Amputation and cancer
Amputation is a surgical procedure involving the removal of all or part of a limb, often necessitated by severe disease, injury, or tumors, including various types of cancers such as soft-tissue sarcomas and bone malignancies. The primary goals of amputation include the eradication of diseased tissue, pain relief, and prevention of tumor metastasis, while also facilitating proper healing and function of the remaining limb. A multidisciplinary approach is essential, addressing not only the physical but also the psychological aspects of losing a limb, as this can significantly impact a patient's body image and mental health.
Preoperative evaluations focus on the patient’s overall health, including immune function and nutritional status, which are critical for successful healing. Post-surgery, various wound care techniques and rehabilitation efforts are emphasized to optimize recovery and prosthetic fitting, which are key for regaining independence. While amputation is sometimes compared to limb salvage techniques, studies suggest similar functional outcomes for both, although the choice may depend on specific patient circumstances and tumor characteristics. Common complications include pain, risk of infection, and challenges related to prosthetic use. Advances in surgical techniques, such as the Agonist-Antagonist Myoneural Interface, are continually improving the potential for better control of prosthetic limbs and enhancing patient outcomes.
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Subject Terms
Amputation and cancer
DEFINITION: Surgical removal of all or part of a limb as a result of peripheral vascular disease, trauma, tumor, infection, or congenital anomaly.
Cancers treated: Soft-tissue neoplasias (malignant fibrous histiocytoma, fibrosarcoma, rhabdomyosarcoma, synovial sarcoma); bone malignancies (osteosarcoma, chondrosarcoma, adamantinoma, Ewing sarcoma)
Why performed: Amputations are performed to remove extremities that are severely diseased, injured, or no longer functional. Amputation has five goals: removal of all diseased tissue, relief of pain, proper wound healing, prevention of metastatic spread of tumor cells, and construction of a stump that will permit useful function. Amputation as a musculoskeletal procedure is often accomplished as an alternative to limb salvage and should be considered a reconstructive maneuver. Because of the psychological implications and the alteration of body self-image with amputation, a multidisciplinary team approach should be taken to return the patient to a maximum level of independent function. The process should be considered the first step in the rehabilitation of the patient, rather than a failure of treatment.
Patient preparation: Amputation and subsequent healing depend on several factors, including vascular inflow, nutrition, and an adequate immune system. Prior to surgery, patients should be evaluated regarding these parameters. Patients with malnutrition or immune deficiency have a high rate of wound breakdown or infection. A serum albumin level below 3.5 grams per deciliter (g/dl) indicates a malnourished patient. An absolute lymphocyte count below 1,500 cubic millimeters is a sign of immune deficiency. If possible, amputation should be delayed in patients until these values can be improved by nutritional support. In severely affected patients, nasogastric or percutaneous gastric feeding tubes are necessary.
Oxygenated blood is a prerequisite for wound healing. A hemoglobin level of more than 10 g/dl is required. Doppler ultrasonography has been used to measure vascular inflow and to predict the success of wound healing. An absolute Doppler pressure of 70 millimeters of mercury (mm Hg) and an ischemic index of 0.5 or greater are necessary at the surgical site. The transcutaneous partial pressure of oxygen (Tcp02) is used to measure vascular inflow. Values greater than 40 mm Hg correlate with acceptable healing rates.
Steps of the procedure: With regard to tumor stage and desired functional outcome, there are a variety of surgical procedures pertaining to upper-limb, lower-extremity, or axial skeletal amputation. Patients with musculoskeletal neoplasms can choose limb salvage techniques and adjuvant chemotherapy and radiation therapy. If an amputation is chosen, then the incision must be planned carefully to achieve the appropriate surgical margin. These surgical margins are characterized by the relationship of the surgical incision to the lesion, to the inflammatory zone surrounding the lesion, and to the anatomic compartment in which the lesion is located. The four types of surgical margins include the following:
- intralesional: the surgical incision enters the lesion
- marginal: the surgical incision enters the inflammatory zone but not the lesion
- wide margin: the incision enters the same anatomic compartment of the lesion but is outside the inflammatory zone
- radical: the incision remains outside the anatomic compartment
After the procedure: A variety of wound care methods are used after amputation, including rigid dressings, soft dressings, controlled environment chambers, air splints, and skin traction. The use of an immediate postoperative prosthesis (IPOP) has been shown to be effective in decreasing the time to limb maturation and definitive prosthetic fitting. Rehabilitation and prosthetic fitting remain the primary postoperative goals.
Risks: The amputee is at risk for deep vein thrombosis (between 7 and 16 percent) and pulmonary embolism (between 3 and 12 percent). Prolonged postoperative immobilization, stagnation of blood due to ligation of large veins, delayed prosthetic fitting, and inactivity increase the overall risk of thromboembolism (clot). Up to 85 percent of amputees experience some episodes of phantom limb pain, which are often severe but infrequent. Other major complications include failure of wound healing, infection, postoperative edema, joint contractures, and dermatological problems such as skin irritation from improper prosthetic fit, breakdown over stump margins, and episodes of contact dermatitis.
Results: Controversy exists in the medical community when comparing limb salvage to amputation with regard to energy expenditure to ambulate, quality-of-life measures, and the performance of activities of daily living. Studies suggest that functional outcomes are comparable with either limb salvage or amputation. Overall survival remains comparable with either treatment, although it appears it is slightly longer with limb salvage, which may be due in part to the rigors of rehabilitation. With some tumors, amputation may achieve better local disease control. Both treatment groups report quality-of-life problems involving employment, health insurance, social isolation, and poor self-esteem. Advances continue to be made in surgical techniques as well. Agonist-Antagonist Myoneural Interface was developed as a surgical technique that can improve a patient's ability to control their prosthetic limb following surgery due to muscle reconnection techniques.
Bibliography
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