Özgür BAYSAL, Fevzi SAĞLAM, Ömer SOFULU, Okan YİĞİT, Evrim SİRİN, Bülent EROL

Indications of amputation after limb-salvage surgery of patients with extremitylocated bone and soft-tissue sarcomas: A retrospective clinical study

Objective: This study aimed to investigate amputation-related factors after limb-salvage surgery (LSS) in patients with extremity-located bone and soft-tissue sarcomas and determine the relationship between these factors and patient survival.Methods: In this retrospective study at our institution, patients in whom LSS was first performed because of an extremity-located musculoskeletal sarcoma, and subsequently amputation was carried out for various indications were included. Patient andtumor characteristics, details of surgical procedures, indications of amputation, number of operations, presence of metastasisbefore amputation, and post-amputation patient survival rates were analyzed.Results: A total of 25 patients (10 men, 15 women; mean age=41.96±21.88 years), in whom amputation was performed afterLSS as initial resection of an extremity sarcoma or re-resection(s) of a local recurrence, were included in the study. The leadingoncological indication for amputation was local recurrence that occurred in 18 (72%) patients. Non-oncological indications included prosthetic infection in 5 (20%), mechanical failure in 1 (4%), and skin necrosis in 1 (4%) patient. The patients underwent amedian of 2 (range, 1–4) limb-salvage procedures before amputation. Distant organ metastasis was detected in 22 (88%) patientsduring follow-up; in 13 (52%) of these patients, metastasis was present before amputation. A total of 11 (44%) patients were aliveat the time of study with no evidence of the disease (n=3) or with disease (n=8), and 14 (56%) patients died of disease. The meanoverall and post-amputation survival were 47±20.519 (range, 11–204) months and 22±4.303 (range, 2–78) months, respectively.The median follow-up was 27 (range, 6–125) months.Conclusion: The most common causes of amputation after LSS were local recurrence and prosthetic infection. Patients whounderwent amputation after LSS developed a high rate of distant organ metastasis during follow-up and had reduced survival.Level of Evidence: Level IV, Therapeutic Study

___

1. DiCaprio MR, Friedlaender GE. Malignant bone tumors: limb sparing versus amputation. J Am Acad Orthop Surg 2003; 11: 25-37.

2. Ferrone ML, Raut CP. Modern surgical therapy: limb salvage and the role of amputation for extremity soft-tissue sarcomas. Surg Oncol Clin N Am 2012; 21: 201-13.

3. Cirstoiu C, Cretu B, Serban B, Panti Z, Nica M. Current review of surgical management options for extremity bone sarcomas. EFORT Open Rev 2019; 4: 174-82.

4. Jeys LM, Grimer RJ, Carter SR, Tillman RM. Risk of amputation following limb salvage surgery with endoprosthetic replacement, in a consecutive series of 1261 patients. Int Orthop 2003; 27: 160-3.

5. Simon MA. Limb salvage for osteosarcoma in the 1980s. Clin Orthop Relat Res 1991; 270: 264-70.

6. Stojadinovic A, Jaques DP, Leung DH, Healey JH, Brennan MF. Amputation for recurrent soft tissue sarcoma of the extremity: indications and outcome. Ann Surg Oncol 2001; 8: 509-18.

7. Erstad DJ, Ready J, Abraham J, et al. Amputation for extremity sarcoma: contemporary indications and outcomes. Ann Surg Oncol 2018; 25: 394- 403.

8. Smith HG, Thomas JM, Smith MJF, Hayes AJ, Strauss DC. Major Amputations for extremity soft-tissue sarcoma. Ann Surg Oncol 2018; 25: 387-93.

9. Sauter ER, Hoffman JP, Eisenberg BL. Diagnosis and surgical management of locally recurrent soft-tissue sarcomas of the extremity. Semin Oncol 1993; 20: 451-5.

10. Giuliano AE, Eilber FR, Morton DL. The management of locally recurrent soft-tissue sarcoma. Ann Surg 1982; 196: 87-91.

11. Sawamura C, Matsumoto S, Shimoji T, Tanizawa T, Ae K. What are risk factors for local recurrence of deep high-grade soft-tissue sarcomas? Clin Orthop Relat Res 2012; 470: 700-5.

12. Lahat G, Lazar A, Lev D. Sarcoma epidemiology and etiology: potential environmental and genetic factors. Surg Clin North Am 2008; 88: 451-81.

13. Henderson ER, Groundland JS, Pala E, et al. Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am 2011; 93: 418-29.

14. Tande AJ, Patel R. Prosthetic joint infection. Clin Microbiol Rev. 2014; 27: 302-45.

15. Malawer MM, Chou LB. Prosthetic survival and clinical results with use of large-segment replacements in the treatment of high-grade bone sarcomas. J Bone Joint Surg Am 1995; 77: 1154-65.

16. Rothermundt C, Whelan JS, Dileo P, et al. What is the role of routine follow-up for localised limb soft tissue sarcomas? A retrospective analysis of 174 patients. Br J Cancer 2014; 110: 2420-6.

17. Clark MA, Thomas JM. Amputation for soft-tissue sarcoma. Lancet Oncol 2003; 4: 335-42.