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---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 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.
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.
- 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
- 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.
- Rosen, G, Marcove RC, Caparros B, et al. Primary osteogenic sarcoma. The rationale for preoperative chemotherapy and delayed surgery. Cancer. 43: 2163-2177, 1979
- 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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