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For young sarcoma patients, limb salvage may not be the best option

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Don’t assume that lower limb salvage yields better functional and quality-of-life outcomes than amputation for children and adolescents with bone and soft tissue sarcomas, according to a review article in the September 15th issue of Cancer.

Dr. Ronald D. Barr, from McMaster University in Hamilton, Ontario, and Dr. Jay S. Wunder from Mount Sinai Hospital in Toronto note that limb salvage, facilitated by “remarkable…accomplishments in orthopedic surgical oncology,” is increasingly used for these young patients.

In nearly 1000 sarcoma patients diagnosed from 1970 to 1986, the Childhood Cancer Survivor Study found that limb salvage and amputation have similar survival and recurrence rates but that complications are more frequent after limb salvage.

What about functional outcomes and quality of life, however? In 1994, when members of the Musculo-Skeletal Tumor Society assessed function in 78 survivors of lower-limb sarcomas and quality of life in 29 survivors, they concluded “that functional outcomes were better after limb salvage surgery (including rotationplasty) than after above-knee amputation or hip disarticulation, but that psychosocial outcomes…were no different between the three groups,” Drs. Barr and Wunder report.

That study, however, used a scoring tool that “relies on the subjective ratings of clinicians.” The Childhood Cancer Survivor Study, in contrast, used the self-assessment Toronto Extremity Salvage Score and found no difference between amputees and limb salvage survivors in function, physical disability or activity limitations. Toronto Extremity Salvage Score scores and health related quality of life were also well correlated.

In a separate study from Boston’s Massachusetts General Hospital on more than 400 patients with lower-extremity tumors, there was “no notable difference” between amputation and limb-salvage groups in functional outcomes, employment or marital status, but “significantly fewer limb salvage patents had active sex lives and significantly fewer had children.”

Smaller studies from the United States, Australia, and the Netherlands have found no significant differences in psychological outcomes and health-related quality of life between amputees and those who have undergone limb salvage, according to the article.

The reviewers also consider the financial costs of therapy, noting “a tradeoff between the up-front costs of limb salvage and the maintenance costs associated with amputation.”

They cite Grimer et al, who reported that up-front surgical costs, duration of rehabilitation, and frequency of need for revisions, are all greater with limb salvage. On the other hand, “the considerable cost of having an amputation” is “surprising.” Most active young patients will need sophisticated artificial limbs and spare prostheses. Many will also need sports limbs and swimming limbs. All will need new prostheses as they grow.

“Although this challenge is clearly a moving target, formal economic evaluation would make a useful contribution to future decision making by patients and their healthcare providers, surgeons and others alike,” the reviewers conclude.

Cancer 2009.