Limb-salvage strategies to optimize quality of life: the M.D. Anderson Cancer Center experience

Systemic Cisplatin Does Not Affect the Bone Regeneration Process in a Critical Size Defect Murine Model

Osteosarcoma (OS) is the most common primary malignant bone tumor, and the current standard of care for OS includes neoadjuvant chemotherapy, followed by an R0 surgical resection of the primary tumor, and then postsurgical adjuvant chemotherapy. Bone reconstruction following OS resection is particularly challenging due to the size of the bone voids and because patients are treated with adjuvant and neoadjuvant systemic chemotherapy, which theoretically could impact bone formation. We hypothesized that an osteogenic material could be used in order to induce bone regeneration when adjuvant or neoadjuvant chemotherapy is given. We utilized a biomimetic, biodegradable magnesium-doped hydroxyapatite/type I collagen composite material (MHA/Coll) to promote bone regeneration in the presence of systemic chemotherapy in a murine critical size defect model. We found that in the presence of neoadjuvant or adjuvant chemotherapy, MHA/Coll is able to enhance and increase bone formation in a murine critical size defect model (11.16 ± 2.55 or 13.80 ± 3.18 versus 8.70 ± 0.81 mm3) for pre-op cisplatin + MHA/Coll (p-value = 0.1639) and MHA/Coll + post-op cisplatin (p-value = 0.1538), respectively, at 12 weeks. These findings indicate that neoadjuvant and adjuvant chemotherapy will not affect the ability of a biomimetic scaffold to regenerate bone to repair bone voids in OS patients. This preliminary data demonstrates that bone regeneration can occur in the presence of chemotherapy, suggesting that there may not be a necessity to modify the current standard of care concerning neoadjuvant and adjuvant chemotherapy for the treatment of metastatic sites or micrometastases.

Osteogenesis in the presence of chemotherapy: A biomimetic approach

Osteosarcoma (OS) is the most common bone tumor in pediatrics. After resection, allografts or metal endoprostheses reconstruct bone voids, and systemic chemotherapy is used to prevent recurrence. This urges the development of novel treatment options for the regeneration of bone after excision. We utilized a previously developed biomimetic, biodegradable magnesium-doped hydroxyapatite/type I collagen composite material (MHA/Coll) to promote bone regeneration in the presence of chemotherapy. We also performed experiments to determine if human mesenchymal stem cells (hMSCs) seeded on MHA/Coll scaffold migrate less toward OS cells, suggesting that hMSCs will not contribute to tumor growth and therefore the potential of oncologic safety in vitro. Also, hMSCs seeded on MHA/Coll had increased expression of osteogenic genes ( BGLAP, SPP1, ALP) compared to hMSCs in the 2D condition, even when exposed to chemotherapeutics. This is the first study to demonstrate that a highly osteogenic scaffold can potentially be oncologically safe because hMSCs on MHA/Coll tend to differentiate and lose the ability to migrate toward tumor cells. Therefore, hMSCs on MHA/Coll could potentially be utilized for bone regeneration after OS excision.

QUALITY OF LIFE IN ADULTS WITH SARCOMAS UNDER CONSERVATIVE SURGERY OR AMPUTATION

OBJECTIVE

To understand the perception of quality of life, functionality, and psychological aspects of adults with lower limb sarcoma who underwent conservative surgery or amputation.

METHODS

Sociodemographic data were collected, and the following questionnaires were used: EORTC QLQ - C30 for quality of life, the Functional Assessment System (MSTS) for functionality and the Beck Depression Inventory (BDI) for depression symptoms.

RESULTS

The sample consisted of 45 young adults with sarcoma, divided into two groups: amputation (29) and conservative surgery (16). Most were male, single and students. Average family income before and after the disease did not differ, but those that were employed had a better perception of general quality of life, as well as those with higher family income after the disease. Regarding the type of surgery, there was a predominance of amputation; osteosarcoma was the most common histological type and the most affected region was the femur. All participants participated in social, cultural, sporting or religious activities. MSTS and Beck scale values did not differ between procedures.

CONCLUSION

Given the scarcity of studies on the subject at the national level, further investigations are suggested to explore aspects related to quality of life for patients with sarcomas. Level of Evidence III, Retrospective comparative study.

Rehabilitation to Improve the Function and Quality of Life of Soft Tissue and Bony Sarcoma Patients

Sarcomas are bone and soft tissue tumors that can have significant effects on patient function and quality of life. Like most malignancies, treatment includes a combination of chemotherapy, radiation, and surgical resection, all of which also carry risks and long-term effects. A multidisciplinary rehabilitation plan can help minimize symptoms and sequelae which negatively affect the patient function and quality of life, including pain, chemotherapy-induced peripheral neuropathy, radiation fibrosis, activity restrictions following surgical excision, amputation, bowel and bladder dysfunction, and lymphedema. Patients should be evaluated by a rehabilitation specialist at any point during their diagnosis, treatment, and survivorship phase to determine appropriate interventions to minimize the impact of sarcomas and their treatment on patient function and quality of life.

QUALITY OF LIFE OF PATIENTS WITH SARCOMA AFTER CONSERVATIVE SURGERY OR AMPUTATION OF LIMBS

OBJECTIVE

To conduct an integrative review on quality of life (QOL) of patients with sarcoma who underwent conservative surgery or limb amputation.

METHODS

We conducted a six-step integrative review by searching the databases LILACS, SciELO, PePSIC, Embase, and PubMed, using the descriptors: "Quality of life", "Bone cancer", "Sarcoma", "Limb Salvage," and "Amputation." Ten studies were selected according to: database, type of study, methods, researcher's profession, sex, histological type, title, country/region, and periodical/year of publication.

RESULTS

Nine quantitative and one qualitative studies were included. All were conducted by physicians and correlated to QOL with the impact of diagnosis, psychosocial aspects, cancer treatment, and survival. Other aspects included type of surgery, functionality, rehabilitation, and a multidisciplinary approach. The QOL results were similar for conservative surgery and amputation in eight studies. In two, it was concluded that patients undergoing conservative surgery had a better QOL.

CONCLUSION

The number of studies on QOL in patients with sarcoma is small. In most, there was no difference between the study groups. In addition, the studies indicated the importance of evaluation of QOL, since it has a direct effect on patients' physical manifestations and impacts their coping abilities. Level of evidence III, System review.

Repiphysis prosthesis for limb preservation in pediatric patients with bone cancer: a literature review

Osteosarcoma is the most common bone sarcoma in children and adolescents. It occurs mainly around the knee joint; the distal femur is the most common location. When it occurs in children who are skeletally immature, a significant limb length discrepancy can occur. The Repiphysis prosthesis was developed in the 1980s to assist in reconstruction of the affected limb in these patients. Ten articles were reviewed to identify the challenges and complications that affect the functional outcome on this population. The reports included patients, aged 7-16 years, who were skeletally immature and had bone sarcomas of the lower extremities. Complications reported by the authors were similar and included aseptic loosening, mechanical failure, infection, flexion contracture of the knee, fracture, and neuropraxia.

Outcome of expandable prostheses in children

BACKGROUND

Expandable prostheses offer the advantages of limb-salvage and limb-length equality at skeletal maturity. However, what is the cost for achieving that goal, and in how many children this is achieved?

MATERIALS AND METHODS

We present 32 children (16 boys and 16 girls; mean age, 9 y) with bone sarcomas of the femur treated with limb salvage using expandable prostheses. The Kotz Growing prosthesis and the noninvasive Repiphysis and Stanmore expandable prostheses were used. The mean follow-up was 49 months. Survival analysis of the children and primary implants and functional evaluation were performed.

RESULTS

Survival of the children was 94% and 84% at 48 and 72 months. Survival of the primary prostheses was 78% and 66% at 48 and 72 months; survival was significantly higher only for the Kotz when compared with the Repiphysis prostheses (P=0.026). The rate of implant-related complications was 51.3%; 9 prostheses (23%) were revised because of aseptic loosening, infection, and breakage. A mean total lengthening of 28 mm (4 to 165 mm) was achieved by 84 procedures (2.6 procedures/patient). Three of the 9 children who reached skeletal maturity had limb-length equality and 6 discrepancy of 15 to 30 mm. The mean Musculoskeletal Tumor Society score was excellent (79%) without a significant difference between the type of prostheses (P=0.934).

CONCLUSIONS

The Kotz Growing prosthesis, although it requires an open lengthening procedure, has shown higher survival when compared with the noninvasive Repiphysis prosthesis. However, the total lengthening remains small, and the complications rates are high even with the noninvasive prostheses.

Factors Influencing Prognosis After Initial Inadequate Excision (IIE) for Soft Tissue Sarcoma

Purpose. The influence of initial inadequate excision (IIE) of soft tissue sarcoma (STS) on local control and overall survival is not well established. It is generally believed that an IIE may have a negative impact on both, despite subsequent treatment by radical surgery and radiotherapy. However, data on local recurrence-free survival/overall survival are conflicting and there are no data on the effect of IIE on overall survival.Patients and methods. A retrospective analysis was made of 86 patients with soft tissue sarcoma of the extremities and trunk after an IIE had been performed due to inappropriate work-up. The minimal follow-up was 7 years. Specimens of the subsequent radical resection were evaluated for residual tumor, grade of tumor and complications of IIE. Endpoints were recurrence-free survival and overall survival.Results. Specimens of the subsequent radical resection showed residual tumor in 66 patients (77%). The most common complication after IIE was hematoma. In both univariate and multivariate analyses, grade II/III tumors and complications after IIE are significant negative prognostic factors for local recurrence-free survival (P = 0.008 and P = 0.002, respectively, in the Cox model). For this survival, three prognostic groups could be formed based on grade, or presence or absence of complications. Adjuvant radiotherapy did not change the rate of local recurrence-free survival. For overall survival, only tumor grade is a significant factor (log-rank test).Conclusion. This retrospective study shows that complications associated with an IIE have a significant negative effect on local control, but not on overall survival, because IIE is often the result of inappropriate work-up before surgery. For better diagnosis and therapy STS should be treated in specialized centers.

Complications of limb salvage surgery in childhood tumors and recommended solutions

Bone and soft tissue malignancies are associated with serious diagnostic and therapeutic problems in every level of pubertal growth in children. Current treatment modality preferred in bone and soft tissue tumors is wide resection of tumor followed by the reconstruction of consequent defect by various methods. Chemotherapy and radiotherapy are applied for systemic effects to the patient pre- and post-operatively and for local effects that facilitate the surgical procedure. Mostly, it is very difficult to control problems following wide resection and reconstruction. In this study, our aim is to discuss the problems encountered in different resection and reconstruction approaches in childhood bone and soft tissue tumors, and the recommended solutions addressed to these problems. From 1990 to 2003, a total of 68 patients (38 female, 30 male) with a mean age of 13.1 (1.5-18) were included in the study. 85.3% of patients were diagnosed as osteosarcoma and the rest was Ewing's sarcoma. Seventy-five percent of patients had stage IIB disease. The lesions of 34 patients were detected to be in distal femur, 26 in proximal tibia and fibula, 4 in foot and ankle joint, and the remaining 4 in pelvis. As reconstructive surgery, 40 patients had modular prosthesis, vascularized fibular graft was performed in 13 patients, and 10 patients underwent arthrodesis with vascularized fibular graft. 20.6% of patients had shortened limb, infection was detected in 4 patients, laxity in 5, and restricted motion in 4 as complication of prosthesis. With sacrificed physis, 13 patients had a mean value of 4.6 cm limb shortness. Limb salvage surgery has been considered as the gold standard treatment in orthopedic oncological surgery. More understanding of the biology of sarcoma, introduction of new effective chemotherapeutic agents, development of new techniques concerning the surgical resection, advances in diagnostic methods, and improvements in reconstructive surgery all make a major contribution to limb salvage surgery. Since some problems are still encountered, we offer a therapeutic algorithm for complications in the management of childhood tumors that we have encountered so far.

The role of physical therapy and occupational therapy in the rehabilitation of pediatric and adolescent patients with osteosarcoma

The approach to rehabilitation of patients with osteosarcoma has evolved with the many advances in the medical treatment and surgical management of this pediatric and adolescent cancer. In the past, amputation (often radical amputation) was the standard method for treating patients with extremity sarcomas, and rehabilitation was geared toward providing either functional training for patients who had not had limb replacement or prosthetic training for those who had received prostheses. Currently, limb-sparing procedures combined with adjuvant chemotherapy (and occasionally radiotherapy) are used to treat most patients with this disease. In addition, physical-therapy and occupational-therapy interventions are now tailored to address the multiple physical and psychosocial difficulties these patients will face for the remainder of their lives. Integral parts of the interdisciplinary team, practitioners of these disciplines, provide services that enable patients to achieve their highest functional status to permit them to return to their role in society and hence enjoy dignity and improved quality of life.

Limb salvage surgery for children and adolescents with malignant bone tumors in a developing country

PURPOSE

To describe the 5-year experience of a multidisciplinary limb salvage program for children and adolescents with malignant bone tumors in Lebanon.

PATIENTS AND METHODS

Between January 2002 to February 2007, 30 children and adolescents (2 with Ewing sarcoma and 28 with osteosarcoma) underwent Limb Salvage Surgeries (LSS) at the American University of Beirut Medical Center after partnering with the multidisciplinary team at St. Judes Children's Research Hospital (SJCRH). Procedures performed included 12 Repiphysis, noninvasively expandable, prostheses inserted in skeletally immature children, 15 modular prostheses, 2 allografts and 1 rotationplasty. All patients received pre- and postoperative chemotherapy.

RESULTS

With a mean follow-up of 31 months, 20 patients are now off therapy, 4 died, and 6 are receiving chemotherapy (3 due to pulmonary recurrence). Complications of surgery included infections in three cases, failure of the expansion mechanism in two, femoral stem fracture in one, prostheses femoral stem loosening in one and wound dehiscence in one. Lengthening of Repiphysis prostheses was achieved by subjecting the limb to an electromagnetic field that would allow controlled release of the Repiphysis expansion mechanism. Ten patients underwent a total of 42 lengthening procedures with an average of 9 mm lengthened per procedure (range 2-15 mm). All patients have good function of the affected limb.

CONCLUSION

Our LSS results are comparable to those reported in the literature. Collaboration with SJCRH and fund raising were critical to the program's success. This endeavor could serve as a model for establishing LSS programs in developing countries.

Locally advanced and metastatic sarcoma (adult type) including gastrointestinal stromal tumors

STS belong to the most challenging diseases in oncology that demand all resources of modern clinical oncology. With the improvement of surgical techniques and radiation therapy the majority of patients with localized disease can be cured. However, for patients with locally advanced or metastatic disease chemotherapeutic treatments have not greatly changed the poor outcome of the disease. The introduction of combined chemoradiotherapy as well as isolated limb-perfusion has improved the limb-salvage rate in locally advanced disease but the impact of systemic chemotherapy on overall survival remains a subject of dispute. For patients with metastatic sarcoma long-term survival can only be achieved in a small number of patients with mostly resectable disease. The list of effective drugs for palliative treatment in general still remains short and the duration of remissions usually does not exceed several months. The lack of alternative chemotherapeutic drugs imposes a considerable challenge in daily clinical practice with many young patients exhibiting a good performance status but progressive disease after standard treatment. A variety of new drugs or drug combinations seem to exhibit considerable activity in certain histological sarcoma subtypes, which may soon broaden the armamentarium of drugs for a subset of patients. However, with the vastly improved understanding of the biology and pathology of soft tissue sarcoma an era of opportunities seems to have begun and the recent success in the treatment of gastrointestinal stromal tumors impressively shows how fast a gain in the understanding of oncogenic mechanisms may translate into a highly efficient, clinically useful treatment.

Early distal femoral endoprosthetic survival: cemented stems versus the Compress implant

Aseptic loosening is well known following endoprosthetic replacement (EPR) using cemented intramedullary stems (CISs). The Compress (CPS) implant uses a novel spring system, achieving immediate, high compression fixation that induces bone hypertrophy and avoids stress shielding. We compared 26 oncologic distal femoral CPS patients treated at the University of California, San Francisco (UCSF, USA) with 26 matched CIS patients from the Royal Orthopaedic Hospital, Birmingham (ROH, UK). The predominant diagnosis was osteosarcoma. Each centre had only one device-related prosthetic failure. In the short term these results show CPS to be safe and effective. We await longer follow-up to assess the ongoing potential for prosthetic failure.

Advantage of limb salvage over amputation for proximal lower extremity tumors

Although function after lower extremity amputation and limb salvage has been compared, no study has assessed individual functional variables by surgical level. Our aim was to determine whether risks of long-term psychologic and physical limitations were associated with amputation or limb salvage at four levels: below-knee, above-knee, hip, and pelvis. We included 408 patients with sarcomas and postoperative followup of 2 years or greater who had completed a quality-of-life self-report questionnaire. The mean length of followup was 8.91 +/- 5.15 years (range, 2-27 years). Relative risk analysis was done on 12 dichotomous general health, psychologic, and physical function variables. At the below-knee level, outcomes were similar after both procedures. At the above-knee level, amputation was associated with increased risk of limp (RR = 1.6), walking aid use (RR = 2.1), anxiety (RR = 2.4), and inability to drive (RR = 3), and decreased risk of muscle weakness (RR = 0.57). At the hip and pelvic levels, outcomes were descriptively compared because of the small number of amputations. At these higher levels, limitations were more common after amputation. The difference in results between the below-knee and above-knee levels supports the importance of distinguishing surgical levels. Limb salvage offers a functional advantage at proximal tumor locations.

LEVEL OF EVIDENCE

Therapeutic study, Level III (retrospective, comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Reconstruction for lower extremity limb salvage in soft tissue carcinoma

Limb salvage procedures for the lower extremity have a 95% success rate and have essentially supplanted primary amputation as the primary treatment for limb-threatening malignancies. En bloc tumor resection involving major neural and vascular structures that once led to amputation are now successfully reconstructed using free-tissue transfer in combination with neoadjuvant and adjuvant chemoradiation therapies and brachytherapy. Planning for reconstruction of complex lower extremity wounds begins at the time of diagnosis and extends to postoperative rehabilitation. Developing a successful reconstructive plan requires a team approach with accurate assessment of the anticipated loss of critical structures, wound location, defect size, and an understanding of the local and distant tissues available for reconstruction. Comprehensive assessment of the anticipated wound combined with an understanding of the distant and local tissues available for reconstruction allows the reconstructive surgeon to select tissues from the entire body that have improved functional and aesthetic outcomes for patients.

Lower limb proximal amputation for a tumour: a retrospective study of 12 patients

OBJECTIVE

To analyse survival, prosthetic fitting and functional status after trans-femoral amputation or hip disarticulation for a primitive tumour.

METHODS

Retrospective study of all patients admitted since 1985.

RESULTS

Mean age at amputation was 55. Causes of amputation were osteosarcoma in 50%. Eight (8) patients had initial conservative surgery. Local recurrence was never observed. Nine (9) developed metastasis and required further hospitalisation. Fifty percent (50%) of patients died. Inpatient rehabilitation started 14 days after amputation (7-27), and was of a mean duration of 32 days. Prosthetic fitting was performed 13 days after admission (7 days when a liner was used). Further improvement of the prosthesis was performed in 10 patients. Among the patients who died, 5 had gone home, 4 were wearing their prosthesis all day long and 2 walked indoors with no additional support at discharge. Three (3) patients lived less than 2 months at home. Among the patients who did survive, all went home, 5 were wearing their prosthesis all day long and 2 walked indoors without aid at discharge. Two (2) patients practised sport and 4 drove. All the patients who were active have gone back to work.

CONCLUSIONS

Gain due to prosthesis provision is undebatable. Good functional results can be obtained with adapted materials. Initial problems due to the synchronisation of treatments are resolved with multidisciplinary care. All patients should have a rapid and short hospitalisation in a rehabilitation unit and receive a first, simple prosthesis that can be further adapted.

Outcome of lower extremity malignancy survivors treated with transfemoral amputation

OBJECTIVE

To determine outcomes of surviving patients who underwent transfemoral amputation as part of treatment for lower extremity malignancy at a mean 15 years postoperatively, with a minimum 2-year follow-up.

DESIGN

Retrospective, case control.

SETTING

Tertiary care university medical center.

PATIENTS

Thirty-five of 38 consecutively admitted patients free of metastatic disease managed with transfemoral amputation as part of treatment of a lower extremity bone and/or soft tissue malignancy between 1966 and 1997 at 1 institution. The control group included 35 age- and gender-matched subjects recruited from the local driver's license office.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Musculoskeletal Function Assessment (MFA), Short Form-12 General Health Status Survey (SF-12), physical performance battery, cost, and demographic data.

RESULTS

Controls showed superior scores as measured by the MFA (P < .0001), the physical component summary of the SF-12 (P = .0002), and the physical performance battery (P < .0001), but had inferior scores on the mental component summary of the SF-12 (P < .0001). With the numbers available, no differences were found between study and control subjects in terms of employment rate (P = .51), education level (P = .66), income level (P =.44), marital status (P = .79), incidence of self-reported health problems (P = .14), and alcohol (P =.42) and tobacco (P = .82) use. Ten patients were included in the cost analysis; the mean cost to obtain and maintain a lower extremity prosthesis was $4225 per year (range, 623 dollars-8517 dollars).

CONCLUSIONS

Although the decrease in physical performance was anticipated in the study group, the group differed very little from the control population in terms of employment, education level, income, marital and home status, incidence of self-reported health problems, incidence of self-reported depression, and alcohol and tobacco use. Also, the long-term cost of maintaining a lower extremity prosthesis is noted.