Limb-Salvage Surgery for Upper-Extremity Sarcoma Has Long-term Advantages Over Amputation

Thanks to advances in multimodal management of upper-extremity sarcoma, limb salvage (LS) is now possible for about 90% of patients. LS is comparable to amputation in achieving local control.

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Researchers at Massachusetts General Hospital recently determined that long-term, patient-reported functional advantages of LS over amputation are statistically significant and clinically relevant, which had not been demonstrated before. Yannick A. J. Hoftiezer, MD, research fellow, Jonathan Lans, MD, PhD, Orthopaedic Surgery resident, Neal Chen, MD, chief of the Hand & Arm Center, Kyle R. Eberlin, MD, associate director of the Mass General Hand and Arm Fellowship and the Harvard Plastic Surgery Residency Program, and Santiago Lozano-Calderon, MD, PhD, surgeon in the Orthopaedic Oncology Service, and colleagues published their findings in the Journal of Surgical Oncology.

Study Methods

By searching records at two tertiary centers, the researchers identified 43 adults who:

• Were diagnosed with an upper-extremity bone or soft tissue sarcoma between January 1, 1992, and August 31, 2018
• Had a non-metastasized tumor located distal to the scapular body and proximal to the proximal carpal row
• Underwent primary or secondary amputation (n=12) or an LS procedure with complex reconstruction (n=31)
• Were still alive and had at least 12 months of follow-up

The patients were invited to complete questionnaires about their outcomes online or by telephone. 16 responded, of whom 10 had undergone complex LS (free flap, n=7; pedicled flap, n=3) and six had undergone amputation. The median follow-up after the latest surgery was 9.5 years.

Questionnaires

Median scores in the LS and amputation cohorts were:

• PROMIS Anxiety—52.7 vs. 53.8 (P=0.59)
• PROMIS Depression—52.0 vs. 50.5 (P=0.75)
• PROMIS Pain Interference—37.9 vs. 53.4 (P=0.07)
• PROMIS Upper Extremity—50.1 vs. 40.3 (P=0.04)
• Toronto Extremity Salvage Score (TESS)—96.0 vs. 71.7 (P=0.03)
• Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH)—6.82 vs. 36.4 (P=0.057)

PROMIS measures utilize a common metric: the T-score (mean = 50, standard deviation = 10). In most cases, 50 equals the mean in the U.S. general population. TESS assesses activity limitations on a scale of 0% to 100%, with higher scores reflecting better function. On QuickDASH, scores range from 0 to 100, with higher scores signifying more disability.

Global Rating

Patients were also asked, "How would you rate the long-term effect of treatment on your overall quality of life?" with a scale of five possible answers ranging from:

• Significantly negative—1/10 patients in the LS cohort vs. 3/6 in the amputation cohort
• Significantly positive—5/10 vs. 2/6

Surgical Outcomes

All 43 eligible patients were analyzed for surgical outcomes:

• Unplanned reoperation—16 patients after LS cohort (52%; 30 reoperations) vs. one after amputation (8%; two reoperations)
• Postoperative wound complications—29% vs. 8%
• Operative or non-operative flap revision—40% vs. not applicable
• Symptomatic neuroma or phantom limb pain—Not applicable vs. 50%

Commentary

The rate of neuropathic stump pain in the amputation cohort is noteworthy, as such pain is highly debilitating. None of the patients in this series underwent targeted muscle reinnervation or regenerative peripheral nerve interfacing, and adding those procedures during primary amputation may be beneficial.

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Learn more about the Orthopaedic Oncology Service

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