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Category: Volume 05 Issue 12 December 2017
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Title: Limb Salvage Surgery in Bone Tumors: A Single Institutional Study-K.M.I.O Experience

Authors: Dr Ashwathappa Dasappa, Dr S. Krishna Murthy, Dr P.Sridhar, Dr S. Balu, Dr S.D. Madhu

 DOI:  https://dx.doi.org/10.18535/jmscr/v5i12.149

Abstract

Introduction: Limb salvage surgery is the procedure which helps to remove tumours of Extremities and reconstruction is done with acceptable oncologic, functional and cosmetic results. The first priority is given for oncologic clearance followed by functional result. There is a change in trend all over the world from Amputations to Limb Salvage Surgery for appropriate candidates because of effective chemotherapy regimens, newer imaging techniques, advanced radiotherapy precision delivery, better reconstructive options and advances in Bio-Engineering.

Materials and Methodology: A retrospective analysis of 50 patients treated by Limb Salvage procedures in Bone tumours during a 5 year period from (2007–2011) in our Regional cancer centre which is also a tertiary care referral center was done. Before consideration of limb preservation procedures, all the patients were appropriately staged and assessed at a multidisciplinary tumour board meet. All patients with a proven histopathology of Osteosarcoma and Ewing’s sarcoma were given neoadjuvant chemotherapy. At our centre, we use 3 cycles of IAP (Ifosfamide 1.5 gm/m2 Day 1–3, Adriamycin 25 mg/m2 Day 1–3, Cisplatin 90 mg/m2) as neoadjuvant for Osteosarcomas and 4 cycles of IE/VAC (alternating, Ifosfamide 2 gm/m2 Day 1–3, Etoposide 100 mg/m2 Day 1–3, Vincristine 1.4 mg/m2, Adriamycin 60 mg/m2, Cyclophosphamide 600 mg/m2) for Ewing’s sarcoma. Response to chemotherapy was assessed by Imaging modalities and compared with previous imaging findings. The surgery was performed according to the general principles of limb salvage surgery.

Results: Most of the patients underwent surgery under general anaesthesia and few under spinal/epidural anaesthesia. General principles of limb salvage surgery was followed strictly.

The medium resection length as 15 cm (range 6-25). The largest resections were performed in distal femur 16 cm (range 12-25), followed by proximal femur 15 cm  (range 6-25), proximal Tibia 12 cm (range 7-15). Extra reconstructive interventions were needed for soft tissue coverage around knee joint in Osteosarcoma patients who have received neoadjuvant chemotherapy. Complications specific to endoprosthetic reconstruction may be related to mechanical or biological factors. Fatigue failure, aseptic loosening, Local Recurrence , peri-prosthetic fracture

Conclusion: The surgical management of patients with bone tumors of bone is challenging, particularly malignant tumors. Limb sparing surgery is a safe procedure, oncologically sound, provides good functional and cosmetic results. Appropriate patient selection for limb sparing procedure is essential to ensure good and consistent result.

Keywords: L.S.S,  Endoprosthesis,  Neoadjuvant Therapy, Bio-Engineering.

References

  1. Enneking WF. An abbreviated history of orthopaedic oncology in North America. Clin Orthop. 2000;374:115–24.
  2. Eckardt JJ, Yang RS, Ward WG, Kelly C, Eilber FR. Endoprosthetic reconstruction for malignant bone tumors and nonmalignant tumorous conditions of bone. In: Stauffer RN, Erlich MG, Fu FH, Kostuik JP, Manske PR, Sim FH, editors. Advances in operative orthopaedics. 3. St. Louis: Mosby; 1995. pp. 61–83.
  3. Choong PF, Sim FH. Limb-sparing surgery for bone tumors: new develop-ments.  Semin Surg  1997;13:64–9.
  4. Ries LAG, Smith MA, Gurney JG, et al (1999) Cancer incidence and survival among children and adolescents: United States SEER program 1975–1995. Bethesda, Md: National Cancer Institute; NIH Pub No 99–4649.
  5. Link MP, Eilber F. Osteosarcoma. In: Pizzo PA, Poplack DG, editors. Principles and practice of pediatric oncology. 3. Philadelphia: Lippincott-Raven; 1997. pp. 889–920.
  6. Weis LD. Common malignant bone tumors: Osteosarcoma. In: Simon MA, Springfield D, editors. Surgery for bone and soft-tissue tumors. Philadelphia: Lippincott-Raven; pp. 265–74.
  7. Ebeid W, Amin S, Abdelmegid A. Limb salvage management of pathologic fractures of primary malignant bone tumors. Cancer Control. 2005;12:57–61. 
  8. Kim SY, Helman LJ. Strategies to explore new approaches in the investigation and treatment of osteosarcoma. Cancer Treat Res. 2009;152:517–28.
  9. Sluga M, Windhager R, Lang S, Heinzl H, Bielack S, Kotz R. Local and systemic control after ablative and limb sparing surgeryin patients with Osteosarcoma. Clin   1999;358:120.
  10. Biermann JS, Adkins D, Benjamin R, et al. Bone cancer. J Natl Compr Canc Netw 2007;5:420–437.
  11. Mankin HJ, Hornicek FJ, Rosenberg AE, Harmon DC, Gebhardt MC. Survival data for 648 patients with osteosarcoma treated at one institution. Clin Orthop Relat Res. 2004;429:286–91.
  12. Bacci G, Ferrari S, Lari S, et al. Osteosarcoma of the limb: amputation or limb salvage in patients treated by neoadjuvant chemotherapy. J Bone Joint Surg Br. 2002;84:88–92.
  13. Enneking WF, Shirley PD. Resection-arthrodesis for malignant and potentially malignant lesions about the knee using an intramedullary rod and local bone grafts. J Bone Joint Surg Am. 1997;59:223–36. 
  14. Weinberg H, Kenan S, Lewis MM, et al. The role of microvascular surgery in limb-sparing procedures for malignant tumors of the knee. Plast Reconstr Surg. 1993; 92:692–8.
  15. Marulanda GA, Henderson ER, Johnson DA, Letson GD, Cheong D. Orthopedic surgery options for the treatment of prim-ary osteosarcoma. Cancer Control.  2008; 15:13–20.
  16. Gebhardt MC, Flugstad DI, Springfield DS, et al. The use of bone allografts for limb salvage in high-grade extremity osteosarcoma. Clin Orthop Relat Res. 1991;270:181–96.
  17. Sim FH, Frassica FJ. Use of allografts following resection of tumors of the musculoskeletal system. Instr Course Lect. 1993;42:405–13.
  18. Bradish CF, Kemp HB, Scales JT, Wilson JN. Distal femoral replacement by custom-made prostheses. Clinical follow-up and survivorship analysis. J Bone Joint Surg  1987;69:276–84. 
  19. Neel MD, Letson GD. Modular endopros-theses for children with malignant bone tumors. Cancer Control. 2001;8:344–8.
  20. Zehr RJ, Enneking WF, Scarborough MT. Allograft-prosthesis composite versus megaprosthesis in proximal femoral reconstruction. ClinOrthop. 1996;322:207–21.
  21. Kabukcuoglu Y, Grimer RJ, Tillman RM, Carter SR. Endoprosthetic replacement for primary malignant tumors of the proximal femur. Clin Orthop. 1999;358:8–14.
  22. Farid Y, Lin PP, Lewis VO, Yasko AW. Endoprosthetic and allograft-prosthetic composite reconstruction of the proximal femur for bone neoplasms. Clin Orthop Relat 2006:442:223-9
  23. 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  1995;77:1154–65.
  24. Horowitz SM, Glasser DB, Lane JM, Healey JH. Prosthetic and extremity survivorship after limb salvage for sarcoma: how long do the reconstructions last? Clin  1993;293:280–6.
  25. Simon MA. Limb salvage for osteosarcoma in the 1980s. Clin Orthop. 1991;270:264.

Corresponding Author

Dr P.Sridhar

Dept of Radiation oncology,

Kidwai Cancer Institute, Bengaluru