Amputation for Sarcoma: Revisiting a 19th Century Treatment in the 21st Century

Excerpt

Major amputation was once a mainstay of therapy for extremity sarcoma (ES). Wardrop published the first illustration of amputation for a fungating “soft cancer” in 1809.1 A critical step in the transition from amputation to limb-sparing surgery was the recognition that inherent tumor biology, rather than local disease control, was the primary determinant of overall outcome. In 1982, Rosenberg and colleagues published a seminal, randomized controlled trial evaluating limb-sparing surgery with adjuvant radiotherapy compared with major amputation.2 There was no difference in disease-specific survival (DSS) or overall survival (OS) between treatment groups. Subsequent improvements in surgical technique, including soft-tissue flap reconstruction and nerve and vessel grafting, allowed for more aggressive resections while preserving critical structures and, importantly, limb function, expanding the range of tumors operable with limb-sparing techniques.3 In addition, advances in neoadjuvant/adjuvant therapies including external-beam radiotherapy (EBRT) and brachytherapy expanded treatment options while providing excellent local disease control, reducing the need for reoperation and recurrent treatment.4,5 Finally, isolated limb perfusion with melphalan and tumor necrosis factor alpha (TNFα), the latter not Food and Drug Administration (FDA) approved in the USA, has also been shown to provide value regarding local control for inoperable or locally advanced ES for patients treated in Europe.6 …