Is Amputation Necessary for Sarcomas? A Seven-Year Experience with Limb Salvage

Abstract

The rationale for amputation for local tumor control of skeletal and soft tissue sarcomas was based on results obtained from surgical therapy alone. However, our previous results from a pilot trial of multimodality therapy of preoperative chemotherapy and radiation therapy followed by surgical resection indicated that limb salvage (without amputation) could be accomplished in most patients with little morbidity and low recurrence rate. This report summarizes our experience in a prospective trial from January 1972 to December 1979. A total of 105 consecutive patients with soft tissue sarcomas (65 patients) or bone sarcomas (40 patients) were treated with preoperative intraarterial adriamycin, 3500 rads of rapid-fraction radiation and radical en bloc resection of primary tumor. Diseased bones were replaced with cadaver allografts (22 patients), metallic endoprostheses (10 patients) autologous bone (2 patients), or no replacement (ilium or fibula-4 patients). Salvage of a viable, neurologically intact, functional extremity was achieved in 98/105 patients (98%); 97% of limb salvage patients were free of local recurrence after a median follow-up period of 28 months. Major complication rate that required amputation was 3/105 patients (2%). Postoperative adjuvant chemotherapy with cyclical adriamycin and high-dose methotrexate was employed for all patients with osteosarcoma and 35 patients with grade III soft tissue sarcomas. The overall disease-free rate is 50% (18/35) for osteosarcomas and 65% (42/65) for soft tissue sarcomas. These results indicate that local tumor control can be achieved in 91% of patients without amputation. Their functional capabilities are excellent with a low complication rate. Since the advent of adriamycin and methotrexate has significantly improved the overall survival for patients with skeletal and soft tissue sarcomas, the quality of this survival has become even more important. Preoperative multimodality therapy is a major advance in this direction and since results of limb salvage procedures appear to be equal or superior to those achieved by amputation we believe these alternatives should be offered to all patients.

Intraoperative radiotherapy in the multidisciplinary treatment of bone sarcomas in children and adolescents

“…The multidisciplinary approach has brought significant advances in the local control of bone sarcomas, which allows more conservative attitudes in planning surgery, without detriment to the long-term survival rates [13,29,30].…”

“…Twenty-two patients entered this protocol, which included neoadjuvant chemotherapy with three cycles with intra-arterial cisplatinum and systemic doxorubicin, repeated every 3 weeks and followed by a wide surgical en bloc tumor-bearing resection, with an IORT boost (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) to the tumor bed area.…”

“…The tendency towards radical tumor surgical removal with amputation [11][12][13] has given way to programs with extremity preservation by combining surgery and neoadjuvant and adjuvant radiation therapy and chemotherapy without compromising the results in disease-free survival [14][15][16].…”

Groin soft tissue tumors—a challenge for local control and reconstruction: A prospective cohort analysis

“…The absence of local recurrence despite marginal resections in most of these patients, tumors larger than 10 cm in forty-five percent, and moderate or high-grade tumors in more than twothirds supports the efficacy of neoadjuvant combined chemoradiation or full dose radiation protocols. The combined chemoradiation approach (modified from Eilber et al [4]) has been used for all extremity sarcomas at our centre with 97% local control [5]. A Tri-Center Study confirmed local control rates of 98.5% [6].…”

51. Perioperative Radiotherapie von Knochen- und Weichgewebetumoren

“…Diese Art der Ausbreitung und die multizentrische Entstehung sind wichtige Ursachen ffir postoperative Lokalrezidive [7,10], ebenso die Streuung von Tumorzellen bei der Operation: selbst radikale Mal3nahmen, wie Amputationen, sind noch mit 10-15% Lokalrezidiven behaftet [1,12]. Um den Patienten nach M6glichkeit verstfimmelnde MaBnahmen zu ersparen, wurde in den beiden letzten Jahrzehnten die Kombination konservativer chirugischer Mai3nahmen mit der Strahlenbehandlung eingeffihrt [5,13,20,21]. Regionale Lymphknotenmetastasen sind selten (3-6%), auger bei Synovialsarkomen, Rhabdomyosarkomen, Leiomyosarkomen, Endotheloidsarkomen und malignen fibr6sen Histiocytomen (10 -30%) [ 12,27].…”