Download PDF
Semin Plast Surg 2010; 24(1): 018-033
DOI: 10.1055/s-0030-1253240
© Thieme Medical Publishers

Limb Salvage in Malignant Tumors

Hans-Ulrich Steinau1 , Adrien Daigeler1 , Stefan Langer1 , Lars Steinsträsser1 , Jörg Hauser1 , Ole Goertz1 , Markus Lehnhardt1
  • 1Department of Plastic Surgery and Burns, Sarcoma Reference Center, BG–University Hospital “Bergmannsheil,” Ruhr-University, Bochum, Germany
Further Information

Publication History

Publication Date:
05 May 2010 (online)

Also available at
    Permissions and Reprints

ABSTRACT

Limb-sparing resection and reconstruction has become the treatment of choice in extremity malignancies, as amputation does not provide better long-term survival rates or functional advantages. R0 resection, the removal of the tumor in sano, remains the prerequisite and most important oncologic parameter to avoid local recurrence. Successful treatment requires the combination of surgical eradication and the patient's specific functional and aesthetic rehabilitation. Our clinical rationale resulting from more than 2000 cases will be demonstrated. The problematic aspects of different tumor entities and the locoregional clearance of lymphatic pathways will be discussed. Differential diagnosis and multimodality treatment in high-volume tumor centers is likely to achieve superior oncologic statistics. Long-term survivors after microsurgical reconstructions and possible secondary malignancies will be addressed.

KEYWORDS

Microsurgery in limb oncology - resection and functional reconstruction - tendon transfer in the lower extremity - soft tissue sarcoma - secondary malignancies in long-term survivors

REFERENCES

  • 1 Arbiser Z K, Folpe A L, Weiss S W. Consultative (expert) second opinions in soft tissue pathology. Analysis of problem-prone diagnostic situations.  Am J Clin Pathol. 2001;  116 473-476
    CrossrefPubMedGoogle Scholar
  • 2 Gutierrez J C, Perez E A, Moffat F L, Livingstone A S, Franceschi D, Koniaris L G. Should soft tissue sarcomas be treated at high-volume centers? An analysis of 4205 patients.  Ann Surg. 2007;  245 952-958
    CrossrefPubMedGoogle Scholar
  • 3 Rock M G, Wood M B. Reconstruction for malignant tumors of the upper limb. In: Bogumill GP, Fleegler CI Tumors of the Hand and Upper Limb. Edinburgh; Churchill Livingstone 1993: 413-433
    PubMedGoogle Scholar
  • 4 Bray P W, Bell R S, Bowen C V, Davis A, O'Sullivan B. Limb salvage surgery and adjuvant radiotherapy for soft tissue sarcomas of the forearm and hand.  J Hand Surg [Am]. 1997;  22 495-503
    PubMedGoogle Scholar
  • 5 Delaney T F, Kepka L, Goldberg S I et al.. Radiation therapy for control of soft-tissue sarcomas resected with positive margins.  Int J Radiat Oncol Biol Phys. 2007;  67 1460-1469
    CrossrefPubMedGoogle Scholar
  • 6 Gerrand C H, Wunder J S, Kandel R A et al.. The influence of anatomic location on functional outcome in lower-extremity soft-tissue sarcoma.  Ann Surg Oncol. 2004;  11 476-482
    CrossrefPubMedGoogle Scholar
  • 7 Karakousis C P, De Young C, Driscoll D L. Soft tissue sarcomas of the hand and foot: management and survival.  Ann Surg Oncol. 1998;  5 238-240
    CrossrefPubMedGoogle Scholar
  • 8 Lehnhardt M, Kuhnen C, Drücke D, Homann H H, Joneidi Jafari H, Steinau H U. [Liposarcoma of the extremities: recent developments in surgical therapy—analysis of 167 patients].  Chirurg. 2004;  75 1182-1190
    CrossrefPubMedGoogle Scholar
  • 9 Pisters P W, Pollock R E, Lewis V O et al.. Long-term results of prospective trial of surgery alone with selective use of radiation for patients with T1 extremity and trunk soft tissue sarcomas.  Ann Surg. 2007;  246 675-681 discussion 681-682
    CrossrefPubMedGoogle Scholar
  • 10 Weitz J, Antonescu C R, Brennan M F. Localized extremity soft tissue sarcoma: improved knowledge with unchanged survival over time.  J Clin Oncol. 2003;  21 2719-2725
    CrossrefPubMedGoogle Scholar
  • 11 Chen Z W. Microsurgery. Heidelberg, Germany; Springer 1982
    PubMedGoogle Scholar
  • 12 Cordeiro P G, Neves R I, Hidalgo D A. The role of free tissue transfer following oncologic resection in the lower extremity.  Ann Plast Surg. 1994;  33 9-16
    CrossrefPubMedGoogle Scholar
  • 13 Harii K. Microvascular free flaps for skin coverage. Indications and selections of donor sites.  Clin Plast Surg. 1983;  10 37-54
    PubMedGoogle Scholar
  • 14 Hidalgo D A, Disa J J, Cordeiro P G, Hu Q Y. A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique.  Plast Reconstr Surg. 1998;  102 722-732 discussion 733-734
    CrossrefPubMedGoogle Scholar
  • 15 Steinau H U, Büttemeyer R, Vogt P, Hussmann J, Hebebrand D. Reconstruction and salvage of extremities. In: Kroll SS Reconstructive Plastic Surgery for Cancer. St. Louis, MO; Mosby 1996: 68-77
    PubMedGoogle Scholar
  • 16 Kuettner H, Simon H. Die Sarkome. In: Kuettner H Neue Deutsche Chirurgie. Stuttgart, Germany; 1928 43: 96
    PubMedGoogle Scholar
  • 17 Bell R S, O'Sullivan B, Liu F F et al.. The surgical margin in soft-tissue sarcoma.  J Bone Joint Surg Am. 1989;  71 370-375
    PubMedGoogle Scholar
  • 18 Owens J C, Shiu M H, Smith R, Hajdu S I. Soft tissue sarcomas of the hand and foot.  Cancer. 1985;  55 2010-2018
    CrossrefPubMedGoogle Scholar
  • 19 Rydholm A. Prognostic factors in soft tissue sarcoma.  Acta Orthop Scand Suppl. 1997;  273 148-155
    PubMedGoogle Scholar
  • 20 Steinau H U, Biemer E. [Possibilities of plastic surgical reconstruction in limb-sparing resection of malignant soft tissue tumors of the extremities].  Chirurg. 1985;  56 741-745
    PubMedGoogle Scholar
  • 21 Rydholm A, Gustafson P, Rööser B, Willén H, Berg N O. Subcutaneous sarcoma. A population-based study of 129 patients.  J Bone Joint Surg Br. 1991;  73 662-667
    PubMedGoogle Scholar
  • 22 Coindre J M. Grading of soft tissue sarcomas: review and update.  Arch Pathol Lab Med. 2006;  130 1448-1453
    PubMedGoogle Scholar
  • 23 Enneking W F. A system of staging musculoskeletal neoplasms.  Clin Orthop Relat Res. 1986;  204 9-24
    PubMedGoogle Scholar
  • 24 Kotilingam D, Lev D C, Lazar A J, Pollock R E. Staging soft tissue sarcoma: evolution and change.  CA Cancer J Clin. 2006;  56 282-291 quiz 314-315
    CrossrefPubMedGoogle Scholar
  • 25 Puls A, Kuhnen C, Steinau H U. The value of expert second opinion in diagnosis of soft tissue sarcomas.  J Surg Oncol. 2008;  97 40-43
    CrossrefPubMedGoogle Scholar
  • 26 Steinau H U, Gradinger R, Claudi B, Biemer E. Soft tissue sarcomas of the extremities: limb sparing resection and reconstruction. In: Russel RC PSEF Instructional Courses. St. Louis, MO; Mosby 1990: 116-138
    PubMedGoogle Scholar
  • 27 Okunieff P, Suit H D, Proppe K H. Extremity preservation by combined modality treatment of sarcomas of the hand and wrist.  Int J Radiat Oncol Biol Phys. 1986;  12 1923-1929
    PubMedGoogle Scholar
  • 28 Khouri R K. Avoiding free flap failure.  Clin Plast Surg. 1992;  19 773-781
    Google Scholar
  • 29 Germann G, Steinau H U. The clinical reliability of vein grafts in free-flap transfer.  J Reconstr Microsurg. 1996;  12 11-17
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Vogt P M, Steinau H U, Spies M et al.. Outcome of simultaneous and staged microvascular free tissue transfer connected to arteriovenous loops in areas lacking recipient vessels.  Plast Reconstr Surg. 2007;  120 1568-1575
    CrossrefPubMedGoogle Scholar
  • 31 Stricker J, Goertz O, Steinau H U. Lymph node metastases in soft tissue sarcomas: a single center analysis of 1,597 patients.  Langenbecks Arch Surg. 2009;  394 321-329
    CrossrefPubMedGoogle Scholar
  • 32 Fong Y, Coit D G, Woodruff J M, Brennan M F. Lymph node metastasis from soft tissue sarcoma in adults. Analysis of data from a prospective database of 1772 sarcoma patients.  Ann Surg. 1993;  217 72-77
    CrossrefPubMedGoogle Scholar
  • 33 Barwick W J, Goldberg J A, Scully S P, Harrelson J M. Vascularized tissue transfer for closure of irradiated wounds after soft tissue sarcoma resection.  Ann Surg. 1992;  216 591-595
    CrossrefPubMedGoogle Scholar
  • 34 Grunhagen D J, de Wilt J H, Graveland W J, Verhoef C, van Geel A N, Eggermont A M. Outcome and prognostic factor analysis of 217 consecutive isolated limb perfusions with tumor necrosis factor-alpha and melphalan for limb-threatening soft tissue sarcoma.  Cancer. 2006;  106 1776-1784
    CrossrefPubMedGoogle Scholar
  • 35 Hoven-Gondrie M L, Thijssens K M, Van den Dungen J J, Loonstra J, van Ginkel R J, Hoekstra H J. Long-term locoregional vascular morbidity after isolated limb perfusion and external-beam radiotherapy for soft tissue sarcoma of the extremity.  Ann Surg Oncol. 2007;  14 2105-2112
    CrossrefPubMedGoogle Scholar
  • 36 Vogt P M, Steinau H U, Chang D, Robb G, Evans G R. Intraarterial chemotherapy: the effects on free-tissue transfer.  Plast Reconstr Surg. 2002;  109 1254-1258
    CrossrefPubMedGoogle Scholar
  • 37 Graham J D, Robinson M H, Harmer C L. Re-irradiation of soft-tissue sarcoma.  Br J Radiol. 1992;  65 157-161
    CrossrefPubMedGoogle Scholar
  • 38 Kretzler A, Molls M, Gradinger R, Lukas P, Steinau H U, Würschmidt F. Intraoperative radiotherapy of soft tissue sarcoma of the extremity.  Strahlenther Onkol. 2004;  180 365-370
    CrossrefPubMedGoogle Scholar
  • 39 Serletti J M, Carras A J, O'Keefe R J, Rosier R N. Functional outcome after soft-tissue reconstruction for limb salvage after sarcoma surgery.  Plast Reconstr Surg. 1998;  102 1576-1583 discussion 1584-1585
    CrossrefPubMedGoogle Scholar
  • 40 Hauser J, Steinstraesser L, Steinau H U. Proximal major limb amputations—a retrospective analysis of 45 oncological cases.  World J Surg Oncol. 2009;  7 15
    CrossrefPubMedGoogle Scholar
  • 41 Jupiter J B, Bour C J, May Jr J W. The reconstruction of defects in the femoral shaft with vascularized transfers of fibular bone.  J Bone Joint Surg Am. 1987;  69 365-374
    PubMedGoogle Scholar
  • 42 Arbeit J M, Hilaris B S, Brennan M F. Wound complications in the multimodality treatment of extremity and superficial truncal sarcomas.  J Clin Oncol. 1987;  5 480-488
    PubMedGoogle Scholar
  • 43 Chen C M, Disa J J, Lee H Y et al.. Reconstruction of extremity long bone defects after sarcoma resection with vascularized fibula flaps: a 10-year review.  Plast Reconstr Surg. 2007;  119 915-924 discussion 925-926
    CrossrefPubMedGoogle Scholar
  • 44 Evans G R, Black J J, Robb G L et al.. Adjuvant therapy: the effects on microvascular lower extremity reconstruction.  Ann Plast Surg. 1997;  39 141-144
    CrossrefPubMedGoogle Scholar
  • 45 Talbot S G, Mehrara B J, Disa J J et al.. Soft-tissue coverage of the hand following sarcoma resection.  Plast Reconstr Surg. 2008;  121 534-543
    CrossrefPubMedGoogle Scholar
  • 46 Daigeler A, Drücke D, Tatar K et al.. The pedicled gastrocnemius muscle flap: a review of 218 cases.  Plast Reconstr Surg. 2009;  123 250-257
    CrossrefPubMedGoogle Scholar
  • 47 de Boer H H, Wood M B. Bone changes in the vascularised fibular graft.  J Bone Joint Surg Br. 1989;  71 374-378
    PubMedGoogle Scholar
  • 48 Hsu R W, Wood M B, Sim F H, Chao E Y. Free vascularised fibular grafting for reconstruction after tumour resection.  J Bone Joint Surg Br. 1997;  79 36-42
    CrossrefPubMedGoogle Scholar
  • 49 Usui M, Ishii S, Yamamura M, Minami A, Sakuma T. Microsurgical reconstructive surgery following wide resection of bone and soft tissue sarcomas in the upper extremities.  J Reconstr Microsurg. 1986;  2 77-85
    Article in Thieme ConnectPubMedGoogle Scholar
  • 50 Wei F C, El-Gammal T A, Lin C H, Ueng W N. Free fibula osteoseptocutaneous graft for reconstruction of segmental femoral shaft defects.  J Trauma. 1997;  43 784-792
    CrossrefPubMedGoogle Scholar
  • 51 Baumgartner R, Botta P. Amputation und Prothesenversorgung der unteren Extremität. Stuttgart, Germany; Ferdinand Enke-Verlag 1989
    PubMedGoogle Scholar
  • 52 Campbell L A, Ferguson R, Cummings K M et al.. Clean surgical wound infections at an oncology center.  Infect Med. 1994;  11 280-286
    PubMedGoogle Scholar
  • 53 Tseng J F, Ballo M T, Langstein H N et al.. The effect of preoperative radiotherapy and reconstructive surgery on wound complications after resection of extremity soft-tissue sarcomas.  Ann Surg Oncol. 2006;  13 1209-1215
    CrossrefPubMedGoogle Scholar
  • 54 Germain M A, Mascard E, Dubousset J, Nguefack M. Free vascularized fibula and reconstruction of long bones in the child—our evolution.  Microsurgery. 2007;  27 415-419
    CrossrefPubMedGoogle Scholar
  • 55 Steinau H U, Hebebrand D, Vogt P, Josten C. [Plastic soft tissue coverage in defect fractures of the tibia].  Chirurg. 1996;  67 1080-1086
    CrossrefPubMedGoogle Scholar
  • 56 Chang D W, Weber K L. Use of a vascularized fibula bone flap and intercalary allograft for diaphyseal reconstruction after resection of primary extremity bone sarcomas.  Plast Reconstr Surg. 2005;  116 1918-1925
    CrossrefPubMedGoogle Scholar
  • 57 Adelani M A, Holt G E, Dittus R S, Passman M A, Schwartz H S. Revascularization after segmental resection of lower extremity soft tissue sarcomas.  J Surg Oncol. 2007;  95 455-460
    CrossrefPubMedGoogle Scholar
  • 58 Fuchs B, Sim F H. Rotationplasty about the knee: surgical technique and anatomical considerations.  Clin Anat. 2004;  17 345-353
    CrossrefPubMedGoogle Scholar
  • 59 Knox K, Bitzos I, Granick M, Datiashvili R, Benevenia J, Patterson F. Immediate reconstruction of oncologic hemipelvectomy defects.  Ann Plast Surg. 2006;  57 184-189
    CrossrefPubMedGoogle Scholar
  • 60 Küntscher M V, Erdmann D, Homann H H, Steinau H U, Levin S L, Germann G. The concept of fillet flaps: classification, indications, and analysis of their clinical value.  Plast Reconstr Surg. 2001;  108 885-896
    CrossrefPubMedGoogle Scholar
  • 61 Shenaq S M, Krouskop T, Stal S, Spira M. Salvage of amputation stumps by secondary reconstruction utilizing microsurgical free-tissue transfer.  Plast Reconstr Surg. 1987;  79 861-870
    CrossrefPubMedGoogle Scholar
  • 62 Tran N V, Evans G R, Kroll S S et al.. Free filet extremity flap: indications and options for reconstruction.  Plast Reconstr Surg. 2000;  105 99-104
    CrossrefPubMedGoogle Scholar
  • 63 Windhager R, Millesi H, Kotz R. Resection-replantation for primary malignant tumours of the arm. An alternative to fore-quarter amputation.  J Bone Joint Surg Br. 1995;  77 176-184
    PubMedGoogle Scholar
  • 64 Askari M, Fisher C, Weniger F G, Bidic S, Lee W P. Anticoagulation therapy in microsurgery: a review.  J Hand Surg [Am]. 2006;  31 836-846
    PubMedGoogle Scholar
  • 65 Goldberg J A, Pederson W C, Barwick W J. Salvage of free tissue transfers using thrombolytic agents.  J Reconstr Microsurg. 1989;  5 351-356
    Article in Thieme ConnectPubMedGoogle Scholar
  • 66 Olsson E, Svartling N, Asko-Seljavaara S, Lassila R. Activation of coagulation and fibrinolysis during reconstructive microsurgery in patients with cancer.  Microsurgery. 2001;  21 208-213
    CrossrefPubMedGoogle Scholar
  • 67 Kunisada T, Ngan S Y, Powell G, Choong P F. Wound complications following pre-operative radiotherapy for soft tissue sarcoma.  Eur J Surg Oncol. 2002;  28 75-79
    CrossrefPubMedGoogle Scholar
  • 68 Doi K, Kuwata N, Kawakami F, Hattori Y, Otsuka K, Ihara K. Limb-sparing surgery with reinnervated free-muscle transfer following radical excision of soft-tissue sarcoma in the extremity.  Plast Reconstr Surg. 1999;  104 1679-1687
    CrossrefPubMedGoogle Scholar
  • 69 McPhee M, McGrath B E, Zhang P, Driscoll D, Gibbs J, Peimer C. Soft tissue sarcoma of the hand.  J Hand Surg [Am]. 1999;  24 1001-1007
    PubMedGoogle Scholar
  • 70 Weinberg H, Kenan S, Lewis M M, Hausman M R, Vickery C B, Bloom N D. The role of microvascular surgery in limb-sparing procedures for malignant tumors of the knee.  Plast Reconstr Surg. 1993;  92 692-698
    CrossrefPubMedGoogle Scholar
  • 71 Schwaiberger V, Goertz O, Kuhnen C, Steinau H U. MFH revisited: outcome after surgical treatment of undifferentiated pleomorphic or not otherwise specified (NOS) sarcomas of the extremities—an analysis of 140 patients.  Langenbecks Arch Surg. 2009;  394 313-320
    CrossrefPubMedGoogle Scholar

Hans-Ulrich SteinauM.D. 

Head, Department of Plastic Surgery and Burns, Sarcoma Reference Center, BG–University Hospital “Bergmannsheil,” Ruhr-University Bochum

Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany

Email: hans-ulrich.steinau@bergmannsheil.de