The role of radical amputations for extremity tumors: a single institution experience and review of the literature

Abstract

Background: Major amputations are indicated for advanced tumors when limb-preservation techniques have been exhausted. Radical surgery can result in significant palliation and possible cure.

Methods: We identified 40 patients who underwent forequarter (FQ) or hindquarter (HQ) amputations between May 2000 and January 2011. Patient demographics, tumor-related factors, and outcomes were reviewed.

Results: There were 30 FQ and 10 HQ amputations. The most common diagnoses were sarcoma (55%) and squamous cell carcinoma (25%). Patients presented with primary tumors (35%), regional recurrence (57.5%), or unresectable limb metastatic disease (7.5%). Presenting symptoms included fungating wounds (35%), intractable pain (78%), and limb dysfunction (65%). Operations were performed with curative intent (10%), curative/palliative intent (70%), or palliation alone (20%). Wound complications occurred in 35%. Pain was improved in 78% of patients following surgery. Despite a 91% negative margin rate, 79% of patients recurred either locally or distantly. Median overall survival was 10.9, 13.2, and 3.4 months in the curative, curative/palliative, and palliative groups, respectively.

Conclusions: In the absence of conservative options, major amputations are indicated for the management of advanced tumors. These operations can be performed safely, resulting in effective palliation of debilitating symptoms. While recurrence rates remain high, some patients can achieve prolonged survival.

Fig. 1

Extreme example of a patient with locally advanced sarcoma causing extensive soft tissue destruction.

Fig. 2

Incidence (percentage) of postoperative complications in 40 patients undergoing FQ and HQ amputations.

Fig. 3

Rate (percentage) and site of recurrence in curative and curative/palliative patients following margin-negative amputation for sarcoma and squamous cell carcinoma (SCC).

Fig. 4

Kaplan–Meier curves illustrating overall survival based on the (A) total study group, (B) surgical intent, (C) type of amputation, and (D) tumor type.

Fig. 5

Forty-nine-year-old woman with recurrent left breast cancer. Salvage chemotherapy and radiation therapy had only a transient response. The tumor progressed, encasing the neurovascular bundle and causing debilitating pain, swelling, and limb dysfunction. A,B: Coronal and axial MRI images of the tumor involving the clavicle, chest wall, brachial plexus, and subclavian vessels. C: Deltoid fasciocutaneous flap following forequarter amputation. The first and second ribs were resected en bloc and the chest wall was reconstructed with mesh. D: Closure of the deltoid fasciocutaneous flap. E,F: Postoperative results at 2 weeks. The patient had significant improvement in her pain.

Fig. 6

Example of a postoperative rehabilitation with prosthesis.