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Recent advance
C. Lazerges
Chirurgie de la main et du membre supérieur, chirurgie des nerfs périphériques, hôpital Lapeyronie, CHRU de Montpellier, 191, avenue du
Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France
A R T I C L E I N F O A B S T R A C T
Article history: Soft tissue sarcoma of the forearm, wrist and hand are rare. Their benign appearance leads often to
Received 26 September 2016 primary inadequate treatment. Due to the complex anatomy of the hand and forearm, they are
Received in revised form 4 December 2016 challenging to treat. The two goals are to obtain wide resection of the primary tumor while preserving
Accepted 22 December 2016
function. Limb-sparing surgery is now the cornerstone for the treatment of most sarcomas of the
Available online 16 June 2017
forearm, hand and wrist. To achieve optimal oncological and functional outcomes, the surgical excision
should be associated with early reconstructive procedures and a multidisciplinary meeting to define the
Keywords:
treatment strategy including adjuvant medical treatments. This article outlines the current principles
Soft tissue sarcoma
Wrist
and presents the results of the treatment of soft tissue sarcomas with emphasis on to particularities
Hand related to their forearm, wrist and hand location.
C 2017 SFCM. Published by Elsevier Masson SAS. All rights reserved.
Limb-sparing surgery
Reconstructive surgery
R É S U M É
Mots clés : Les tumeurs malignes des parties molles de l’avant-bras, du poignet et de la main sont des tumeurs rares,
Sarcome tissus mous souvent d’apparence bénigne et régulièrement initialement négligées. De par la complexité de
Main l’anatomie de la main et de l’avant-bras, leur prise en charge est difficile et représente un vrai challenge
Poignet
thérapeutique. L’objectif à atteindre est de concilier à la fois une exigence carcinologique et une exigence
Chirurgie conservatrice
Chirurgie reconstructrice
fonctionnelle d’importance majeure à l’avant-bras, au poignet et à la main. La chirurgie d’exérèse
conservatrice est aujourd’hui la pierre angulaire du traitement de la plupart des sarcomes à l’avant-bras,
au poignet et à la main. Pour permettre un résultat carcinologique et fonctionnel optimal, cette exérèse
chirurgicale doit être associée à une chirurgie reconstructrice précoce et à une prise en charge
multidisciplinaire, afin de définir un projet thérapeutique global incluant les traitements médicaux
adjuvants. Cet article précise les principes actuels et les résultats de prise en charge des tumeurs
malignes des parties molles en insistant sur les aspects spécifiques des localisations à l’avant-bras, au
poignet et à la main.
C 2017 SFCM. Publié par Elsevier Masson SAS. Tous droits réservés.
1. Introduction affect the hand or wrist [5–7]. STS are histologically heteroge-
neous, with about 50 different histological kinds described [8]. In
Malignant tumors of the soft tissues, or soft tissue sarcomas the upper limb, the most common STS are synovial sarcomas,
(STS), are rare malignant tumors. They make up less than 1% of epithelioid sarcomas and malignant histiocytofibromas [5,9]
newly diagnosed cancers each year [1]. Their incidence is 2–3 cases (Table 1).
per 100,000 [2] and there are an estimated 3000 to 4000 new cases These tumors in the forearm, wrist and hand are challenging to
each year in France [3,4]. About 60% of these STS develop in the treat. Optimal treatment for the cancer should be balanced with
limbs, of which 15% to 25% affect the upper limb and only 5% to 10% minimal impact on function.
Since the end of the 1970s, radical treatment by amputation is
no longer the reference surgical treatment for these lesions
E-mail address: c-lazerges@chu-montpellier.fr [10,11]. Limb-sparing excision and reconstructive surgery are now
http://dx.doi.org/10.1016/j.hansur.2016.12.010
2468-1229/
C 2017 SFCM. Published by Elsevier Masson SAS. All rights reserved.
234 C. Lazerges / Hand Surgery and Rehabilitation 36 (2017) 233–243
Table 1 the diagnosis [18], it has no certitude and cannot substitute for a
The most common histological types of soft tissue sarcomas in the hand, wrist and biopsy.
forearm.
Local CT scan of the STS region is only relevant if MRI cannot be
Malignant histiocytofibroma (undifferentiated pleomorphic sarcoma)
performed, or if bone invasion is present.
Synovial sarcoma
Epithelioid sarcoma
Chest and abdomen/pelvis CT with contrast is the gold standard
Clear-cell sarcoma examination for disease staging. Metastasis typically impacts the
Fibrosarcoma lungs, infrequently the soft tissues or abdomen in certain
Leiomyosarcoma histological STS types (myxoid liposarcoma, clear-cell sarcoma)
Liposarcoma
and even more rarely the lymph nodes (clear-cell sarcoma,
Malignant peripheral nerve sheath tumor
Dermatofibrosarcoma protuberans epithelioid sarcoma, synovial sarcoma, rhabdomyosarcoma, angio-
Myxoinflammatory fibroblastic sarcoma sarcoma). In certain histological STS types, a positron emission
tomography (PET) scan, which has growing indications for STS
[19–21], can be proposed in the context of disease staging or of
used in the hand and wrist [12–14]. To achieve the best possible recurrences. However, this examination is not currently recom-
functional and cancer-related outcomes, this surgical excision mended in the context of STS care [20].
must be combined with early reconstructive surgery and Lastly, vascular imaging (angiography, CT angiography, MR
multidisciplinary care, in order to define the overall treatment angiography) can be indicated, particularly for tumors requiring
plan including adjuvant medical treatments (chemotherapy and complex reconstruction.
radiation therapy). The current principles of the various steps of Carrying out this complete diagnostic strategy will reduce the
the care of these STS are presented in succession, with specific probability of diagnostic errors and inappropriate surgical
features related to the forearm, hand and wrist. treatments. Also, a complete preoperative imaging work-up will
make surgical revisions easier to perform, if needed.
2. Diagnosis
3. Treatment
The clinical presentation of STS is often misleading and can
appear trivial [15]. In most cases, a subcutaneous mass is discovered The treatment principles for STS in the hand, wrist and forearm
by chance, sometimes during the final healing phases of an injury; it are widely described in the literature and do not differ from the
is often painless and without associated symptoms. In this location, treatment of STS in other locations [3,15,22–24]. There are
the tumors are usually small – less than 4 cm – in size [5]. The however some distinctive features in the hand and wrist.
chronicity of the mass is not evidence of its benign nature and rapid Because of their small size and more superficial nature, STS of
progression is more suggestive a high-grade tumor. It is important the hand, wrist and forearm are often operated on right away
to remember that in the hand and wrist, there are more benign than without appropriate consideration of the possibility of malignancy,
malignant tumors. However, any atypical ‘‘suspicious’’ mass must with or without an incomplete, or even inappropriate preoperative
receive comprehensive care, including a full clinical examination work-up. This was the case for 38% of patients in the Pradhan study
and imaging work-up. If malignancy is still suspected after this [25] and 68% of patients in the Bray study [26]. And yet, the impact
assessment, a primary biopsy is recommended. of the initial surgery on the risks of residual or recurrent disease it
The clinical examination must qualify the mass (size, adhesion, is widely reported in the literature [27–30], along with the
hardness, cutaneous invasion, etc.), evaluate the local consequen- importance of care in a specialized cancer center [31–33] and a
ces (functional, vascular, neurological) and in general, palpate the review of the case in a multidisciplinary meeting (MDM) before
lymph nodes (certain tumors target the lymph nodes: epithelioid treatment is initiated [22].
sarcomas, clear-cell sarcomas, synovial sarcomas, rhabdomyosar-
coma) and look for familial disease that is often associated with a 3.1. Biopsy
tumor (e.g. malignant tumor of the peripheral nerve sheaths and
type I neurofibromatosis, Li-Fraumeni syndrome, etc.) or even The first phase of care is the biopsy. It will be used to confirm
exposure to carcinogens (herbicides, pesticides, radiation) [15]. the benign or malignant nature of the mass, classify the tumor,
The imaging work-up must include standard X-ray views to rule plan the type of surgery needed in an optimal manner and in
out bone tumors or invasion of neighboring bones. advanced STS cases, to consider performing neoadjuvant preoper-
Ultrasound imaging, which is commonly available and non- ative treatments (chemotherapy, isolated limb perfusion, radio-
irradiating, now has very extensive indications for the assessment therapy) [3].
of forearm, wrist and hand masses. While ultrasonography only Not every soft tissue mass in the hand and forearm require a
amounts to a scout scan, it makes it possible to evaluate the liquid biopsy. There are many more benign than malignant tumors. If the
or solid, homogeneous or heterogeneous, superficial or deep clinical and radiological findings are typical (synovial cyst, para-
nature of the mass. When correlated with the clinical findings, it is articular mucoid cyst, superficial lipoma, giant cell tumor of the
often able to confirm the benign nature of most suspicious masses synovial sheaths, etc.), an excision biopsy can be performed right
in these locations. If the results of US are atypical, not well away. However, if there is even the slightest clinical or radiological
correlated with the clinical findings and do not allow malignancy suspicion on the potential malignancy of a mass, primary biopsy is
to be ruled out, MRI is required before any treatment is initiated. justified. There are no formal clinical or imaging criteria for
Ultrasonography is also indicated in the supplemental assessment malignancy. A long-standing mass is not always benign. Converse-
of STS to look for associated adenopathy. ly, a rapidly growing mass is not always malignant [15]. However, a
MRI is now the gold standard examination for STS. The MRI must mass that has rapidly grown, of more than 3 cm in the upper limb,
be performed before any biopsy is done [15] and consists of several adhering to the superficial or deep layers, that is poorly defined or
T1- and T2-weighted sequences, with and without contrast. In each subfascial, must be suspected for malignancy. Similarly, on
sequence, orthogonal planes [16] (ideally with an axial plane) must imaging, a heterogeneous mass that is poorly systematized, that
be visible to allow better surgical targeting of the tumor margins takes up contrast agent on MRI and is intramuscular, must be
and anatomical structures and to facilitate preoperative planning of suspected for malignancy. Under these conditions, a primary
the tumor excision margins [17]. While MRI often orients biopsy is indicated.
C. Lazerges / Hand Surgery and Rehabilitation 36 (2017) 233–243 235
3.3. Surgical excision treatment T: tumor features; T1: small (< 5 cm); T2: large (> 5 cm); a: superficial location
above fascia; b: deep to fascia; N: lymph node characteristics; N0: no evidence of
lymph node metastases; N1: presence of lymph node metastases; M: distant
Surgical excision is the cornerstone of STS treatment. The metastases status; M0: no evidence of distant metastases; M1: presence of distant
surgical resection margins are the primary prognostic factor for metastases; G: histologic grade of tumor; G1: low grade; G2: intermediate grade;
the local and general control of the tumor [13,41], along with the G3: high grade; GX: indeterminate grade.
236 C. Lazerges / Hand Surgery and Rehabilitation 36 (2017) 233–243
Fig. 1. High-grade undifferentiated pleomorphic sarcoma on the dorsal side of the left forearm. Clinical appearance (A) and MRI appearance in T1 FS DIXON axial slice with
contrast with suspicion of periosteal invasion of the distal ulna (B). One-piece excision that takes a 10 15 cm skin pallet with the finger extensors, extensor carpi ulnaris and
distal ulna (C). Excised tumor (D). Design of made-to-measure contralateral free anterolateral thigh (ALT) perforator flap. Skin reconstruction with ALT without immediate
reconstruction of the extensor tendons or bone reconstruction of the distal ulna (F). Postoperative chemotherapy and radiation therapy.
For bone defects under 5 cm, reconstruction is typically done and/or ulna (split fibula), to performing radiocarpal or radio-
using an autologous corticocancellous bone graft (iliac crest, scapholunate fusion, or even to performing a one-bone forearm
proximal ulna, radius, proximal tibia). In the context of STS, reconstruction. Masquelet’s induced membrane technique has a
contrary to benign hand tumors, corticocancellous allografts and role here also [56] in the diaphyseal reconstruction of the forearm.
bone substitutes are rarely used. In the hand, in most cases, In STS of the hand and wrist, structural articular allografts of the
autologous corticocancellous grafts allow reconstruction of the distal radius or metacarpals, described in the context of giant cell
metacarpals and fusion of the carpometacarpal and/or metatarso- tumors and arthroplasty procedures, have little role in current
phalangeal joints. In more rare cases, these standard corticocan- practice.
cellous grafts can be used to perform radiocarpal or And in the wrist, wide resection (more than 6 cm) of the distal
radiometacarpal fusion (Fig. 2), but this increases the risk of ulna can be reconstructed with a vascularized fibula graft,
nonunion when the graft exceeds 5 cm. These grafts are done in lengthening [57] or a distal radio-ulnar prosthesis, even though
one or two stages using the induced membrane technique, some authors have found no functional consequences to wide
according to the preoperative plan and while waiting for the resection of the distal ulna [58].
histopathology results.
With bone defects larger than 5 cm, it is classically recom- 3.4.4. Tendon reconstruction
mended to use vascularized bone grafts [55]. In the forearm and In the ideal case, tendon reconstruction will be performed right
wrist, a vascularized fibular graft is preferred [15]. Its shape and always if skin coverage is appropriate [15]. In the context of tendon
diameter are suitable to diaphyseal reconstruction of the radius defects with the muscle belly intact, reconstruction is done with
238 C. Lazerges / Hand Surgery and Rehabilitation 36 (2017) 233–243
Fig. 2. Grade 2 myxofibrosarcoma on the dorsal side of the right wrist that has invaded the radiocarpal and distal radio-ulnar joints. Frontal T2 STIR MRI slice (A) and axial T2
STIR MRI slice (B). Frontal MRI showing the bone invasion (C). Clinical presentation (D). One-piece radiocarpal and distal radio-ulnar arthrectomy with musculotendinous
resection of the wrist and finger extensors (E). Surgical resection piece (F). Reconstruction by tenodesis of the finger extensors, radiometacarpal fusion, and M1-M2 fusion
with corticocancellous iliac crest graft and fixation by locking plate (G). Radiograph taken at the latest follow-up (H). Neoadjuvant chemotherapy and postoperative radiation
therapy. Functional results: MSTS 76%, DASH 45, VAS for pain 3.
standard tendon autografts (palmaris longus, hemi-flexor carpi 3.5. Adjuvant treatments
radialis, gracilis, semitendinosus, fascia lata, plantaris) (Fig. 3). The
advantage of gracilis tendon, semitendinosus tendon and fascia 3.5.1. Isolated limb perfusion [61]
lata autografts is that they can be used to reconstruct multiple This consists of perfusing a limb (with tourniquet) with tumor
tendon slips. necrosis factor a (TNF-a) or Melphalan, and is mainly indicated for
When the muscle bellies are sacrificed during the tumor STS in the extremities. It can be performed in the same way as
excision, reconstruction makes use of the standard tendon transfer neoadjuvant radiation therapy, in the context of locally very
techniques for radial palsy or brachial plexus injuries. Functional advanced STS, in which immediate excision is likely to induce
free flaps are rarely used (free re-innervated transfer of gracilis to major functional sequelae or does not allow for limb-sparing
reconstruct finger flexors and extensors [59], free tendon transfer surgery.
(dorsalis pedis flap) to reconstruct the finger extensors [60]).
3.5.2. Radiation therapy
3.4.5. Nerve reconstruction Radiation therapy is standard in STS treatment. It is known to
Nerve reconstruction also typically uses interposition grafts improve the local control of STS [62]. The effectiveness in terms of
(sural nerves), or even distal nerve transfers and in rare cases, local control is the same whether it is done as a neoadjuvant
vascularized nerve grafts. A vascular graft may also be needed. (before surgical excision) or adjuvant (after surgical excision)
The complexity of the treatment at the hand and wrist stems treatment. However, there is a greater risk of postoperative
from the combination of defects in multiple tissues and the need complications with neoadjuvant treatment and a greater risk of
for combined functional reconstruction. Consequently, reconstruc- delayed complications with adjuvant treatment [63]. In the hand
tion procedures must not be considered individually, but as a and forearm, despite the thin tissues and nearby functional
whole (Fig. 4). For example, bone and skin defects can be treated anatomical structures, Bray et al. [26] have found that toxicity is
with an osteofasciocutaneous flap (free osteocutaneous flap of rarely a problem and should not preclude radiation therapy from
vascularized fibula); skin, bone and vascular defects can be treated being performed. Nevertheless, radiation therapy will not negate
with an osteocutaneous vessel-holder flap (free contralateral the consequences of positive surgical margins [64]. Also, neoadju-
radial antebrachial flap). vant or adjuvant radiation therapy does not appear to hinder the
C. Lazerges / Hand Surgery and Rehabilitation 36 (2017) 233–243 239
Fig. 3. Epitheloid sarcoma on the volar side of the right hand that has extended to the thenar eminence and encompasses the trapeziometacarpal joint. T2-weighted FS axial
MRI slice: hyperintense infiltrate that is poorly limited on the superficial side of the flexor retinaculum, extending to the 1st metacarpal (A). T1-weighted GADO frontal MRI
slice: poorly limited hyperintense infiltrate (B). Preoperative clinical presentation (C). En bloc skin and bone excision taking the flexor retinaculum, 1st metacarpal and
trapezium (D). Temporary fixation while waiting for the histopathology results (E). Delayed reconstruction after the surgical excision margins were confirmed. Skin coverage
using a pedicled posterior interosseous flap (F). Bone reconstruction of the 1st metacarpal with a corticocancellous graft with thumb metacarpophalangeal fusion and M1-M2
fusion (G). Functional outcomes at latest follow-up: MSTS 70%, DASH 49, VAS pain 4. Postoperative radiation therapy (H).
microsurgical reconstruction [65] that is often needed in the hand development of targeted therapies could modify this care in
and forearm. the future.
Fig. 4. Synovial sarcoma on the dorsal side of the 1st web space of the left hand discovered by chance after cyst excision. Secondary treatment with no imaging done before the
first excision. Clinical presentation with drawing of the initial surgical scar and the excision margins (A). ‘‘En bloc’’ skin and tendon excision with resection of the abductor
pollicis longus, extensor pollicis longus and brevis, and extensor carpus brevis (B). Surgical excision piece (C). Locating the abductor longus, extensor pollicis longus and
extensor carpus tendons before the tendon reconstruction (D). Tendon reconstruction by transfer of the extensor indicis proprius on the extensor pollicis longus and palmaris
longus interposition graft on the abductor pollicis longus and the carpal extensors (E). Skin coverage using a pedicled posterior interosseous flap (F). Functional outcomes:
MSTS 93%, DASH 0, VAS pain 0 (G). Neoadjuvant and adjuvant chemotherapy, no radiation therapy.
5. Results of the treatment of hand and forearm STS well-differentiated tumors, or to preserve important anatomical
structures, the local recurrence does not seem to be higher when
5.1. Cancer-related outcomes marginal resection is planned [47]. Kemp et al. found similar
results in the context of liposarcoma that make contact with major
There are only a few studies on survival specifically for STS in nerves in the forearm and were treated by epineurectomy without
the hand and forearm. Many studies are small case reports or nerve sacrifice [45].
clinical case-series. STS in the hand or wrist appears to have a STS that are initially operated in an inadequate manner have a
better prognosis than in other locations [68]. Yamada et al. worse prognosis [27–30,41]. However, after re-excision and radia-
reported overall 5-year survival of 89% for distal STS in the upper tion therapy, some studies, particularly ones in the hand [25], have
limb relative to 66% for proximal STS in the upper limb; the found similar results with STS patients operated correctly right away
recurrence-free 5-year survival was 87% versus 74% and the [72]. Any microscopic residual found during the re-excision is a
survival without metastasis was 84% versus 66% [69]. Most studies prognostic factor for worse overall survival, recurrence-free survival
of hand and wrist STS report overall 5-year survival between 80% and metastasis [41,72]. And despite appropriate treatment, certain
and 90% [12,25,70,71]. However, these studies emphasize the need histological STS types, particularly clear-cell sarcomas and epitheli-
to obtain clear surgical margins to limit the risk of local recurrence oid sarcomas appear to have a worse prognosis [25].
or metastasis. According to Pradhan et al., inappropriate surgical
margins lead to a 12-times higher risk of local recurrence [25]. The 5.2. Functional outcomes
local recurrence risk was 37% at 5 years and 52% at 10 years. Overall
survival went from 87% at 5 years to 71% at 10 years. They Most authors now defend the importance of microsurgical
concluded that limb-sparing surgery must not be done at the reconstructive surgery for STS of the hand and forearm to optimize
expense of good surgical margins. the functional outcomes [12,73]. In fact, surgery, even limb-
Gerrand et al. introduced the concept of ‘‘planned positive sparing, is often mutilating given the proximity of functional
margins’’ followed by radiation therapy. In certain cases of anatomical structures. It is however difficult to accurately define
C. Lazerges / Hand Surgery and Rehabilitation 36 (2017) 233–243 241
Fig. 5. Treatment algorithm for the care of soft tissue tumors in the hand, wrist and forearm.
the functional outcomes, given the polymorphism of STS in the patient to a specialized cancer treatment center. A biopsy is
forearm and hand, with extremely variable surgical excision and essential before any surgical treatment and drives the treatment.
surgical reconstruction. Surgical excision is the primary component of treatment. It
Most clinical studies evaluate the functional outcomes using must be as conservative as possible to limit the functional impact,
the Enneking score (Musculoskeletal Tumor Society rating Scale but must not be minimized at the expense of good tumor resection.
[MSTS]) [74] and report good or excellent scores, with average Other than for STS in the fingers, multiple surgical reconstruction
scores of 83% or better [12,26,71,73]. Lehnhardt et al. found a mean techniques can be used to avoid radical surgical excision by
DASH score of 37; Mirous et al., who emphasized the need for early amputation. These techniques, when planned preoperatively,
functional reconstruction, found a mean DASH score of 18. In the make it possible to reconcile both the cancer-related and
Bray et al. study, the functional outcomes were better for STS in the functional requirements.
forearm relative to STS in the hand and wrist, with MSTS scores of
31 versus 27 (out of 35) and Toronto Extremity Salvage Score Disclosure of interest
(TESS) of 94 versus 88 [75]. In their study, 88% of non-amputated
STS patients were able to resume their previous activities [26]. The author declares that he has no competing interest.
As expected, STS patients who required radical treatment by
amputation had worse functional results [12,26,71,73]. According References
to Yamada et al., deep STS and STS that were initially operated in a
non-specialist center seem to have the worse functional results [1] Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin
2013;63:11–30.
[69]. Lastly, radiation therapy, even when it is combined with
[2] Jane MJ, Hughes PJ. Disease incidence and results of extremity lesion treat-
reconstructive techniques, appears to be a prognostic factor for ment: Mersey region soft tissue sarcomas (1975–1985). Sarcoma 1998;2:
worse functional outcomes [12,26,71]. 89–96.
[3] Bonvalot S, Missenard G, Rosset P, Terrier P, Le Péchoux C, Le Cesne A. Principes
du traitement chirurgical des sarcomes des tissus mous des membres et du
6. Conclusion tronc de l’adulte. EMC – Appar Locomoteur 2013;8(4):1–11 [Paris: Elsevier
Masson].
While malignant soft tissue tumors of the hand, wrist and [4] Mastrangelo G, Coindre J-M, Ducimetière F, Dei Tos AP, Fadda E, Blay J-Y, et al.
Incidence of soft tissue sarcoma and beyond: a population-based prospective
forearm appear to have a better prognosis than those in other study in 3 European regions. Cancer 2012;118:5339–48.
locations, their treatment must not be taken lightly. Too often [5] Gerrand CH, Bell RS, Wunder JS, Kandel RA, O’Sullivan B, Catton CN, et al. The
these tumors undergo an inappropriate first-line treatment, which influence of anatomic location on outcome in patients with soft tissue sarcoma
of the extremity. Cancer 2003;97:485–92.
negatively impacts both survival and function. By following a well-
[6] Gustafson P, Arner M. Soft tissue sarcoma of the upper extremity: descriptive
defined diagnostic and treatment protocol, these diagnostic errors data and outcome in a population-based series of 108 adult patients. J Hand
can be minimized and these tumors can be treated in the optimal Surg Am 1999;24:668–74.
manner (Fig. 5). [7] Lahat G, Lazar A, Lev D. Sarcoma epidemiology and etiology: potential envi-
ronmental and genetic factors. Surg Clin North Am 2008;88:451–81.
Hence, for any mass in the hand, wrist or forearm that has an [8] Fletcher CDM, Bridge JA, Hogendoorn P, Mertens F. WHO Classification of
atypical presentation, one must suspect malignancy and refer the tumours of soft tissue and bone, 4th ed., Lyon: IARC; 2013.
242 C. Lazerges / Hand Surgery and Rehabilitation 36 (2017) 233–243
[9] Murray PM. Soft tissue sarcoma of the upper extremity. Hand Clin A study of 546 patients from the French Federation of Cancer Centers Sarcoma
2004;20:325–33. Group. J Clin Oncol 1996;14:869–77.
[10] Alamanda VK, Crosby SN, Archer KR, Song Y, Schwartz HS, Holt GE. Amputation [39] Trojani M, Contesso G, Coindre JM, Rouesse J, Bui NB, de Mascarel A, et al.
for extremity soft tissue sarcoma does not increase overall survival: a retro- Soft-tissue sarcomas of adults; study of pathological prognostic variables and
spective cohort study. Eur J Surg Oncol 2012;38:1178–83. definition of a histopathological grading system. Int J Cancer 1984; 33:37–42.
[11] Rosenberg SA, Tepper J, Glatstein E, Costa J, Baker A, Brennan M, et al. The [40] Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th
treatment of soft-tissue sarcomas of the extremities: prospective randomized edition of the AJCC cancer staging manual and the future of TNM. Ann Surg
evaluations of (1) limb-sparing surgery plus radiation therapy compared with Oncol 2010;17:1471–4.
amputation and (2) the role of adjuvant chemotherapy. Ann Surg [41] Pisters PW, Leung DH, Woodruff J, Shi W, Brennan MF. Analysis of prognostic
1982;196:305–15. factors in 1,041 patients with localized soft tissue sarcomas of the extremities.
[12] Mirous MP, Coulet B, Chammas M, Cupissol D, Lazerges C. Extensive limb- J Clin Oncol 1996;14:1679–89.
sparing surgery with reconstruction for sarcoma of the hand and wrist. Orthop [42] Wright EHC, Gwilym S, Gibbons CLMH, Critchley P, Giele HP. Functional and
Traumatol Surg Res 2016;102:467–72. oncological outcomes after limb-salvage surgery for primary sarcomas of the
[13] Muramatsu K, Ihara K, Yoshida K, Tominaga Y, Hashimoto T, Taguchi T. upper limb. J Plast Reconstr Aesthet Surg 2008;61:382–7.
Musculoskeletal sarcomas in the forearm and hand: standard treatment [43] Koulaxouzidis G, Simunovic F, Bannasch H. Soft tissue sarcomas of the arm –
and microsurgical reconstruction for limb salvage. Anticancer Res oncosurgical and reconstructive principles within a multimodal, interdisci-
2013;33:4175–82. plinary setting. Surg Oncol 2016;12.
[14] Leit ME, Tomaino MM. Principles of limb salvage surgery of the upper [44] Sobin LH, Gospodarowicz MK, Wittekind C, International Union against Can-
extremity. Hand Clin 2004;20:167–79. cer, editors. TNM classification of malignant tumours. 7th ed., Chichester,
[15] Athanasian EA, Jebson PJL, Kakar S, Murray PM. Tumors of the hand and upper West Sussex, UK; Hoboken, NJ: Wiley-Blackwell; 2010.
extremity. Chicago: ASSH; 2015. [45] Kemp MA, Hinsley DE, Gwilym SE, Giele HP, Athanasou NA, Gibbons CL.
[16] Peterson JJ, Bancroft LW, Kransdorf MJ. Principles of bone and soft tissue Functional and oncological outcome following marginal excision of well-
imaging. Hand Clin 2004;20:147–66. differentiated forearm liposarcoma with nerve involvement. J Hand Surg
[17] Berger F, Winkler EC, Ruderer C, Reiser MF. Imaging of soft tissue sarcomas: Am 2011;36:94–100.
standard approaches and new strategies. Chirurg 2009;80:175–85. [46] Clarkson PW, Griffin AM, Catton CN, O’Sullivan B, Ferguson PC, Wunder JS,
[18] Capelastegui A, Astigarraga E, Fernandez-Canton G, Saralegui I, Larena JA, et al. Epineural dissection is a safe technique that facilitates limb salvage
Merino A. Masses and pseudomasses of the hand and wrist: MR findings in surgery. Clin Orthop 2005;438:92–6.
134 cases. Skeletal Radiol 1999;28:498–507. [47] Gerrand CH, Wunder JS, Kandel RA, O’Sullivan B, Catton CN, Bell RS, et al.
[19] Al-Ibraheem A, Buck AK, Benz MR, Rudert M, Beer AJ, Mansour A, et al. (18) F- Classification of positive margins after resection of soft-tissue sarcoma of
fluorodeoxyglucose positron emission tomography/computed tomography for the limb predicts the risk of local recurrence. J Bone Joint Surg Br 2001;
the detection of recurrent bone and soft tissue sarcoma. Cancer 83:1149–55.
2013;119:1227–34. [48] Puhaindran ME, Steensma MR, Athanasian EA. Partial hand preservation
[20] Kogay M, Thariat J, Benisvy D, Dufour M, Gastaud L, Saada E, et al. [Is FDG TEP for large soft tissue sarcomas of the hand. J Hand Surg Am 2010;35:291–5.
CT practice changing in the management of sarcomas in adults?] Bull Cancer [49] Puhaindran ME, Athanasian EA. Double ray amputation for tumors of the hand.
(Paris) 2016;103:735–42. Clin Orthop 2010;468:2976–9.
[21] Choi YY, Kim JY, Yang S-O. PET/CT in benign and malignant musculoskeletal [50] Puhaindran ME, Healey JH, Athanasian EA. Single ray amputation for tumors of
tumors and tumor-like conditions. Semin Musculoskelet Radiol 2014;18: the hand. Clin Orthop 2010;468:1390–5.
133–48. [51] Sakellariou VI, Mavrogenis AF, Papagelopoulos PJ. Negative-pressure wound
[22] Dujardin F, Abdulmutalib H, Aktouf G, Michelin P. Principes du traitement therapy for musculoskeletal tumor surgery. Adv Skin Wound Care
chirurgical des sarcomes des tissus mous de l’adulte. EMC – Tech Chir – 2011;24:25–30.
Orthopedie – Traumatol 2013;8(2):1–9 [Paris: Elsevier Masson]. [52] Chen YU, Xu S-F, Xu M, Yu X-C. Use of negative pressure wound therapy as an
[23] Casali PG, Blay JY. Soft tissue sarcomas: ESMO clinical practice guidelines for adjunct to the treatment of extremity soft-tissue sarcoma with ulceration or
diagnosis, treatment and follow-up. Ann Oncol 2010;21(Suppl. 5):v198–203. impending ulceration. Oncol Lett 2016;12:757–63.
[24] Grimer R, Judson I, Peake D, Seddon B. Guidelines for the management of soft [53] Barner-Rasmussen I, Popov P, Böhling T, Blomqvist C, Tukiainen E. Microvas-
tissue sarcomas. Sarcoma 2010;2010:506182. cular reconstructions after extensive soft tissue sarcoma resections in the
[25] Pradhan A, Cheung YC, Grimer RJ, Peake D, Al-Muderis OA, Thomas JM, et al. upper limb. Eur J Surg Oncol 2010;36:78–83.
Soft-tissue sarcomas of the hand: oncological outcome and prognostic factors. [54] Payne CE, Hofer SOP, Zhong T, Griffin AC, Ferguson PC, Wunder JS. Functional
J Bone Joint Surg Br 2008;90:209–14. outcome following upper limb soft tissue sarcoma resection with flap recon-
[26] Bray PW, Bell RS, Bowen CV, Davis A, O’Sullivan B. Limb salvage surgery and struction. J Plast Reconstr Aesthet Surg 2013;66:601–7.
adjuvant radiotherapy for soft tissue sarcomas of the forearm and hand. J Hand [55] Wood MB. Free vascularized bone transfers for nonunions, segmental gaps,
Surg Am 1997;22:495–503. and following tumor resection. Orthopedics 1986;9:810–6.
[27] Qureshi YA, Huddy JR, Miller JD, Strauss DC, Thomas JM, Hayes AJ. Unplanned [56] Micev AJ, Kalainov DM, Soneru AP. Masquelet technique for treatment of
excision of soft tissue sarcoma results in increased rates of local recurrence segmental bone loss in the upper extremity. J Hand Surg Am 2015;40:593–8.
despite full further oncological treatment. Ann Surg Oncol 2012;19:871–7. [57] Lazerges C, Mares O, Chammas M, Coulet B. Lengthening osteotomy for
[28] Siebenrock KA, Hertel R, Ganz R. Unexpected resection of soft-tissue sarcoma. reconstruction following wide resection of the distal part of the ulna: a report
More mutilating surgery, higher local recurrence rates, and obscure prognosis of two cases. J Bone Joint Surg Am 2011;93 [e91 1-5].
as consequences of improper surgery. Arch Orthop Trauma Surg 2000;120: [58] Wolfe SW, Mih AD, Hotchkiss RN, Culp RW, Keifhaber TR, Nagle DJ. Wide
65–9. excision of the distal ulna: a multicenter case study. J Hand Surg Am
[29] Noria S, Davis A, Kandel R, Levesque J, O’Sullivan B, Wunder J, et al. Residual 1998;23:222–8.
disease following unplanned excision of soft-tissue sarcoma of an extremity. J [59] Chuang DC, Strauch RJ, Wei FC. Technical considerations in two-stage func-
Bone Joint Surg Am 1996;78:650–5. tioning free muscle transplantation reconstruction of both flexor and extensor
[30] Davis AM, Kandel RA, Wunder JS, Unger R, Meer J, O’Sullivan B, et al. The functions of the forearm. Microsurgery 1994;15:338–43.
impact of residual disease on local recurrence in patients treated by initial [60] Vila-Rovira R, Ferreira BJ, Guinot A. Transfer of vascularized extensor tendons
unplanned resection for soft tissue sarcoma of the extremity. J Surg Oncol from the foot to the hand with a dorsalis pedis flap. Plast Reconstr Surg
1997;66:81–7. 1985;76:421–7.
[31] Rydholm A. Improving the management of soft tissue sarcoma. Diagnosis and [61] Lejeune FJ, Pujol N, Liénard D, Mosimann F, Raffoul W, Genton A, et al. Limb
treatment should be given in specialist centres. BMJ 1998;317:93–4. salvage by neoadjuvant isolated perfusion with TNFalpha and melphalan for
[32] Bhangu AA, Beard JS, Grimer RJ. Should soft tissue sarcomas be treated at a non-resectable soft tissue sarcoma of the extremities. Eur J Surg Oncol
specialist centre? Sarcoma 2004;8:1–6. 2000;26:669–78.
[33] Lehnhardt M, Daigeler A, Homann HH, Hauser J, Langer S, Steinsträsser L, et al. [62] Jebsen NL, Trovik CS, Bauer HCF, Rydholm A, Monge OR, Hall KS, et al.
Importance of specialized centers in diagnosis and treatment of extremity-soft Radiotherapy to improve local control regardless of surgical margin and
tissue sarcomas. Review of 603 cases. Chirurg 2009;80:341–7. malignancy grade in extremity and trunk wall soft tissue sarcoma: a Scandi-
[34] Mankin HJ, Lange TA, Spanier SS. The hazards of biopsy in patients with navian sarcoma group study. Int J Radiat Oncol Biol Phys 2008;71:1196–203.
malignant primary bone and soft-tissue tumors. J Bone Joint Surg Am [63] O’Sullivan B, Davis AM, Turcotte R, Bell R, Catton C, Chabot P, et al. Preoperative
1982;64:1121–7. versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a
[35] Hoeber I, Spillane AJ, Fisher C, Thomas JM. Accuracy of biopsy techniques for randomised trial. Lancet 2002;359:2235–41.
limb and limb girdle soft tissue tumors. Ann Surg Oncol 2001;8:80–7. [64] Brien EW, Terek RM, Geer RJ, Caldwell G, Brennan MF, Healey JH. Treatment of
[36] Skrzynski MC, Biermann JS, Montag A, Simon MA. Diagnostic accuracy and soft-tissue sarcomas of the hand. J Bone Joint Surg Am 1995;77:564–71.
charge-savings of outpatient core needle biopsy compared with open biopsy of [65] Townley WA, Mah E, O’Neill AC, Wunder JS, Ferguson PC, Zhong T, et al.
musculoskeletal tumors. J Bone Joint Surg Am 1996;78:644–9. Reconstruction of sarcoma defects following pre-operative radiation: free
[37] Ray-Coquard I, Montesco MC, Coindre JM, Dei Tos AP, Lurkin A, Ranchère- tissue transfer is safe and reliable. J Plast Reconstr Aesthet Surg 2013;66:
Vince D, et al. Sarcoma: concordance between initial diagnosis and centralized 1575–9.
expert review in a population-based study within three European regions. Ann [66] Woll PJ, Reichardt P, Le Cesne A, Bonvalot S, Azzarelli A, Hoekstra HJ, et al.
Oncol 2012;23:2442–9. Adjuvant chemotherapy with doxorubicin, ifosfamide, and lenograstim for
[38] Coindre JM, Terrier P, Bui NB, Bonichon F, Collin F, Le Doussal V, et al. resected soft-tissue sarcoma (EORTC 62931): a multicentre randomised con-
Prognostic factors in adult patients with locally controlled soft tissue sarcoma. trolled trial. Lancet Oncol 2012;13:1045–54.
C. Lazerges / Hand Surgery and Rehabilitation 36 (2017) 233–243 243
[67] Pervaiz N, Colterjohn N, Farrokhyar F, Tozer R, Figueredo A, Ghert M. A [72] Fiore M, Casali PG, Miceli R, Mariani L, Bertulli R, Lozza L, et al. Prognostic effect
systematic meta-analysis of randomized controlled trials of adjuvant chemo- of re-excision in adult soft tissue sarcoma of the extremity. Ann Surg Oncol
therapy for localized resectable soft-tissue sarcoma. Cancer 2008;113:573–81. 2006;13:110–7.
[68] Buecker PJ, Villafuerte JE, Hornicek FJ, Gebhardt MC, Mankin HJ. Improved [73] Muramatsu K, Ihara K, Doi K, Hashimoto T, Taguchi T. Sarcoma in the forearm
survival for sarcomas of the wrist and hand. J Hand Surg Am 2006;31:452–5. and hand: clinical outcomes and microsurgical reconstruction for limb sal-
[69] Yamada Y, Nishida Y, Nakashima H, Sugiura H, Tsukushi S, Kamei Y, et al. vage. Ann Plast Surg 2009;62:28–33.
Oncologic and functional outcomes of soft tissue sarcomas of the distal upper [74] Wada T, Kawai A, Ihara K, Sasaki M, Sonoda T, Imaeda T, et al. Construct validity
extremity: comparison with those of the proximal upper extremity. Int Surg of the Enneking score for measuring function in patients with malignant or
2010;95:33–9. aggressive benign tumours of the upper limb. J Bone Joint Surg Br
[70] Lehnhardt M, Hirche C, Daigeler A, Goertz O, Ring A, Hirsch T, et al. Soft tissue 2007;89:659–63.
sarcoma of the upper extremities. Analysis of factors relevant for prognosis in [75] Davis AM, Wright JG, Williams JI, Bombardier C, Griffin A, Bell RS. Develop-
160 patients. Chirurg 2012;83:143–52. ment of a measure of physical function for patients with bone and soft tissue
[71] Puhaindran ME, Rohde RS, Chou J, Morris CD, Athanasian EA. Clinical sarcoma. Qual Life Res 1996;5:508–16.
outcomes for patients with soft tissue sarcoma of the hand. Cancer
2011;117:175–9.