Göran Markhede

A multivariate analysis of the prognosis after surgical treatment of malignant soft-tissue tumors.

Ninety‐seven patients who had received their primary and definitive surgical treatment for a soft‐tissue sarcoma during the years 1956–1976 were studied with respect to local recurrence, metastasis, and survival. The aim of the treatment was to eradicate the tumor while preserving good function. The influence of host and tumor properties and different diagnostic and surgical procedures on the prognosis was studied by means of nonparametric multivariate analysis. Ninety‐four percent of the tumors were located in the extremities. Malignant fibrous histiocytoma was the most common histologic type. A four‐grade scale of histologic malignancy was used. Eighty‐eight percent of the tumors were Grade III or IV. In 85% of the patients with an extremity lesion, local extirpation was carried out. The overall local recurrence rate was 21.7% and in 76 patients who underwent an adequate surgical procedure it was 6.6%. The overall five‐year survival rate was 59%. The survival depended on the local control of the primary tumor, which was related to the adequacy of the surgical procedure and to the histologic grade of malignancy. No patient with a Grade I or II tumor died. The five‐year survival rate for patients with Grade III tumors was 68% and for patients with Grade IV tumors 47%.

Extra-abdominal desmoid tumors

A follow-up study of 53 patients with extra-abdominal desmoid tumor is presented. Fine-needle aspiration biopsy seemed to be valuable in the differentiation between a desmoid tumor and a truly malignant soft tissue tumor. The angiographic pictures did not differ from those of other soft tissue tumors, but valuable topographic information was obtained from the angiography in the preoperative planning. The overall local recurrence rate was 17/44, and 15 of the recurrences occurred within the first 2 years. Complete removal of the affected muscle or muscle group is recommended. Local control can be achieved by non-ablative surgery even after multiple recurrences. Only one out of 53 patients died of the tumor disease. Radiotherapy can be attempted in extensive tumors, and amputation should be reserved for tumors which have failed to respond to this treatment.

Function After Removal of Various Hip and Thigh Muscles for Extirpation of Tumors

Forty-six patients who had undergone excision of one or more well defined hip and/or thigh muscles because of a soft-tissue tumor or a tumoriform lesion were investigated with respect to the function of the operated limb and the isometric and isokinetic strength of the affected motion or motions, relative to the non-operated side (percentage). Hip flexion: Loss of the iliopsoas caused slight impairment of function. The flexion strength decreased with increasing flexion of the hip joint. Loss of the rectus femoris reduced the isometric strength by 37 and the isokinetic strength by 17 per cent. Hip abduction: The strength reduction was only about 50 per cent and the impairment of function only slight or moderate even in patients with extensive loss of abductor muscles. Hip adduction: Removal of all three prime adductors (longus, brevis, magnus) caused a strength reduction of about 70 per cent but the impairment of function was only slight or moderate. Hip extension: Loss of the gluteus maximus caused only a small strength reduction and no impairment or only slight impairment of function. Significant strength reduction was only seen when all hamstrings had been removed. Knee extension: Loss of one, two, and three of the quadriceps muscles reduced the isometric strength by 22, 33, and 55 per cent, respectively. The isokinetic strength was reduced somewhat more. The strength reduction usually had to exceed 50 per cent to cause more than slight impairment of function. Knee flexion: Loss of the semitendinosus, the biceps femoris, and all the hamstrings reduced the isometric strength by 24, 28, and 67 per cent, respectively. The isokinetic strength was reduced somewhat less. Loss of one of the hamstrings usually caused no impairment of function whereas loss of all three resulted in moderate impairment of function.

Surgery for soft tissue sarcoma in the extremities: A multivariate analysis of the 6–26-year prognosis in 137 patients

In 137 patients with soft tissue sarcomas in the extremities, the influence of patient and tumor characteristics and surgical procedures on prognosis was studied using a multivariate statistical analysis. The minimum follow-up time was 6 years, and no patient was lost to follow-up. Eighty-nine patients were referred with the tumor intact (primary series), while 48 were referred after biopsy or with local recurrence after previous surgery (secondary series). The frequency of amputation was 15 percent in the primary series and 48 percent in the secondary series. A local, function-preserving operation with a wide margin was performed in 37 patients without biopsy (clinical diagnosis alone). Local control of the disease was obtained in all but one of these patients without any adjunctive treatment. Independent, unfavorable factors concerning local recurrence were advancing age, open biopsy, and marginal surgery. Independent, unfavorable factors concerning survival were advancing age, increasing histologic malignancy grade, and ablative surgery. A tumor-related death was observed in 0, 29, 47, and 67 percent of the patients with tumors of malignancy grades I, II, III, and IV, respectively.

STRENGTH OF PLANTAR FLEXION AND FUNCTION AFTER RESECTION OF VARIOUS PARTS OF THE TRICEPS SURAE MUSCLE

Nine patients who had undergone resection of various well defined parts of the triceps surae muscle because of tumour were examined. The function was estimated from the patients history and the muscle strength was measured statically and dynamically using a Cybex II dynamometer. Two patients reported slight symptoms. The loss of strength was less than one might expect from theoretical calculations. The strength of the operated limb showed a particular pattern depending on the part resected. From this pattern it was concluded that the soleus is more active when the foot is dorsiflexed and the gastrocnemius more active when the foot is in plantar flexion, and that the gastrocnemius is most important in quick movements of the foot.

Scapulectomy for malignant tumor: Function and shoulder strength in five patients

Function and muscular strength were studied in five patients who had undergone either total or subtotal scapulectomy for malignant tumor. We found a striking difference in the functional impairment between the two patients with total and the three patients with subtotal scapulectomy. The latter three patients were able to handle light objects with their hands over their heads, and reached or nearly reached the horizontal plane in flexion and abduction of the shoulder. The two patients with total scapulectomy had a flexion and abduction range between 40 and 50 degrees. The mean isometric muscle strength in flexion relative to the non-operated side was 17 and 37 per cent for patients with total and subtotal scapulectomy, respectively, and the abduction strength 14 and 44 per cent, respectively. After scapulectomy, a reasonably good function can be expected, especially if it is possible to preserve the glenoid fossa and/or the acromion.

FACTORS INFLUENCING RESULTS OF HIGH TIBIAL OSTEOTOMY IN GONARTHROSIS

Based on our results with high tibia osteotomy for gonarthrosis in 96 knees, the type of primary deformity was found to significantly influence the patients subjective assessment of the results. Knees with valgus deformity secondary to changes in other joints are not suitable for correction by HTO. Knees with varus deformity exceeding 10 degrees and with roentgenological signs of reduction of the medial tibial condyle are seldom corrected by HTO and the results in these knees are poor. There is a clear correlation between patients satisfaction with HTO done for gonarthrosis and the correction of femorotibial deformity.

Amputation for tumor of the upper arm.

In a 10-year period 35 patients underwent a proximal amputation of the upper limb because of a malignant tumor. In 27 patients a forequarter amputation was made, in one a humeroscapular disarticulation and in seven an amputation through the humerus. The observed 5-year survival was 23 per cent. Twelve out of 23 patients followed for at least 3 years also survived 3 years. Fifteen living patients were questioned concerning prosthetic use and social and psychologic factors. Only three patients used a functional (mechanical) prosthesis and only five used a cosmetic prosthesis. The other seven patients rejected the use of a prosthesis. Half of the patients had the same occupation postoperatively as preoperatively. Activities of daily living did not constitute any major problem. One of three housekeepers needed daily help. One patient seemed to have suffered obvious psychologic damage.

Extirpation of Tumors Located Near the thoracic Cage: A Method for Increasing the Margin of Healthy Tissue on the Deep Side of the Tumor

When an aggressive tumor develops in a flat muscle near the thoracic cage the question may arise as to how achieve an adequate margin on the deep side of the tumor. This is especially the case if the tumor has recurred after a previous non-radical operation. A method is described by which the external thoracic fascia, the external intercostal musculature, and the periosteum on the external surface of the ribs can be included in the specimen as a continuous wall of healthy tissue on the deep side of the tumor. This technique has been used in 11 patients, 9 of whom had undergone one or more inadequate operations earlier. Eight patients had a malignant tumor, three an extra-abdominal desmoid. In one of the latter patients, in whom a recurrent tumor was adherent to rib periosteum, the method was unsuitable. In the other patients the method appears to have been adequate for local control of the tumor.

Function After Anterolateral Resection of the Lower Leg for Extirpation of Tumors: Extension and Pronation of the Foot Restored by Transfer of the Tibialis Posterior Muscle

A function preserving method for radical removal of tumors located anterolaterally in the lower leg is described. The loss caused by the inclusion of all extensors and pronators of the foot in the surgical specimen is compensated for, to a large extent, by transfer of the tendon of the tibialis posterior muscle to the conjoint tendons of the extensor digitorum longus and peroneus tertius. The function after such an operation has been studied in two patients using various methods including strength measurements and, in one of them, electromyography.