General Considerations

Kristy L. Weber

The shoulder is a relatively common location for tumor resections that involve limb-sparing operations for primary bone sarcomas as well as metastatic disease. The complex anatomy about the shoulder girdle and the need to maintain maximal function for the patient to perform activities of daily living underscore the importance of a thorough understanding of the issues related to complex surgery in this area. The options for reconstruction of the humerus and shoulder girdle after tumor resection are varied and explained in detail in the following chapters.

INDICATIONS

Resection

Primary bone/soft tissue sarcomas or occasionally isolated bone metastasis that involve the humerus or scapula without involvement of the main neurovascular bundle are indicated for wide resection with goals to achieve lasting local control and potentially increase the patient’s survival (Figs. 26.1 and 26.2).
Widespread metastatic bone disease with a pathologic fracture of the humerus that is not amenable to internal fixation is often indicated for resection. The goal is to achieve pain relief rather than local control, thus a wide resection is often not necessary. If an intralesional or marginal resection is performed, postoperative external beam radiation is used (Fig. 26.3).

FIGURE 26.1 A: AP radiograph of the left humerus in a 17-year-old man with a humeral osteosarcoma. Note the ossification of the soft tissue tumor extension after chemotherapy. Coronal (B) and axial (C,D) postgadolinium MR images reveal the bony extent of tumor and the surrounding soft tissue mass. Careful evaluation of the medial neurovascular structures is necessary in order to determine whether the patient is a candidate for limb-sparing surgery.

FIGURE 26.2 A: AP radiograph of the scapula in a 72-year-old woman with a primary sarcoma of bone reveals the obvious destruction of the glenoid. Coronal T2 (B), sagittal T2 (C), and axial T2 (D) MR images show the lateral and distal extent of the tumor. E: The entire scapula was removed, and the humerus was resuspended to the clavicle.

FIGURE 26.3 A: AP radiograph of a 62-year-old man with metastatic lung cancer to the left proximal humerus. The osteolytic lesion is progressive and his pain is severe despite external beam radiation. Note the cortical bone loss medially. Coronal T1 (B) and axial T2 (C) MR images reveal the localized disease in this area. D: Postoperative radiograph after wide resection of the metastasis with reconstruction using a megaprosthesis. There was not thought to be enough proximal bone to allow stability with intramedullary fixation.

FIGURE 26.4 A: AP radiograph of the right humerus in a 62-year-old woman with widely metastatic breast cancer. Although this fracture can be treated nonoperatively, she required the use of her right upper extremity for ambulation due to painful lower extremity lesions that limited her weightbearing capacity and a prior pathologic fracture of the left humerus (B). C: Postoperative radiograph after intramedullary fixation of the right humerus. She could bear full weight on this arm after surgery.

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