsst?rungen an den Beinen Unfall- und Kriegsverletzter allen anderen Ma?nahmen überlegen gezeigt. Gleich gute Erfolge hatten wir bei der Behandlung der ?deme nach Verletzungen an der oberen Extremit?t, insbesondere beim posttraumatischen Handrücken?dem. Herrn Direktor Paul Lohmar zum 70. Geburtstag gewidmet.     

Defektmissbildungen an den unteren Extremitäten

Malformations with deficiencies of the lower extremities are rare. They are usually caused by toxic influences during pregnancy between the 4th and the 12th week of gestation. Some malformations have a genetic origin. The total incidence of congenital deficiencies of the lower extremities is approximately 18 in 100,000 newborns. The most common deficiencies are fibular hemimelias, followed by congenital femoral deficiencies and tibial hemimelias. Hemimelias are often associated with deficient toes or ray defects. Congenital pseudarthrosis of the tibia is less common, but this diagnosis is underestimated in epidemiological studies in neonates, because the fracture usually only occurs at walking age. Other deficiencies such as bladder exstrophy with pelvic defects, split feet and defects in association with hereditary skeletal dysplasias (Apert syndrome, constriction band syndrome) are extremely rare. Various treatment options are available, including shoe elevation, orthotic or prosthetic devices, realignment osteotomy, arthrodesis, rotationplasty, amputation and surgical leg lengthening. Complex deformities should be treated by a team of specialists such as orthopedic surgeons, orthotists, physiotherapists, psychologists and possibly other surgeons too.     

Das akute Kompartmentsyndrom der Extremitäten

Acute compartment syndrome of the upper and lower limbs is observed following trauma, reperfusion or as an intraoperative complication caused by positioning. The pathophysiology of the disorder has been extensively described and is well known as a loss of perfusion due to rising compartmental pressures. It is a serious and potentially limb- and life-threatening complication. Early diagnosis is made primarily based on clinical findings. Early and focused therapy is crucial to prevent the devastating complications of this acute condition. However, diagnosis can be difficult, particularly in unconscious patients. Thus, in uncertain cases, pressure measurements are essential. Dermato-fasciotomy is the routine method to decompress the compartmental space. This review article examines the clinical findings, diagnostic techniques, and management options for the patient with musculoskeletal injuries.     

Achsenfehler an den unteren Extremitäten

Deviations in the axes can be physiological or pathological. During growth, the axes of the lower extremities undergo significant changes. The femoral neck-shaft-angle decreases from 150 degrees on average at birth to 120 degrees on average at the end of growth. The lower leg is bowed in a varus direction at birth. After a child begins to walk, the knee axis deviates to a slight valgus. This goes back to normal before the age of ten. Pathologic deviations of the axis are rare. They occur in congenital deformations, after trauma or infection, or as a result of metabolic diseases. In association with coxa vara pseudarthrosis of the femoral neck usually develops. Therefore this deformation has to be treated. Correction is best made with a Y-shaped osteotomy according to Pauwels. At the lower leg, a deviation of 15 degrees from the normal axis is usually an indication for operative treatment. In children and adolescents, corrections are best made with (monolateral) external fixators. They allow early weight bearing, which is especially desirable in bilateral corrections.     

Diagnostik und sofortige Therapiemaßnahmen bei Verletzungen der Extremitäten

OBJECTIVE: Limb injuries are often underestimated in the diagnostic procedures initiated in the resuscitation room. Missed diagnosis is therefore a frequent consequence in this issue. A systematic analysis of evidence-based procedures was therefore investigated in this paper. METHODS: Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). RESULTS: Following admission of a multiple trauma patient vital functions have to be established in first priority. After stabilization a systematic clinical investigation and consecutive specific radiological procedures should rule out extremity injuries. These are the only evidence-based criteria leading to a complete detection of all limb injuries. All other aspects are only based on clinical experience or the opinion of expert committees. CONCLUSION: The quality of shock room management is mostly dependent on the experience of the " trauma team" (and especially of the trauma leader). Guidelines and specific trauma algorithms can provide a helpful instrument in this issue.     

Strahlentherapie bei Weichteilsarkomen der Extremitäten

Background

Function-preserving treatment in patients with soft tissue sarcomas (STS) of the limbs is an interdisciplinary challenge.

Objective

Analysis of evidence on the status and type of radiotherapy (RT) within multimodal concepts.

Material and method

Compilation of current guidelines and publications on multimodal treatment, in particular on the role of preoperative and postoperative RT for STS of the limbs. Presentation and explanation of the role of modern and special RT techniques.

Results

Both preoperative and postoperative RT are recommended indications for patients with stage II and III STS. Furthermore, postoperative RT after incomplete resection has a clear recommendation. The use of both preoperative and postoperative RT correlates with an increase in local control but a positive influence on survival is most likely limited to the subgroup of patients with high-grade STS. In the long term preoperative RT shows less late toxicity but leads to more acute wound complications. Modern special techniques, such as imaging-guided magnetic resonance imaging (IG-MRI), intraoperative radiotherapy (IORT) and brachytherapy (BT) can significantly reduce side effects as well as reduce safety margins during irradiation planning.

Conclusion

In patients with STS of the limbs, preoperative and/or postoperative RT should be performed in stages II and III and after incomplete resection. The use of special techniques and modern target volume concepts leads to a reduction of side effects.

     

Indikation,Prozedere und Outcome der präklinischen Notfallthorakotomie – eine systematische Literaturrecherche

Die Unfallchirurgie - Die präklinische Notfallthorakotomie (?prehospital resuscitative thoracotomy“, PHRT) ist eine von den aktuellen Reanimationsleitlinien des European...     

Beitrag zur Spontangangrän der Extremitäten

Zusammenfassung Will man die ganze Krankheit überhaupt mit einem Eigennamen bezeichnen, so scheint es uns nicht nur historisch eher gerechtfertigt, vonWinniwarterscher als von -Bürgerscher Krankheit zu sprechen. Denn nach unserer Auffassung hatWinniwarter das Wesen und die Pathogenese der ganzen Krankheit richtig erkannt. Bedürfnis zu einer neuen Namengebung (TeleangiostenoseKrompecher) scheint uns nicht vorzuliegen. Klinischer und histologischer Bericht über 7 F?lle.