Functional and psychosocial effects of multimodality limb-sparing therapy in patients with soft tissue sarcomas.

We have documented functional and psychosocial changes in patients with extremity soft tissue sarcomas who have undergone multimodality limb-sparing treatments. In 88 patients, parameters related to economic status, sexual activity, pain, limb function, and global quality of life (QOL) were recorded prior to surgery and every 6 months postoperatively. Changes from the preoperative assessment for every parameter were analyzed in each patient. Six months after surgery, there was a decrease in employment status, sexual activity, and in limb function in a significant number of patients. At 12 months, these decreases were still evident. Despite these changes, global QOL measured by a standardized test showed at least some improvement in a significant proportion of patients at 12 months. These findings highlight the difficulty in defining QOL. It could not be ascertained if radiation therapy and/or chemotherapy were causative factors in specific changes because of the small numbers of patients in each subgroup. However, among 60 patients with high-grade sarcomas, significant wound problems developed in 10 of 33 who received postoperative radiation therapy in combination with adjuvant doxorubicin and cyclophosphamide chemotherapy compared with one of 27 patients who received adjuvant chemotherapy alone (P = .016). Also, among high-grade sarcoma patients with 12-month follow-up, six of 19 patients who received radiation therapy and chemotherapy developed joint contractures compared with zero of 15 patients who received chemotherapy alone (P less than .04). The combination of postoperative radiation therapy and chemotherapy appeared to be associated with significantly more tissue-related injury in patients with high-grade sarcomas compared with chemotherapy alone.

Acute and long-term effects on limb function of combined modality limb sparing therapy for extremity soft tissue sarcoma.

A retrospective review is presented on 145 patients who underwent limb-sparing surgery and radiation therapy (with or without adjuvant chemotherapy) for their primary soft tissue sarcomas of the extremities on protocol between 1975 and 1986. The focus on our analysis was the acute and long term toxicity of treatment on limb function. The most common acute complication was skin reaction, occurring in 52 patients (36%). Long term (occurring after more than 1 year following all treatment) treatment complications in the extremity were as follows: bone fracture = 6%; contracture = 20%; pain requiring narcotics = 7%; edema greater than 2+ = 19%; moderate to severe decrease in range of motion = 32%; moderate to severe decrease in manual muscle strength = 20%; orthotic device required = 9%; cane or crutch required = 7%; chronic infection = 9%; and tissue induration = 57%. Three amputations for treatment complications were required. Inclusion of more than 50% of the joint in the radiation portal was associated with a higher frequency of contracture. High nominal standard dose (greater than 1760 rets, greater than 63 Gy at 1.8 Gy per fraction) resulted in more painful limbs as well as limbs with increased edema, decreased manual muscle strength, decreased range of motion, and skin telangiectasias. Edema was more often noted in patients with a longer radiation portal (greater than 35 cm), as was tissue induration. Chronic ulcer or infection was more frequently seen in patients with lower extremity tumors and when more than 75% of the extremity diameter was irradiated. Although chemotherapy given concurrent with radiation therapy was associated with a higher number of acute skin reactions, this did not appear to translate into increased long term morbidity. The percentage of patients ambulating without assistive devices and with mild or no pain was 84%. Careful attention to the techniques of radiation therapy may have a significant impact on minimizing acute and long term complications of limb sparing treatment for extremity soft tissue sarcoma.

Excision of quadriceps muscle group.

Excision of the quadriceps muscle group may be selected for definitive treatment of intracompartmental soft tissue sarcomas within this muscle group. After a skin incision is made from anterosuperior iliac spine to the patella, skin flaps are dissected superficial to the fascia lata to the flexor muscles laterally and to the gracilis muscle medially. The superficial femoral artery is dissected free of the quadriceps muscles over the entire thigh. The origins of the sartorius, tensor fascia lata, and rectus femoris muscles are transected from their origins on the pelvis, and the vastus lateralis, vastus medialis, and vastus intermedius muscles are transected from their origins on the femur. To free the specimen, the quadriceps femoris tendon is divided just proximal to its attachment to the patella. The gracilis muscle medially and the short head of the biceps muscle laterally are transected at their insertions and secured to the patella. The subcutaneous tissue and skin are closed over generous suction drains. After operation an ankle-foot orthosis is used to provide for relatively unrestricted ambulation.

Soft tissue sarcoma: functional outcome after wide local excision and radiation therapy.

Functional outcome was evaluated in 40 patients with a diagnosis of soft tissue sarcoma (STS), who had received wide local surgical excision and postoperative radiation therapy. All patients were two or more years postsurgical excision, and 1.75 or more years postradiation. Patients were separated into three anatomic groups: head, neck, or trunk (HNT); lower extremity (LE); and upper extremity (UE). Each patient was assessed for range of motion, muscle strength, edema, pain, activities of daily living (ADL), and vocational changes. There was significantly more (p = 0.037) edema in patients with LE lesions than in patients in either of the other groups. Patients with LE lesions had greater difficulty with ADL and mobility than those with UE or HNT lesions (p = 0.019), and vocational changes were more frequent (p = 0.055). Patients with lower extremity STS are at higher risk for developing disability than patients with STS at other anatomic sites.