Limb salvage in the skeletally immature patient

The most common tumors of bone, osteosarcoma and Ewing sarcoma, commonly occur in the skeletally immature patient. Historically, amputation was the procedure of choice; however, improved oncologic outcome and technical advances in limb salvage surgery have made limb salvage therapy a feasible and valuable treatment option. Nevertheless, depending on the extent of the lesion within the long bone, it may be difficult to spare the physis, and hence, in the skeletally immature patient, resection of a sarcoma of bone can create a limb-length discrepancy and gait abnormalities. This article reviews the limb salvage options available for the skeletally immature patient who requires reconstruction of a segmental long bone defect.     

Personalized 3D-printed guide in malignant bone tumor resection and following reconstruction – 17 cases in pelvic and extremities

IntroductionCustomized accurate tumor resection and individualized reconstruction is a challenging in treatment of malignant bone tumor. Three-dimensional (3D)-printing technique is now widely used in the resection and following reconstruction of malignant bone tumor, which included but not limited to tumor model, osteotomy guide and customized implant.MethodsWe retrospectively reviewed 17 patients, who underwent limb salvage surgery by using 3D-printed guide at a single center between August 2014 and October 2019. The median duration of follow-up was 26.5 months. Osteosarcoma (41.2%) were the predominant diagnoses. The functional outcomes were assessed by Musculoskeletal Tumor Society (MSTS) functional score. We also analyzed survival status, intraoperative data (blood loss, operation time and resection length), reconstruction method, margin outcomes and complications.ResultsWe totally performed 93 guided osteotomies on affected bone and allograft bone in 17 patients. Reconstruction in 12 cases was performed with biological technique: allograft combined with autograft was used in 7 cases. 11 of 12 (91.7%) cases showed a good bone healing in both allograft and autograft. 1 of 12 (8.3%) cases had allograft necrosis. Additional intra-operative extracorporeal radiation was performed in 3 pelvic cases for reconstruction. 63 of 64 (98%) osteotomies achieved wide resection and negative margin. All the cases had successful limb salvage result without amputation. At the latest follow up, the mean MSTS Score was 24 (range: 13–30), 12 patients alive with no evidence of disease, 1 patient alive with disease, 5 patients had died of disease and 5 years overall survival is 73.3%. The most common complications are wound healing disorder in 4 cases (23.5%) and infection in 3 cases (17.6%).ConclusionThe 3D-printed resection guide was easy to use and showed promise in the field of orthopedic oncology. It can not only used in primary malignant bone tumor personalized resection but also in shaping structural bone allograft in biological reconstruction, which can achieve a safety surgical margin and individualized resection at the same time.     

人工特制假体在下肢骨肿瘤保肢治疗中的应用

目的探讨应用人工特制假体在下肢骨肿瘤保肢治疗中的方式和疗效。方法35例下肢骨肿瘤患者,23例行定制带股骨(或胫骨)铰链式膝关节,8例行加长柄人工股骨头置换,4例行加长柄全髋置换。结果治疗后随访9～47个月,平均22个月,生存的30例按Enneking肢体肌肉骨骼肿瘤外科治疗重建术后功能评估标准进行评估。4～5分26例,3分3例,1分1例。结论采用合理的肿瘤边缘完整切除手术,选择特制人工假体并正确安装,辅以综合治疗,能有效提高下肢骨肿瘤保肢率及最大限度保留肢体的功能。     

节段型骨干肿瘤假体置换治疗骨干恶性肿瘤

恶性骨肿瘤的治疗应是在化疗、放疗等辅助治疗基础上的瘤段根治性切除。恶性骨肿瘤瘤段切除后的保肢重建方法依肿瘤病灶部位的不同应有所区别,对位于干骺端的恶性骨肿瘤,可采用人工关节假体置换术、同种异体骨半关节移植术、关节融合术等;而对于发生在骨干部位的恶性肿瘤,手术方式的选择更广。随着新辅助化疗的日渐成熟、影像学的进步以及骨大段缺损重建技术的发展,保肢治疗得以迅速发展。大量实践证明,保肢治疗具有安全性,其与截肢治疗的生存率和复发率几乎相当［1］。     

Selective combination of modalities in soft tissue sarcomas: limb salvage and survival

One hundred fifty-two consecutive patients with soft tissue sarcomas were operated in the period 1977 through 1985. Eighty-seven patients with minimum resection margin of 2 cm or greater had no further local therapy, whereas 65 patients with minimum margin less than 2 cm had adjuvant postoperative radiation. Of 121 patients with extremity sarcomas, only 5 (4%) were managed with amputation. The overall 5-year survival rate is 58%, and for patients with extremity tumors, 67%. The 5-year local recurrence rate in extremity sarcomas was 10% for patients with minimum surgical margins 2 cm or greater and no further local therapy, and 6% for those with lesser surgical margins and adjuvant postoperative radiation. With selective combination of modalities limb salvage can now be practiced in 96% of the patients with acceptable local control and survival rates.     

Preoperative and postoperative irradiation of soft tissue sarcomas: effect of radiation field size

For the treatment of soft tissue sarcomas it has frequently been staged but not quantitatively demonstrated, that the volume irradiated is smaller when irradiation is given preoperatively as compared to postoperatively. In this study the field size used for preoperative irradiation was compared with that necessary in the same patient had the radiation been given postoperatively. Twenty-six patients with soft tissue sarcomas of the extremity, groin, and shoulder girdle who had received preoperative irradiation were resimulated following surgery to determine the size of the postoperative field. The simulation was performed by a physician not involved in the preoperative treatment planning. Preoperatively a radial margin of 5 cm around the tumor was used for low and intermediate grade and 7 cm for high grade sarcomas. Postoperatively the same margins were used but around the surgical field. Twelve patients underwent a wide resection and 14 patients a resection followed by vascularized tissue transfer to the surgical bed. The median follow-up was 22 months (range 13-46). No local recurrences and two cases of distant metastasis were observed. Independently of surgical procedure and tumor grade, the size of the preoperative radiation field and number of joints included in the field were significantly smaller than that of postoperative radiation (p less than 0.001). In two patients preoperatively and four patients postoperatively, the radiation field involved the whole circumference of the limb. Provided that equivalent radiation time-dose-fraction parameters are used and that the complication rate is proportional to the radiation field size, late complications may be less after preoperative irradiation than after post-operative irradiation.     

肩部骨肿瘤保肢治疗

目的探讨肩部骨肿瘤保肢治疗的手术方法。方法对2例肩部恶性肿瘤实施保肢术,肱骨近端成骨肉瘤1例,行肱骨瘤段切除,锁骨翻转重建骨缺损;肩胛骨恶性纤维组织细胞瘤1例,行肿瘤切除、肱骨肩峰悬吊术。结果术后短期随访,肩关节被动活动有一定的功能。结论肩部恶性肿瘤应根据肿瘤发生的不同部位,患者的经济实力,选择不同保肢手术,目的是使肩部保留一定的功能和外形,提高患者的生活质量。     

膝关节周围骨巨细胞瘤的治疗方式及疗效分析

目的探讨治疗膝关节周围骨巨细胞瘤的手术方式及疗效。方法膝关节周围骨巨细胞瘤患者48例,根据患者年龄、肿瘤部位及Campanacci分级,选择手术方式,其中行刮除植骨术32例,瘤段切除＋人工膝关节置换术16例。结果随访时间1～8年,平均4年,刮除植骨术术后复发3例,复发率为9．4％,瘤段切除＋关节置换术无复发者,复发率为0,术后满意度调查：优15例,良26例,差7例,总满意率为85．4％。结论膝关节周围骨巨细胞瘤的外科治疗方法有刮除植骨术,但其复发率高;瘤段切除＋人工膝关节置换术复发率较低,但并发症较多。     

Simultaneous tumor identification,cholangiography, and securing surgical margin for recurrence of hepatocellular carcinoma using the Medical Imaging Projection System

BackgroundIndocyanine green (ICG) fluorescence-guided surgery is a real-time navigation technology for tumor detection, securing surgical margins, segmentation mapping, and cholangiography in liver surgery [1]. According to recent reports, the Medical Imaging Projection System (MIPS) may be a useful new real-time navigation technology for open anatomical liver resection [2]. However, the efficacy of MIPS for tumor identification, cholangiography, and securing surgical margins is uncertain. In this report, we introduce MIPS-assisted liver resection for real-time navigation during simultaneous tumor identification, cholangiography, and securing surgical margins.MethodsA 76-year-old man presented with a 30 × 30 mm recurrent hepatocellular carcinoma on the transection plane after right anterior sectionectomy. Eight radiofrequency ablations were performed after the first hepatectomy. Preoperative computed tomography and three-dimensional simulation revealed a tumor near the posterior Glissonean branch. One day before surgery, 2.5 mg/body ICG was administered. We analyzed whether MIPS could simultaneously facilitate tumor identification, cholangiography, and securing surgical margins. The relationship between fluorescent imaging and the surgical margin was evaluated with a fluorescent microscope [3].ResultsSimultaneous tumor identification, cholangiography, and securing the surgical margins were demonstrated by adjusting the image projection of MIPS, and R0 resection was achieved without biliary injury (Figs. 1 and 2). The operative time and estimated blood loss were 287 minutes and 394 mL, respectively. He was discharged on postoperative day 12 without any complications.ConclusionMIPS could be useful for real-time navigation for tumor identification, cholangiography, and securing surgical margins during liver surgery. The threshold of fluorescent intensity should be set for optimal image projection.     

Large, deep, high-grade extremity sarcomas: treating tumors of the flexor fossae

Limb salvage is now possible for the majority of patients with extremity sarcomas. Although overall prognosis is primarily based on tumor size and histologic grade, complete surgical excision and local control is essential for cure. There are, however, certain anatomic locations such as the flexor fossae in which a complete surgical margin is difficult to attain, and surgery without adjuvant therapy has a high local failure and amputation rate. We have found that preoperative adjuvant therapy consisting of chemotherapy and radiation followed by surgical excision with tumor-free margins has been successful in treating flexor fossa sarcomas with high limb salvage (96%), local control (89%) and overall survival rates (70%). These results are comparable to patients with similar large, high-grade extremity tumors in other compartmental locations.     

Amputation for extremity soft tissue sarcoma does not increase overall survival: A retrospective cohort study

To determine if amputation increases survival when compared to limb salvage surgery in patients with a soft tissue sarcoma (STS) of the extremity when there is often a misconception among physicians and patients that ablative surgery eliminates local recurrence and increases overall survival. This retrospective cohort study assessed 278 patients with STS and compared 18 patients who had undergone amputations for soft tissue sarcomas of the extremities to a comparative cohort of 260 patients who underwent limb salvage surgery during the same time period. Our limb salvage surgery (LSS) rate was 94% overall for soft tissue sarcomas with a median follow-up of 3.1 years. Patients undergoing amputations either had tumors that involved a critical neurovascular bundle (in particular nerve rather than vessel resection was more responsible for a decision toward ablation), or underlying bone or had neoplasms whose large size would require such an enormous resection that a functional limb would not remain. In comparing prognostic effects, mainly death due to sarcoma, distant metastasis and local recurrence, it was found that there was no statistically significant difference between patients undergoing amputation to those undergoing limb salvage surgery (p > 0.05). While amputations do not increase overall survival in soft tissue sarcomas of the extremity as compared to LSS, they are still a valuable option in a surgeon's arsenal. In particular, amputations can provide improved local control and symptomatic treatment in patients who might not be candidates for limb salvage surgery.     

膝关节周围恶性骨肿瘤的保肢治疗（附48例随访报告）

目的总结膝关节周围恶性骨肿瘤的保肢治疗经验。方法回顾分析1999年2月～2007年2月48例接受保肢治疗的膝关节周围恶性骨肿瘤患者的临床资料。男30例,女18例。平均年龄27.3岁（11～67岁）。病理证实：高恶性肿瘤32例（A组）,包括骨肉瘤23例,恶性纤维组织细胞瘤5例,尤文肉瘤2例,恶性淋巴瘤2例;低度恶性肿瘤16例（B组）,包括侵袭性骨母细胞瘤1例,骨巨细胞瘤15例。手术方式包括：瘤段切除假体置换术或灭活再植术、异体骨移植术、异体骨复合假体移植术、病灶刮除充填术保肢。A组术前、术后给予化疗。保留肢体功能按Enneking肌肉骨骼肿瘤外科治疗重建后功能评估标准评估。结果平均随访3.2年（0.5～8年）。A组中因局部肿瘤复发、感染等并发症截肢11例（34.4%）,死亡13例,存活19例,3年存活率59.3%（19/32）。B组中因局部肿瘤复发和感染截肢2例（12.5%,2/16）,死亡1例。肢体功能优良率A组71%,B组81%。结论膝关节周围恶性骨肿瘤保肢应掌握个体化原则,假体置换术及异体骨复合假体移植术保肢功能最佳,高恶性肿瘤患者若无法承受强力的辅助化疗则不宜行保肢术。     

肿瘤型人工膝关节置换治疗儿童股骨远端骨肉瘤

目的评估使用肿瘤型人工膝关节置换治疗儿童股骨远端骨肉瘤的治疗效果。方法2003年12月至2008年12月,36例14岁以下股骨远端骨肉瘤儿童患者行肿瘤型人工膝关节置换手术,31例随访数据完整。患者年龄9～14岁,平均12．3±1．6岁。男11例,女20例。所有患者都是未经治疗的IIB期原发骨肉瘤。所有患者都经过标准术前化疗、肿瘤型人工膝关节置换手术及术后化疗。结果手术使用普通单纯铰链式膝关节8例,普通旋转铰链式膝关节11例,特制远端非水泥固定铰链式膝关节12例。边缘切除9例,广泛切除22例。31例患者随访12～75个月,中位随访时间26个月,平均32个月。随访期间死亡13例,存活18例,无瘤生存16例,带瘤生存2例。Kaplan—Meier生存分析显示2年生存率74．1％,3年生存率44．6％。局部复发2例（6．5％）。转移14例（45．2％）,其中肺转移10例（32．3％）,软组织或骨转移3例（9．7％）,肺转移合并软组织转移或骨转移1例（3．2％）。存活且未截肢患者15例,MSTS功能评分平均21．5±4．7分,肢体功能优良率86．7％。三种假体术后功能比较,差异无显著性（P=0．979）。随访期内假体并发症发生率38．7％,其中假体周围感染2例（6．5％）,假体松动10例（32．3％）。特制远端非水泥固定铰链式关节并发症低于常规使用关节。结论在标准治疗后,肺转移是导致儿童骨肉瘤患者死亡的主要原因;外科边界与局部复发关系密切,提高保肢的安全性需恰当地选择外科边界;特制远端非水泥固定铰链式人工假体与常规使用人工假体功能无明显差异,并不增加早期并发症发生率。     

Recent advances in reconstructive surgery for bone and soft tissue sarcomas

We present the current perspective on reconstructive surgery for soft tissue tumors, especially in the extremities, based on our large series. A total of 1,813 patients with bone and soft tissue sarcomas underwent surgery at our hospital between 1978 and 2011. Reconstructive operations were performed by plastic surgeons. In such reconstructive surgery, to achieve better quality of life for the patient, great effort was made not only for limb salvage but also for functional reconstruction. Although a few surgeries resulted in limb amputation due to multiple tumors, recurrence, or advanced age of the patient, the rate of limb salvage and/or functional recovery has been increasing dramatically using the method of flap surgery and vascular reconstruction. In fact, over more than 30 years, the limb salvage rate at our hospital has increased from 71.6 % around 1980 to 90.5 % around 2010. In this article, we describe our experience in plastic and reconstructive surgeries after operation for bone and soft tissue sarcomas.     

新辅助化疗结合新轴心式肿瘤特制型假体置换治疗膝关节周围骨肉瘤

目的 探讨新辅助化疗结合新轴心式肿瘤型假体置换在膝关节周围骨肉瘤保肢治疗中的临床效果.方法 采用新辅助化疗结合新轴心式肿瘤型假体置换保肢治疗膝关节周围骨肉瘤26例,其中男性15例,女性11例,年龄7～56岁,平均25.3岁.肿瘤部位股骨远端18例,胫骨近端8例.根据Enneking分期：I A期4例,I B期4例,II A期6例,II B期12例.采用化疗药物多柔比星、顺铂、甲氨蝶呤和异环磷酰胺进行新辅助化疗.术前化疗2～3个疗程,2-3周后进行保肢手术,术后继续化疗6个疗程.术前、术后每个化疗疗程间隔2-3周.所有病例切除标本均行病理检查并进行坏死率评估,以调整术后化疗方案.胫骨近端肿瘤切除后行腓肠肌内侧头肌瓣移位修复软组织缺损并与髌韧带缝合重建伸膝装置.术后根据Enneking评分标准评定疗效.结果 26例患者均获得随访,随访时间为8-56个月,平均28个月.经过术前化疗后患者疼痛迅速缓解,通过查体、X线片、CT或磁共振检查发现瘤体不同程度缩小、瘤体硬化、边缘清楚及有部分活动度.肿瘤坏死率测定：＞90%共18例,＜90%共6例.3例出现肺部转移,并因肺转移合并呼吸循环衰竭死亡,3例局部复发,行股骨下段截肢,20例无复发或远处转移.3年生存率为88.0%,复发率为11.5%,最终保肢率88.5%.26例患者术后根据Enneking评分标准评定疗效优19例,良4例,差3例,优良率88.5%.结论 新辅助化疗结合新轴心式肿瘤型膝关节假体置换是膝关节周围骨肉瘤保肢治疗的一种有效方法,能减少复发、远处转移及提高临床治疗效果.     

Periosteal margin in soft-tissue sarcoma

BACKGROUND: Soft-tissue sarcomas frequently rest in contact with bone. The purpose of the study was to evaluate the risk of local recurrence for sarcomas adjacent to bone and to determine whether the periosteum provides an adequate margin of resection. METHODS: Fifty patients with soft-tissue sarcomas abutting bone were treated at a single institution between 1990 and 2004. All patients had high-grade, T2 (>5 cm), nonmetastatic disease in the lower extremity. Bone contact was verified by preoperative magnetic resonance imaging (MRI) and/or computed tomography (CT) scans. Forty-three of 50 patients received preoperative radiation with a mean dose of 50 Gy. In 11 cases a composite resection of bone and soft tissue was performed. In 39 cases the excision involved only soft tissue. RESULTS: True bone invasion was verified by histopathologic examination in 3 of 50 cases (6%). Local recurrence in the soft tissues developed in 8 of 50 (16%) patients. In no case did the recurrence involve destruction of cortical bone or erosion into bone. The recurrent tumor resided against the region of previous bone contact in 1 of 8 cases. There was no statistically significant difference in local recurrence between patients who had composite bone resection and patients who had soft-tissue resection only (P = .87). CONCLUSIONS: Relatively few sarcomas are able to penetrate cortical bone. Composite bone and soft-tissue resections are indicated primarily for frank bone invasion. In the absence of this, the periosteum is an adequate surgical margin for sarcomas treated with wide excision and radiation.     

Techniques in the management of juxta-articular aggressive and recurrent giant cell tumors around the knee.

AIM: Juxta-articular aggressive and recurrent giant cell tumors around the knee pose difficulties in management. This article reviews current problems and options in the management of these giant cell tumors. METHODS: A systematic search was performed on juxta-articular aggressive and recurrent giant cell tumor. Additional information was retrieved from hand searching the literature and from relevant congress proceedings. We addressed the following issues: general consensus on early diagnosis and techniques in its management. In particular, we describe our results with resection arthrodesis performed combining the benefits of both interlocking intramedullary nail and Ilizarov fixator in the management of these tumors around the knee. RESULTS: Mean operative age of the 22 patients undergoing resection arthrodesis was 35.63 years. Seven lesions were in the tibia and fifteen in the femur. Mean length of the bone defect was 12.34 cm. The mean external fixator index was 7.44 days/cm and the distraction index was 7.88 days/cm. Mean period of follow-up for the patients was 64.5 months. The function of the affected limb was rated excellent in 10 and good and fair in six patients each as per Enneking criteria. No local recurrence of tumor was seen. Seven complications occurred in five patients. CONCLUSION: Two-ring construct, bifocal bone transport, and early definite plate osteosynthesis with additional bone grafting of the docking site at the end of distraction even before consolidation of the regenerate helps to reduce the problems of pin tract infections drastically. Thin-diameter long intramedullary nail in addition to preserving the endosteal blood supply also prevents mal-alignment of the regenerate. Thus resection arthrodesis using interlocking intramedullary nail and bone transport using Ilizarov fixator is cost effective and effective in achieving the desired goals of reconstruction with least complications in selected patients with specific indications.     

半膝关节置换治疗儿童膝关节骨肉瘤15例分析

目的探讨半关节假体置换术用于儿童膝关节周围骨肉瘤的疗效。方法1998年10月～2006年7月,对15例膝关节周围骨肉瘤患儿行瘤段切除并半膝关节假体置换。患者病程1～3个月。影像学提示瘤灶位于股骨远端9人,胫骨近端6人,病变范围9～11cm。术前经病理检查确诊为骨肉瘤。按Enneking分期均在Ⅱa期。术前均行1～2个疗程的化疗。术前根据X线、CT或MRI测量设计匹配的假体,假体略长于截骨段1—2cm。髌韧带及侧副韧带重建于人工半膝关节假体上。结果15例患儿手术均成功,随访2～6年,平均4．5年。患儿身高增加了4—6cm,患肢短缩1—3cm,均能进行日常生活学习。结论对于半关节假体应用于儿童膝关节周围骨肉瘤的治疗,具有保留正常骨骺,最大限度减少术后患肢短缩,并为成年后行全关节置换创造了条件。     

骨肉瘤安全外科边界与保肢适应证

目的:通过X 线、MRI 和骨扫描（ECT ）、肉眼边界与病理边界的对比研究来确定骨肉瘤保肢的安全外科边界,并探讨影响骨肉瘤保肢的因素。方法:选择2007年5 月～2008年7 月间在上海交通大学第六人民医院骨科新就诊的骨肉瘤患者,术前X线、ECT 、MRI 检查,根据影像学表现确定手术范围,取术后截除的肿瘤瘤段,用电锯或骨刀沿肿瘤骨的冠状面、矢状面劈开,将标本平分为两等份,取一半为选材对象。肿瘤标本分割之前,需进行肿瘤长度的肉眼测量。对所有取材做经过解剖标志点的冠状面切面,将剖成厚度约10mm断面,行整层分开切成1cm× 1cm切片送病理检查。对于每例标本采集的X 线、MRI 检查及ECT 进行数码照相,并传输到计算机中。参照每例患者的影像学资料的标尺,应用Adobe photoshop 7.0 软件的切片功能进行影像学、实体肿瘤长度的测量,应用统计软件SPSS11.5 进行统计,采用单一因素的两组配对资料的t 检验,P<0.05为有统计学意义。结果:满足入选条件共19例。X 线片显示软组织边界不清。MRI 可以很好的显示软组织的边界。镜下肿瘤边缘可见水肿带,并有出血充血,多数肿瘤沿脂肪细胞间隙浸润生长。X 线、ECT 与病理检查之间有显著性差异,MRI、肉眼观察与病理范围无显著性差异。结论:MRI 测量相对误差较小,术前MRI 加权及脂肪抑制像在肿瘤边界外1.5cm做为保肢截骨平面是安全平面。影响骨肉瘤保肢的因素是多方面的,需要综合考虑。      

Chirurgische Therapie von Weichteilsarkomen der Extremitäten

Background

Surgery with curative intention in multimodal treatment concepts for patients with soft tissue sarcomas is the most important prognostic factor. Clear resection margins (R0) are one of the most important prognostic factors especially in the prevention of local recurrence and probably also in the overall survival of the disease. If R0 resection seems to be possible or can only be realized with mutilating procedures, neoadjuvant therapy concepts must be considered.

Objective

The principles of surgical therapy in patients with soft tissue sarcomas including multimodal strategies are discussed.

Material and methods

A systematic literature review of original articles and review articles over the last 15 years was performed. No prospective, randomized studies on surgery of soft tissue sarcomas were identified. The publications are discussed and assessed.

Results

In recent decades it could be shown that a compartmental resection has no significant advantages over wide resection with respect to local recurrence rate and overall survival. In the literature the rate of local recurrence is cited as being between 10?% and 40?% and the 5-year overall survival for all patients is approximately 50?%. In wide resections the ideal safety margin is not clearly defined. An R0 resection is therefore the most important criterion. A safety margin of at least 1 cm in all directions, as has been recommended for many years, can no longer be justified, the only exception being for liposarcoma (G1), the atypical lipoma of the extremities. Systemic chemotherapy (with or without hyperthermia) or radiotherapy can be beneficial and necessary in a multimodal neoadjuvant or adjuvant setting. With neoadjuvant radiotherapy a significantly increased rate of wound healing problems (>?30?%) in patients must be considered. Isolated hyperthermic limb perfusion (ILP) together with tumor necrosis factor alpha (TNF-alpha) and melphalan is an effective treatment option for patients with locally advanced soft tissue sarcomas of the extremities if an R0 resection could only be achieved by functional or anatomical amputations. Using this procedure allows resection of the soft tissue sarcoma and limb salvage in 81?% of patients. Reconstructive operative methods including flap surgery, vessel reconstruction and mesh grafts can be performed in approximately 20?% of patients.

Conclusions

A planned multidisciplinary concept from primary imaging, radiology, biopsy to histopathological investigation is necessary for defining the multimodal therapy and follow-up of patients with a soft tissue sarcoma. Surgery is still the key factor for local control and overall survival. The standard of care for soft tissue sarcomas of the extremities, with the exception of atypical lipoma, is a wide resection (R0). An ultraradical resection including vital structures for extending an already foreseeable free margin (R0) does not show any benefits. If a resection or re-resection cannot be performed in sano (i.e. R1), additional adjuvant or neoadjuvant radiotherapy should be included. The ILP procedure including TNF-alpha and melphalan is an effective treatment option in selected cases for patients with locally advanced soft tissue sarcomas of the extremities to avoid functional or anatomical amputations.