Annals of the Royal College of Surgeons of England (1991) vol. 73, 163-164
Amputations for soft tissue sarcoma G Westbury FRCS Formerly Professor of Surgery The Royal Marsden Hospital, London
For many years amputation was the standard treatment for soft tissue sarcoma of the limbs, to be carried out as a matter of urgency to prevent bloodstream spread. This precept began to be questioned in the 1930s on two grounds. The first was the appreciation that some sarcomas were situated anatomically within a muscle group so that surgical clearance with a satisfactory margin could be achieved leaving a useful limb. The second related to the fact that the soft tissue sarcomas, contrary to traditional belief, were in fact radio-responsive; the addition of radiotherapy to surgery greatly enhanced the prospect of local control of disease even when the anatomical setting of the tumour did not permit a radical, limbsparing resection. This latter discovery owed much to Sir Stanford Cade at Westminster Hospital, who also observed that the survival of patients so treated was at least as good as those subjected to amputation. For these reasons the consensus has swung to a predominantly limb conservation policy. Amputation is reserved mainly for otherwise irremovable tumour recurrence after the failure of combined limb-sparing management. Primary amputation is seldom indicated because an initial radical course of radiotherapy will often convert a massive, fixed sarcoma to a state of local operability. The scope of limb conservation surgery has been considerably extended by technical advances which permit the resection and replacement of major arteries and the cover of extensive skin defects by cutaneous or myocutaneous flaps. In the case of the limb girdles, forequarter and hindquarter amputation can also sometimes be avoided by intelligent surgical planning. Where the neurovascular bundle of the upper limb is not involved, resection of the scapula or sometimes scapula, clavicle and head of humerus (Tikhoff-Linberg operation), leaves a useful limb with full power and movement of elbow, wrist and hand, and little more disability than that of a frozen shoulder. Buttock tumours may be amenable to radical excision of the gluteal muscles; function even after resection of the sciatic nerve is remarkably good and immensely superior to that associated with a hindquarter prosthesis.
Correspondence to: Professor G Westbury, Institute of Cancer Research, 17A Onslow Gardens, London SW7 3AL
Site of election This is primarily determined by considerations of surgical pathology. Soft tissue sarcomas spread locally along fascial planes and between muscle bundles which are disposed in the long axis of the limbs. The entire musculofascial compartment of tumour origin is therefore at risk and amputation across the compartment may be followed by stump recurrence. Thus, to achieve clearance for recurrent sarcomas in the leg, amputation must be at least through-knee; for the thigh through-hip disarticulation is indicated or, when tumour is proximally sited, hindquarter or modified hindquarter amputation (see below). Another point is the influence of radiation change in the skin which, if severe, may require the level of section to be more proximal in order to achieve sound cover of the stump. Previous full-dose radiotherapy demands even more than the usual meticulous standard of care in tissue handling, avoidance of dead space, etc. These considerations apart, the technique for amputation at the standard sites of election is as for other types of pathology. Since soft tissue sarcoma affects the elderly as well as the young, the state of the peripheral circulation must be assessed in this group to exclude coincidental arterial insufficiency. For some lesions of the proximal arm and axilla it may be possible to retain a major part of the body of the scapula and its acromion process without prejudice to tumour clearance. This conserves the shoulder contour and so materially lessens the deformity of complete forequarter amputation. In the same way, adequate clearance may be achieved for groin and proximal thigh tumours by modified hindquarter amputation, in which the level of bone section runs horizontally through the greater sciatic notch just above the acetabulum. The residual ilium provides a valuable counter-pressure for the prosthesis, considerably enhancing function compared with that fitted after standard hindquarter amputation, where the ilium is sectioned close to the sacro-iliac joint. Where the buttock skin is involved by tumour, or compromised by severe irradiation damage or previous surgery, cover after hindquarter amputation is provided by an anterior flap. This may be cutaneous or myocutaneous (including sartorius and/or rectus femoris) based on the superficial femoral artery.
164
G Westbury
Soft tissue sarcomas of the hands and feet are rare. The mode of local spread dictates that ray amputations of one or more segments will, in selected instances, provide radical tumour clearance. Such procedures are particu-
larly valuable in the hand, but for the foot it is usually preferable, on functional grounds, to proceed to a formal amputation at a more proximal level.
Notes on books The Transplantation and Replacement of Thoracic Organs edited by David K C Cooper and Demetri Novitsky. 543 pages, illustrated. Kluwer Academic Publishers, Dordrecht. 1990. £120. ISBN 0 7923 8909 3 The transplantation of thoracic organs-heart, heart/lung, lung-is a field of surgery that is expanding year by year. The use of mechanical assistance devices and artificial hearts is also developing rapidly. It is therefore timely that a state-of-the-art volume be published collating recent as well as established information. This large and well-produced book should serve this role for the next few years. Comprehensive in coverage, readable, well referenced and well illustrated it is a tribute to the editors and the many contributors.
Management of Intensive Care: Guidelines for better use of resources edited by D Reis Miranda, A Williams and Th P Loirat. 245 pages, illustrated. Kluwer Academic Publishers, Dordrecht. 1990. £61.00. ISBN 0 7923 0754 2
A working group of the European Society of Intensive Care Medicine has come together to recommend guidelines for improving intensive care medicine throughout Europe. Chapters include those on facilities, national and regional organisation of units, management control, education and training and evaluation of outcome.
Pathology of Organ Transplantation edited by George E Sale. 327 pages, illustrated. Butterworths, Boston. 1990. £58. ISBN 0 409 90133 4 Mainly addressed to pathologists, this book nevertheless will interest transplantation surgeons. Beginning with a chapter on the immunopathology of transplantation, different organs are then considered in depth including skin, kidneys, liver, heart, pancreas, intestine, bone marrow and cornea. The volume ends with chapters on infections in transplant recipients and fine needle aspiration in transplantation pathology.
Adult Scoliosis edited by P Bartolozzi, A Ponte, G Frassi, R Savini, F Travaglini and R B Winter. 165 pages, illustrated. Springer-Verlag, Wien. 1990. DM68. ISBN 3 211 82201 1
Volume 5 in the series Progress in Spinal Pathology. The papers in this volume cluster around three themes, namely the natural history of adult scoliosis, the surgical treatment of scoliosis and the benefits of treatment, particularly in regard to pain and
respiratory function.
Cyclosporin: Mode of Action and Clinical Application edited by A W Thomson. 372 pages, illustrated. Kluwer Academic Publishers, Dordrecht. 1989. £50.00. ISBN 0 7462 0124 9
Since it was first identified in the early 1970s cyclosporin has been enormously important in improving the results of organ transplantation. It is fitting that Sir Roy Calne, who first introduced it into clinical use, should write the foreword to this important volume which gives a concise account of current knowledge of this important drug. The volume is extensively referenced and all transplantation units as well as departments of immunology will need to have this volume on their library shelf.
Handbook of Critical Care edited by James L Berk and J E Sampliner. 3rd edition. 812 pages, illustrated, paperback. Little, Brown and Company, Boston. 1990. £32.50. ISBN 0 316 09208 8 The latest edition of an already established book. New to this edition are chapters on ethical issues, in situ monitoring of organs, management of acute coronary occlusions, surgical management of acute heart failure, management of the immunodeficient patient and the perioperative care of the transplant patient.
Hereditary Cancer and Preventive Surgery edited by W Weber, U Laffer and M Durig. 118 pages, illustrated, paperback. Karger, Basel. 1990. £42.60. ISBN 3 8055 5186 X Breast cancer, colorectal cancer and malignant melanoma are the main neoplasms featured in this small book on hereditary cancer. The volume is concerned with the early detection of persons with an increased cancer risk and the effective targeting of preventive efforts.
Clinical Oxygen Pressure Measurement II edited by A M Ehrly, W Fleckenstein, J Hauss and R Huch. 436 pages, illustrated. Blackwell Ueberreuter Wissenschaft, Berlin. 1990. £1 10.00. ISBN 3 89412 082 7 The Proceedings of two separate meetings held in 1988, one in Lubeck and the other in Frankfurt. This volume presents an update on tissue oxygen pressure and transcutaneous oxygen pressure and covers various aspects of physiology, pathophysiology and treatment.
Neurology by Mark Mumenthaler. 3rd edition. 574 pages, illustrated, paperback. Georg Thieme Verlag, Stuttgart. 1990. DM44. ISBN 3 13 523903 9 An extensively revised and updated edition of this popular handbook. Compact, concise but eminently readable.
Amputations for soft tissue sarcoma G Westbury FRCS Formerly Professor of Surgery The Royal Marsden Hospital, London
For many years amputation was the standard treatment for soft tissue sarcoma of the limbs, to be carried out as a matter of urgency to prevent bloodstream spread. This precept began to be questioned in the 1930s on two grounds. The first was the appreciation that some sarcomas were situated anatomically within a muscle group so that surgical clearance with a satisfactory margin could be achieved leaving a useful limb. The second related to the fact that the soft tissue sarcomas, contrary to traditional belief, were in fact radio-responsive; the addition of radiotherapy to surgery greatly enhanced the prospect of local control of disease even when the anatomical setting of the tumour did not permit a radical, limbsparing resection. This latter discovery owed much to Sir Stanford Cade at Westminster Hospital, who also observed that the survival of patients so treated was at least as good as those subjected to amputation. For these reasons the consensus has swung to a predominantly limb conservation policy. Amputation is reserved mainly for otherwise irremovable tumour recurrence after the failure of combined limb-sparing management. Primary amputation is seldom indicated because an initial radical course of radiotherapy will often convert a massive, fixed sarcoma to a state of local operability. The scope of limb conservation surgery has been considerably extended by technical advances which permit the resection and replacement of major arteries and the cover of extensive skin defects by cutaneous or myocutaneous flaps. In the case of the limb girdles, forequarter and hindquarter amputation can also sometimes be avoided by intelligent surgical planning. Where the neurovascular bundle of the upper limb is not involved, resection of the scapula or sometimes scapula, clavicle and head of humerus (Tikhoff-Linberg operation), leaves a useful limb with full power and movement of elbow, wrist and hand, and little more disability than that of a frozen shoulder. Buttock tumours may be amenable to radical excision of the gluteal muscles; function even after resection of the sciatic nerve is remarkably good and immensely superior to that associated with a hindquarter prosthesis.
Correspondence to: Professor G Westbury, Institute of Cancer Research, 17A Onslow Gardens, London SW7 3AL
Site of election This is primarily determined by considerations of surgical pathology. Soft tissue sarcomas spread locally along fascial planes and between muscle bundles which are disposed in the long axis of the limbs. The entire musculofascial compartment of tumour origin is therefore at risk and amputation across the compartment may be followed by stump recurrence. Thus, to achieve clearance for recurrent sarcomas in the leg, amputation must be at least through-knee; for the thigh through-hip disarticulation is indicated or, when tumour is proximally sited, hindquarter or modified hindquarter amputation (see below). Another point is the influence of radiation change in the skin which, if severe, may require the level of section to be more proximal in order to achieve sound cover of the stump. Previous full-dose radiotherapy demands even more than the usual meticulous standard of care in tissue handling, avoidance of dead space, etc. These considerations apart, the technique for amputation at the standard sites of election is as for other types of pathology. Since soft tissue sarcoma affects the elderly as well as the young, the state of the peripheral circulation must be assessed in this group to exclude coincidental arterial insufficiency. For some lesions of the proximal arm and axilla it may be possible to retain a major part of the body of the scapula and its acromion process without prejudice to tumour clearance. This conserves the shoulder contour and so materially lessens the deformity of complete forequarter amputation. In the same way, adequate clearance may be achieved for groin and proximal thigh tumours by modified hindquarter amputation, in which the level of bone section runs horizontally through the greater sciatic notch just above the acetabulum. The residual ilium provides a valuable counter-pressure for the prosthesis, considerably enhancing function compared with that fitted after standard hindquarter amputation, where the ilium is sectioned close to the sacro-iliac joint. Where the buttock skin is involved by tumour, or compromised by severe irradiation damage or previous surgery, cover after hindquarter amputation is provided by an anterior flap. This may be cutaneous or myocutaneous (including sartorius and/or rectus femoris) based on the superficial femoral artery.
164
G Westbury
Soft tissue sarcomas of the hands and feet are rare. The mode of local spread dictates that ray amputations of one or more segments will, in selected instances, provide radical tumour clearance. Such procedures are particu-
larly valuable in the hand, but for the foot it is usually preferable, on functional grounds, to proceed to a formal amputation at a more proximal level.
Notes on books The Transplantation and Replacement of Thoracic Organs edited by David K C Cooper and Demetri Novitsky. 543 pages, illustrated. Kluwer Academic Publishers, Dordrecht. 1990. £120. ISBN 0 7923 8909 3 The transplantation of thoracic organs-heart, heart/lung, lung-is a field of surgery that is expanding year by year. The use of mechanical assistance devices and artificial hearts is also developing rapidly. It is therefore timely that a state-of-the-art volume be published collating recent as well as established information. This large and well-produced book should serve this role for the next few years. Comprehensive in coverage, readable, well referenced and well illustrated it is a tribute to the editors and the many contributors.
Management of Intensive Care: Guidelines for better use of resources edited by D Reis Miranda, A Williams and Th P Loirat. 245 pages, illustrated. Kluwer Academic Publishers, Dordrecht. 1990. £61.00. ISBN 0 7923 0754 2
A working group of the European Society of Intensive Care Medicine has come together to recommend guidelines for improving intensive care medicine throughout Europe. Chapters include those on facilities, national and regional organisation of units, management control, education and training and evaluation of outcome.
Pathology of Organ Transplantation edited by George E Sale. 327 pages, illustrated. Butterworths, Boston. 1990. £58. ISBN 0 409 90133 4 Mainly addressed to pathologists, this book nevertheless will interest transplantation surgeons. Beginning with a chapter on the immunopathology of transplantation, different organs are then considered in depth including skin, kidneys, liver, heart, pancreas, intestine, bone marrow and cornea. The volume ends with chapters on infections in transplant recipients and fine needle aspiration in transplantation pathology.
Adult Scoliosis edited by P Bartolozzi, A Ponte, G Frassi, R Savini, F Travaglini and R B Winter. 165 pages, illustrated. Springer-Verlag, Wien. 1990. DM68. ISBN 3 211 82201 1
Volume 5 in the series Progress in Spinal Pathology. The papers in this volume cluster around three themes, namely the natural history of adult scoliosis, the surgical treatment of scoliosis and the benefits of treatment, particularly in regard to pain and
respiratory function.
Cyclosporin: Mode of Action and Clinical Application edited by A W Thomson. 372 pages, illustrated. Kluwer Academic Publishers, Dordrecht. 1989. £50.00. ISBN 0 7462 0124 9
Since it was first identified in the early 1970s cyclosporin has been enormously important in improving the results of organ transplantation. It is fitting that Sir Roy Calne, who first introduced it into clinical use, should write the foreword to this important volume which gives a concise account of current knowledge of this important drug. The volume is extensively referenced and all transplantation units as well as departments of immunology will need to have this volume on their library shelf.
Handbook of Critical Care edited by James L Berk and J E Sampliner. 3rd edition. 812 pages, illustrated, paperback. Little, Brown and Company, Boston. 1990. £32.50. ISBN 0 316 09208 8 The latest edition of an already established book. New to this edition are chapters on ethical issues, in situ monitoring of organs, management of acute coronary occlusions, surgical management of acute heart failure, management of the immunodeficient patient and the perioperative care of the transplant patient.
Hereditary Cancer and Preventive Surgery edited by W Weber, U Laffer and M Durig. 118 pages, illustrated, paperback. Karger, Basel. 1990. £42.60. ISBN 3 8055 5186 X Breast cancer, colorectal cancer and malignant melanoma are the main neoplasms featured in this small book on hereditary cancer. The volume is concerned with the early detection of persons with an increased cancer risk and the effective targeting of preventive efforts.
Clinical Oxygen Pressure Measurement II edited by A M Ehrly, W Fleckenstein, J Hauss and R Huch. 436 pages, illustrated. Blackwell Ueberreuter Wissenschaft, Berlin. 1990. £1 10.00. ISBN 3 89412 082 7 The Proceedings of two separate meetings held in 1988, one in Lubeck and the other in Frankfurt. This volume presents an update on tissue oxygen pressure and transcutaneous oxygen pressure and covers various aspects of physiology, pathophysiology and treatment.
Neurology by Mark Mumenthaler. 3rd edition. 574 pages, illustrated, paperback. Georg Thieme Verlag, Stuttgart. 1990. DM44. ISBN 3 13 523903 9 An extensively revised and updated edition of this popular handbook. Compact, concise but eminently readable.
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