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Michigan Oncology Journal, Fall 97

Limb Salvage in Sarcoma Management

---J. Sybil Biermann, M.D.

The Origins of Limb Salvage
The evolution of limb salvage for the management of extremity and limb girdle sarcomas is a testament to the success of a multidisciplinary team. In the 1960s and 1970s, before routine use of chemotherapy for osteosarcoma, development of metastatic disease was reported in 80 percent of patients presenting with high-grade osteosarcomas even without evidence of metastatic disease. Most patients were treated with amputation(1). Because of the poor prognosis, orthopaedic surgeons were reluctant to continue with amputations for these patients and began fabricating custom prostheses for limb salvage. Since these early prostheses often took weeks or even months to be made by the manufacturers, medical or pediatric oncologists delivered preoperative chemotherapy to the patients to attempt to halt disease progression in the meantime. However, Rosen et al. were able to demonstrate not only favorable results with neoadjuvant treatment, but also a beneficial effect in that the histologic response to the therapy could be evaluated (2, 3). This was the birth of multidisciplinary team management of limb girdle and extremity sarcomas and resulted in both improved survival and improved limb function.

Advances in Imaging, Adjuvant Therapy
The ability to perform limb salvage for both soft tissue sarcomas and osteogenic sarcomas has been related not only to advances in chemotherapy, but also to advances in other fields including radiation therapy. Resection of soft tissue sarcomas without adjuvant treatment results in unacceptably high local recurrence rates of up to 50 percent, however the use of adjuvant radiation can reduce local recurrence rates for soft tissue sarcomas in the setting of limb salvage (4). The use of three-dimensional planning allows for the delivery of relatively large amounts of radiation with relatively less toxicity than conventional delivery techniques. The use of brachytherapy catheters can allow for maximal radiation of a sarcoma bed with less delivery to adjacent skin, which may help reduce complications while reducing incidence of local recurrence.

Advances in imaging techniques allow surgeons to accurately plan resections and reconstructions. Previously, extent of soft tissue sarcoma had to be determined by exploratory surgery. Bone scans were used as a relatively crude measure for examining the extent of bone marrow involvement in bone sarcomas. However, contemporary magnetic resonance imaging (MRI) allows for precise localization of the neurovascular structures and accurate assessment of the extent of tumor involvement of normal structures. MRI can indicate response to chemotherapy as evidenced by decreasing tumor size and help the surgeon and the medical oncologist optimize the timing of surgical intervention. Bone marrow involvement of bone sarcomas can now be relatively accurately gauged, allowing for preservation of bone stock. Imaging advances have allowed surgeons to more confidently spare normal tissue while obtaining negative surgical margins, resulting in more functional limb restorations.

Skeletal Building Blocks
Advances in biomaterials and availability of allogeneic bone have enhanced the armamentarium of the reconstructive sarcoma surgeon. Developing technologies that have improved the surgical management of osteoarthritis have been applicable to reconstruction of limbs following major tumor resection of bones and joints. Implants now have improved fixation, durability and wear characteristics when compared with those available even a decade ago. With rising interest in limb salvage, modular oncology systems are now available that actually allow the surgeon to construct an appropriate prosthesis in the operating room at the time of the procedure.

While metal and plastic reconstructions may offer some advantages, another alternative is cadaveric large-segment bone reconstructions. Allografts, harvested at the time of organ donation, offer the advantage of improved soft tissue reconstruction, since tendons and joint capsules may be harvested with the donor bone and repaired to the host tendons. Interest in allograft reconstructions has fostered the growth of bone banking, and bone banks in nearly every state procure, process and preserve frozen cadaveric allografts for use in limb reconstruction. Allograft bones are harvested under sterile conditions from carefully screened donors and size-matched preoperatively by the surgeon. They are particularly useful in the reconstruction of intercalary defects of bone where they may be fixed with plates or rods to the host bone. Over time, healing occurs and the host bone actually fuses to the graft bone. Skeletal limb reconstructions may consist of metal prostheses, allografts or a combination of both (see Case Presentation).

Soft Tissues
Soft tissue reconstructions have contributed to making limb salvage practical and possible. Functional muscle transfers can restore lost function when important muscle groups must be fully or partially resected. Knowledge of limb function and anatomy is essential. Reattachment to adjacent soft tissues or bone, or to allografts can restore needed muscle functions. Local or free-tissue transfer can be performed by plastic or microvascular surgeons in concert with the orthopaedic oncologist to help reduce the incidence of wound complications and promote healing.

Summary
Limb salvage for extremity and limb girdle soft tissue and bone sarcomas has advanced considerably over the 20 years since its inception. The vast majority of patients presenting with these malignancies are now candidates for limb-sparing operations and complex, but functional, limb restorations.

References

  1. Marcove, RC, Mike V, Hajek JV, et al. Osteogenic sarcoma under the age of twenty-one. A review of one hundred and forty-five operative cases. J Bone and Joint Surg (Am), 52: 411-423, 1970
  2. Rosen G, Caparros B, Huvos AG, et al. Preoperative chemotherapy for osteogenic sarcoma: Selection of postoperative adjuvant chemotherapy based on the response of the primary tumor to preoperative chemotherapy. Cancer. 49:1221-1230, 1982.
  3. Rosen, G, Marcove RC, Caparros B, et al. Primary osteogenic sarcoma. The rationale for preoperative chemotherapy and delayed surgery. Cancer. 43: 2163-2177, 1979
  4. Lindberg, R.D., Martin, R.G., Romsdahl, M.M. et al. Conservative surgery and postoperative radiotherapy in 300 adults with soft-tissue sarcomas. Cancer. 1981; 47:2391-2397.

J. Sybil Biermann, M.D., is an assistant professor in the Department of Surgery.

 

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Please note: The articles listed in the Cancer Center's News Archive are here for historical purposes. The information and links may no longer be up-to-date.