Limb-Sparing Surgery for Extremity Sarcomas: Outcomes and Functional Analysis in a Six-Year Experience

There are approximately 8300 cases of sarcomas annually, with 50% occurring in the extremities. Currently, limb-sparing surgery is preferred over limb amputation. Extremity sarcomas at the authors' institution undergo limb-sparing surgery, when possible, with wide margin resection, immediate soft-tissue reconstruction, and adjuvant therapy. This report was a retrospective outcomes study and functional analysis of these patients over 6 years.

Between February, 1998 and May, 2004 (75 months), 112 patients (72 males and 40 females, with ages 52.5 years ± 18.5 years) underwent salvage of 115 limbs (75 lower, 40 upper extremities). The thigh was the most common location (n = 44); 66% of the tumors were high-grade (n = 74); and 37.5% were MFH (n = 35). The average tumor size at resection was 6.8 ± 5.5 cm. The rectus abdominis, latissimus dorsi, gastrocnemius, and fasciocutaensou flaps accounted for 81.4% of the flaps used. Resection took 3.4 ± 1.7 hr, and reconstruction took 4.3 ± 2.1 hr. Ninety-five patients had neoadjuvant therapy, with 55 receiving pre- and 77 receiving postoperative therapy. Twenty-nine patients had both pre- and postoperative treatments. Brachytherapy (n = 26) was started on postoperative day 7.0 ± 1.5.

Follow-up has been from 1 to 69 months with 10 patients lost to follow-up and 16 deaths. Twenty-seven developed metastasis, the most common location being the lung (n = 21). Of the 122 flaps, 42 were free with two acute losses (5%) and 4 late losses (10%). All pedicle flaps survived (overall flap survival: 95.1%). Fifty-six patients (50%) had minor or major wound complications, most commonly seromas. One patient (1%) required an above-knee amputation because of refractory periprosthetic infections.

Postoperative function was analyzed with the Toronto Extremity Salvage Score. Of the 103 patients with at least 6 months recovery, 83 were known to be alive and 53 (64%) completed the survey at a mean of 27.6 months post surgery. The mean TESS was 83.2 (UE = 89.3; LE = 79.2, ns), indicating slight disability in daily activities (100 = no difficulty; 75 = slight difficulty). Patients' self-rated disability score was 4.3 (no disability = 5; slight = 4). Patients who had three different modalities of adjuvant therapy were more likely than those with only one modality to have a lower TESS, although not significantly (p = 0.057). There was no significance in TESS with respect to age, sex, adjuvant therapy, or type of adjuvant therapy).

This study showed that even with major surgery, patients noted only limited disability. Despite a high rate of minor wound complications, limb-preservation surgery maintains the patient's ability to achieve a high level of functionality.