MALIGNANT INVOLVEMENT AROUND MAJOR VESSELS: AMPUTATION OR LIMB SALVAGE?

Leggon RE, Huber TS, Scarborough MT (University of Florida, Gainesville, FL 32610)

Amputation has often been a treatment recommendation when malignancy involves major vessels. Our approach has been to consider limb sparing surgery with vascular reconstruction whenever feasible. We have retrospectively reviewed a series of 17 patients treated at our institution to analyze the efficacy of this treatment recommendation. Our graft reconstruction data was added to the English literature and data pooled for global analysis.

Methods: During the period of 1969 to 1999, 17 patients with an average age of 43years (range 8-83) were treated at our institution. Diagnoses included soft tissue sarcoma in 12, recurrent basal cell carcinoma in one, and osteogenic sarcoma in 4. Vessels were completely encased by tumor in 6, nearly encased in 3, invaded by tumor in 4, widely contaminated by inappropriate surgery in 3, and adjacent to tumor in 1. Staging included one I-B, thirteen II-B, two III-B sarcomas; and one high-grade carcinoma. The largest average tumor dimension was 9 cm (range 3.5-15.5cm). Treatment involved resection with vascular grafting in 14, and resection with rotationplasty and primary anastomosis in 3.Adjuvant treatment included chemo in 9, RT in 3, and pulmonary metastectomy in 2. Margins were marginal in 2, wide-contaminated in 2, and wide in 13. Vessels resected included external iliac a and v in 1, common femoral a and v in 7, common femoral a alone in 2, popliteal a and v in 2, posterior tibial a and v in 3,brachial artery in 1 and subclavian vein in 1, with an average length of 14 cm (n=9). Donor sources for grafting was superficial or saphenous veins in all, except one case using Dacron. Major nerves were sacrificed in 9 of 17 patients (53%). Muscle flaps were used in 7 of 17 patients (41%).

Our vascular graft data was added to data from 10 articles and abstracts for pooled analysis. 115 patients in the English literature were then analyzed.

Results: At the time of follow-up (average 53 months), 6 were DOD, 2 were AWD, and 9 were ANED. Local recurrence developed in 2 of 17, infection in 2 of 17, and post-op arterial thrombus in 4. Some complications related to surgery developed in 11 of 17 patients (65%). Only 2 of the 17 patients (12%) had an amputation after their reconstruction:one hemi-pelvectomy for local recurrence, and one above-knee amputation for acute vascular occlusion. 15 of 17 patients (88%) had limb salvage, with functional status judged excellent in 5, good in 8, fair in 1, and poor in 3 (76% G/E).

Pooled data of limb salvage with the use of vascular grafts (including 14 of our patients) yielded 115 patients with an average age of 43 (n=79). At an average follow-up of 39 months, 26% were DOD, 10% were AWD, 63% were ANED, and 1% DOC (n=115). Local recurrence was 11% (n=106), and seemed less after wide surgery 3%(n=60) than with inadequate surgery 18% (n=17), or with inadequate surgery including palliative surgery 30%(n=20). Recurrence was 5% for primary tumors (n=40), 10% for primary tumors including palliative surgery (n=42), and 33% for recurrent tumors (n=12). Infection developed in 14% (n=95) and seemed higher with synthetic arterial grafts 30%(n=23), than with saphenous vein grafts 3%(n=31). In patients who had vascular labs, long term graft patency seemed higher for arterial grafts 87%(n=39) than venous grafts64%(n=28), although more aggressive treatment of thrombus was employed in the arterial graft group. Only 12 of 115 patients (11%) had amputations. Limb salvage was possible in 89% of patients (n=115), with 80% having a functional extremity (n=70).

Conclusions: While the overall complication rate is high, limb salvage with vascular reconstruction can provide satisfactory function, even with partial loss of nerve function. Autogenous vein grafts may yield fewer complications than synthetic graft in this challenging patient group.