It was estimated that more than 3000 people would be diagnosed with a primary bone or joint malignancy and more than 11,000 people would be diagnosed with a soft tissue sarcoma in 2013. Although primary bone and soft tissue tumors of the upper extremity are infrequent, it is imperative that the clinician be familiar with a systematic approach to the diagnosis and treatment of these conditions to prevent inadvertently compromising patient outcome. With advances in chemotherapy, radiotherapy, tumor imaging, and surgical reconstructive options, limb salvage surgery is estimated to be feasible in 95% of extremity bone or soft tissue sarcomas.
References
- 1. In Howlader N., Noone A.M., and Krapcho M. (eds): SEER Cancer Statistics Review, 1975-2010. Bethesda (MD): National Cancer Institute, 2013.
- 2. Pisters P.W., Leung D.H., Woodruff J., et al: Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities. J Clin Oncol 1996; 14: pp. 1679-1689
- 3. Simon M.A., and Finn H.A.: Diagnostic strategy for bone and soft-tissue tumors. J Bone Joint Surg Am 1993; 75: pp. 622-631
- 4. Miller T.T.: Bone tumors and tumorlike conditions: analysis with conventional radiography. Radiology 2008; 246: pp. 662-674
- 5. Lodwick G.S., Wilson A.J., Farrell C., et al: Determining growth rates of focal lesions of bone from radiographs. Radiology 1980; 134: pp. 577-583
- 6. McNeil B.J.: Rationale for the use of bone scans in selected metastatic and primary bone tumors. Semin Nucl Med 1978; 8: pp. 336-345
- 7. Rougraff B.T., Kneisl J.S., and Simon M.A.: Skeletal metastases of unknown origin. A prospective study of a diagnostic strategy. J Bone Joint Surg Am 1993; 75: pp. 1276-1281
- 8. Bastiaanet E., Groen H., Jager P.L., et al: The value of FDG-PET in the detection, grading and response therapy of soft tissue and bone sarcomas; a systematic review and meta-analysis. Cancer Treat Rev 2004; 30: pp. 83-101
- 9. Mankin H.J., Lange T.A., and Spanier S.S.: The hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. J Bone Joint Surg Am 1982; 64: pp. 1121-1127
- 10. Mankin H.J., Mankin C.J., and Simon M.A.: The hazards of biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am 1996; 78: pp. 656-663
- 11. Styring E., Billing V., Hartman L., et al: Simple guidelines for efficient referral of soft-tissue sarcomas: a population-based evaluation of adherence to guidelines and referral patterns. J Bone Joint Surg Am 2012; 94: pp. 1291-1296
- 12. Scarborough M.T.: The biopsy. Instr Course Lect 2004; 53: pp. 639-644
- 13. Enneking W.F., Spanier S.S., and Goodman M.A.: A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res 1980; 153: pp. 106-120
- 14. Wunder J.S., Healey J.H., Davis A.M., et al: A comparison of staging systems for localized extremity soft tissue sarcoma. Cancer 2000; 88: pp. 2721-2730
- 15. Saddegh M.K., Lindholm J., Lundberg A., et al: Staging of soft-tissue sarcomas. Prognostic analysis of clinical and pathological features. J Bone Joint Surg Br 1992; 74: pp. 495-500
- 16. Fleming I.D., Cooper J.S., Henson D.E., et al: AJCC cancer staging manual. Philadelphia: Lippincott-Raven, 1997.
- 17. Bednar M.S., Weiland A.J., and Light T.R.: Osteoid osteoma of the upper extremity. Hand Clin 1995; 11: pp. 211-221
- 18. Soong M., Jupiter J., and Rosenthal D.: Radiofrequency ablation of osteoid osteoma in the upper extremity. J Hand Surg Am 2006; 31: pp. 279-283
- 19. Ambrosia J.M., Wold L.E., and Amadio P.C.: Osteoid osteoma of the hand and wrist. J Hand Surg Am 1987; 12: pp. 794-800
- 20. Gibbs C.P., Weber K., and Scarborough M.T.: Malignant bone tumors. J Bone Joint Surg Am 2001; 83: pp. 1728-1745
- 21. Okada K., Wold L.E., Beabout J.W., et al: Osteosarcoma of the hand. A clinicopathologic study of 12 cases. Cancer 1993; 72: pp. 719-725
- 22. Sforzo C.R., Scarborough M.T., and Wright T.W.: Bone-forming tumors of the upper extremity and Ewing’s sarcoma. Hand Clin 2004; 20: pp. 303-315
- 23. Anninga J.K., Picci P., Flocco M., et al: Osteosarcoma of the hands and feet: a distinct clinco-pathological subgroup. Virchows Arch 2013; 462: pp. 109-120
- 24. Daecke W., Bielack S., Martini A.K., et al: Osteosarcoma of the hand and forearm: experience of the Cooperative Osteosarcoma Study Group. Ann Surg Oncol 2005; 12: pp. 322-331
- 25. Winkler K., Bielack S.S., Delling G., et al: Treatment of osteosarcoma: experience of the Cooperative Osteosarcoma Study Group (COSS). Cancer Treat Res 1993; 62: pp. 269-277
- 26. Bielack S.S., Kempf-Bielack B., Delling G., et al: Prognostic factors in high-grade osteosarcoma of the extremities or trunk: an analysis of 1,702 patients treated on neoadjuvant cooperative osteosarcoma study group protocols. J Clin Oncol 2002; 20: pp. 776-790
- 27. Meyers P.A., Heller G., Healey J., et al: Chemothterapy for nonmetastatic osteogenic sarcoma: the Memorial Sloan-Kettering experience. J Clin Oncol 1992; 10: pp. 5-15
- 28. Picci P., Sangiori L., Rougraff B.T., et al: Relationship of chemotherapy-induced necrosis and surgical margins to local recurrence in osteosarcoma. J Clin Oncol 1994; 12: pp. 2699-2705
- 29. Link M.P., Goorin A.M., Miser A.W., et al: The effect of adjuvant chemotherapy on relapse-free survival in patients with osteosarcoma of the extremity. N Engl J Med 1986; 314: pp. 1600-1616
- 30. O’Connor M.I., and Bancroft L.W.: Benign and malignant cartilage tumors of the hand. Hand Clin 2004; 20: pp. 317-323
- 31. Unni K.K., and Inwards C.Y.: Dahlin’s bone tumors: general aspects and data on 10,165 cases. Philadelphia: Lippincott Williams & Wilkins, 2010.
- 32. Sassoon A.A., Fitz-Gibbon P.D., Harmsen W.S., et al: Enchondromas of the hand: factors affecting recurrence, healing, motion and malignant transformation. J Hand Surg Am 2012; 37: pp. 1229-1234
- 33. Patil S., de Silva M.V., Crossan J., et al: Chondrosarcoma of small bones of the hand. J Hand Surg Br 2003; 28: pp. 602-608
- 34. Lee F.Y., Mankin H.J., Fondren G., et al: Chondrosarcoma of bone: an assessment of outcome. J Bone Joint Surg Am 1999; 81: pp. 326-338
- 35. Mourikis A., Mankin H.J., Hornicek F.J., et al: Treatment of proximal humeral chondrosarcoma with resection and allograft. J Shoulder Elbow Surg 2007; 16: pp. 519-524
- 36. Mittermayer F., Dominkus M., Krepler P., et al: Chondrosarcoma of the hand: is a wide surgical resection necessary? Clin Orthop Relat Res 2004; undefined: pp. 211-215
- 37. Athanasian E.A.: Aneurysmal bone cyst and giant cell tumor of bone of the hand and distal radius. Hand Clin 2004; 20: pp. 269-281
- 38. Mankin H.J., Hornicek F.J., Ortiz-Crus E., et al: Aneurysmal bone cyst: a review of 150 patients. J Clin Oncol 2005; 23: pp. 6756-6762
- 39. Gibbs C.P., Hefele M.C., Peabody T.D., et al: Aneurysmal bone cyst of the extremities. Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999; 81: pp. 1671-1678
- 40. Eckardt J.J., and Grogan T.J.: Giant cell tumor of bone. Clin Orthop Relat Res 1986; 204: pp. 45-58
- 41. Campanacci M., Baldini N., Boriani S., et al: Giant-cell tumor of bone. J Bone Joint Surg Am 1987; 69: pp. 106-114
- 42. Campanacci M.: Giant-cell tumor and chondrosarcomas: grading, treatment and results (studies of 209 and 131 cases). Recent Results Cancer Res 1976; undefined: pp. 257-261
- 43. Nijhuis P.H., Schaapveld M., Otter R., et al: Epidemiological aspects of soft tissue sarcomas (STS)–consequences for the design of clinical STS trials. Eur J Cancer 1999; 35: pp. 1705-1710
- 44. Talbot S.G., Mehrara B.J., Disa J.J., et al: Soft-tissue coverage of the hand following sarcoma resection. Plast Reconstr Surg 2008; 121: pp. 534-543
- 45. Murray P.M.: Soft tissue sarcoma of the upper extremity. Hand Clin 2004; 20: pp. 325-333
- 46. Riad S., Griffin A.M., Liberman B., et al: Lymph node metastasis in soft tissue sarcoma in an extremity. Clin Orthop Relat Res 2004; 426: pp. 129-134
- 47. Rosenberg S.A., Tepper J., Glatstein E., et al: The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. Ann Surg 1982; 196: pp. 305-315
- 48. Keus R.B., Rutgers E.J., Ho G.H., et al: Limb-sparing therapy of extremity soft tissue sarcomas: treatment outcome and long-term functional results. Eur J Cancer 1994; 30A: pp. 1459-1463
- 49. Lin P.P., Guzel V.B., Pisters P.W., et al: Surgical management of soft tissue sarcomas of the hand and foot. Cancer 2002; 95: pp. 852-861
- 50. Pradhan A., Cheung Y.C., Grimer R.J., et al: Soft-tissue sarcomas of the hand: oncological outcome and prognostic factors. J Bone Joint Surg Br 2008; 90: pp. 209-214
- 51. Puhaindran M.E., Steensma M.R., and Athanasian E.A.: Partial hand preservation for large soft tissue sarcomas of the hand. J Hand Surg Am 2010; 35: pp. 291-295
- 52. Puhaindran M.E., Rohde R.S., Chou J., et al: Clinical outcomes for patients with soft tissue sarcoma of the hand. Cancer 2011; 117: pp. 175-179
- 53. Stojadinovic A., Leung D.H., Hoos A., et al: Analysis of the prognostic significance of microscopic margins in 2,084 localized primary adult soft tissue sarcomas. Ann Surg 2002; 235: pp. 424-434
- 54. Gronchi A., Casali P.G., Mariani L., et al: Status of surgical margins and prognosis in adult soft tissue sarcomas of the extremities: a series of patients treated at a single institution. J Clin Oncol 2005; 23: pp. 96-104
- 55. Gerrand C.H., Wunder J.S., Kandel R.A., et al: Classification of positive margins after resection of soft-tissue sarcoma of the limb predicts the risk of local recurrence. J Bone Joint Surg Br 2001; 83: pp. 1149-1155
- 56. Koskinen E.V., Visuri T.I., Holmström T., et al: Aneurysmal bone cyst: evaluation of resection and of curettage in 20 cases. Clin Orthop Relat Res 1976; 118: pp. 136-146
- 57. Biesecker J.L., Marcove R.C., Huvos A.G., et al: Aneurysmal bone cysts. A clinicopathologic study of 66 cases. Cancer 1970; 26: pp. 615-625
- 58. Vergel De Deios A.M., Bond J.R., Shives T.C., et al: Aneurysmal bone cyst. A clinicopathologic study of 238 cases. Cancer 1992; 69: pp. 2921-2931
- 59. Marcove R.C., Sheth D.S., Takemoto S., et al: The treatment of aneurysmal bone cyst. Clin Orthop Relat Res 1995; 311: pp. 157-163
- 60. Peeters S.P., Van der Geest I.C., de Rooy J.W., et al: Aneurysmal bone cyst: the role of cryosurgery as local adjuvant treatment. J Surg Oncol 2009; 100: pp. 719-724
- 61. Puhaindran M.E., Chou J., Forsberg J.A., et al: Major upper-limb amputations for malignant tumors. J Hand Surg Am 2012; 37: pp. 1235-1241
- 62. Malawer M., and Wittig J.: Overview of resections around the shoulder girdle: anatomy, surgical considerations and classification. In Malawer M., and Sugarbaker P.H. (eds): Musculoskeletal cancer surgery: treatment of sarcomas and allied diseases. Boston: Kluwer Academic, 2001. pp. 179-202
- 63. Clarkson P.W., Griffin A.M., Catton C.N., et al: Epineural dissection is a safe technique that facilitates limb salvage surgery. Clin Orthop Relat Res 2005; 438: pp. 92-96
- 64. Ferguson P.C., Kulidjian A.A., Jones K.B., et al: Peripheral nerve considerations in the management of extremity soft tissue sarcomas. Recent Results Cancer Res 2009; 179: pp. 243-256
- 65. Windhager R., Millesi H., and Kotz R.: Resection-replantation for primary malignant tumours of the arm. An alternative to fore-quarter amputation. J Bone Joint Surg Br 1995; 77: pp. 176-184
- 66. Hahn S.B., Choi Y.R., Kang H.J., et al: Segmental resection and replantation have a role for selected advanced sarcomas in the upper limb. Clin Orthop Relat Res 2009; 467: pp. 2918-2924
- 67. Krajbich J.I., and Carroll N.C.: Van Nes rotationplasty with segmental limb resection. Clin Orthop Relat Res 1990; undefined: pp. 7-13
- 68. Mahendra A., Gortzak Y., Ferguson P.C., et al: Management of vascular involvement in extremity of soft tissue sarcoma. Recent Results Cancer Res 2009; 179: pp. 285-299
- 69. Ghert M.A., Davis A.M., Griffin A.M., et al: The surgical and functional outcome of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma of the extremity. Ann Surg Oncol 2005; 12: pp. 1102-1110
- 70. Lee S.K., and Wolfe S.W.: Nerve transfers for the upper extremity: new horizons in nerve reconstruction. J Am Acad Orthop Surg 2012; 20: pp. 506-517
- 71. Ozkan T., Ozer K., and Gülgönen A.: Restoration of sensibility in irreparable ulnar and median nerve lesions with use of sensory nerve transfer: long-term follow-up of 20 cases. J Hand Surg Am 2001; 26: pp. 44-51
- 72. Ratner J.A., Peljovich A., and Kozin S.H.: Update on tendon transfers for peripheral nerve injuries. J Hand Surg Am 2010; 35: pp. 1371-1381
- 73. Gebert C., Hillmann A., Schwappach A., et al: Free vascularized fibular grafting for reconstruction after tumor resection in the upper extremity. J Surg Oncol 2006; 94: pp. 114-127
- 74. Rashid S., Zia ul Islam M., Rizvi S.T., et al: Limb salvage in malignant tumours of the upper limb using vascularized fibula. J Plast Reconstr Aesthet Surg 2008; 61: pp. 648-661
- 75. Murray P.M.: Free vascularized bone transfer in limb salvage surgery of the upper extremity. Hand Clin 2004; 20: pp. 203-211
- 76. Mack G.R., Licthman D.M., and MacDonald R.I.: Fibular autografts for distal defects of the radius. J Hand Surg Am 1979; 4: pp. 576-583
- 77. Maruthainar N., Zambakidis C., Harper G., et al: Functional outcome following excision of tumors of the distal radius and reconstruction by autologous non-vascularized osteoarticular fibula grafting. J Hand Surg Br 2002; 27: pp. 171-174
- 78. Kiss J., Sztrinkai G., Antal I., et al: Functional results and quality of life after shoulder girdle resections in musculoskeletal tumors. J Shoulder Elbow Surg 2007; 16: pp. 273-279
- 79. Hsu R.W., Wood M.B., Sim F.H., et al: Free vascularized fibular grafting for reconstruction after tumour resection. J Bone Joint Surg Br 1997; 79: pp. 36-42
- 80. Talbot S.G., Athanasian E.A., Cordeiro P.G., et al: Soft tissue reconstruction following tumor resection in the hand. Hand Clin 2004; 20: pp. 181-202
- 81. Lohman R.F., Nabawi A.S., Reece G.P., et al: Soft tissue sarcoma of the upper extremity: a 5-year experience at two institutions emphasizing the role of soft tissue flap reconstruction. Cancer 2002; 94: pp. 2256-2264
- 82. Schwab J.H., Healey J.H., and Athanasian E.A.: Wide en bloc extra-articular excision of the elbow for sarcoma with complex reconstruction. J Bone Joint Surg Br 2008; 90: pp. 78-83
- 83. Muramatsu K., Ihara K., and Taguchi T.: Selection of myocutaneous flaps for reconstruction following oncologic resection of sarcoma. Ann Plast Surg 2010; 64: pp. 307-310
- 84. Grinsell D., Di Bella C., and Choong P.F.: Functional reconstruction of sarcoma defects using innervated free flaps. Sarcoma 2012; 2012: pp. 315190
- 85. Malawer M.M.: Tumors of the shoulder girdle. Technique of resection and description of a surgical classification. Orthop Clin North Am 1991; 22: pp. 7-35
- 86. O’Connor M.I., Sim F.H., and Chao E.Y.: Limb salvage for neoplasms of the shoulder girdle. Intermediate reconstructive and functional results. J Bone Joint Surg Am 1996; 78: pp. 1872-1888
- 87. Probyn L.J., Wunder J.S., Bell R.S., et al: A comparison of outcome of osteoarticular allograft reconstruction and shoulder arthrodesis following resection of primary tumours of the proximal humerus. Sarcoma 1998; 2: pp. 163-170
- 88. Rödl R.W., Gosheger G., Gebert C., et al: Reconstruction of the proximal humerus after wide resection of tumours. J Bone Joint Surg Br 2002; 84: pp. 1004-1008
- 89. Getty P.J., and Peabody T.D.: Complications and functional outcomes of reconstruction with an osteoarticular allograft after intra-articular resection of the proximal aspect of the humerus. J Bone Joint Surg Am 1999; 81: pp. 1138-1146
- 90. Potter B.K., Adams S.C., Pitcher J.D., et al: Proximal humerus reconstructions for tumors. Clin Orthop Relat Res 2009; 467: pp. 1035-1041
- 91. van de Sande M.A., Dijkstra P.D., and Taminau A.H.: Proximal humerus reconstruction after tumour resection: biological versus endoprosthetic reconstruction. Int Orthop 2011; 35: pp. 1375-1380
- 92. Tsukushi S., Nishida Y., Takahashi M., et al: Clavicula pro humero reconstruction after wide resection of the proximal humerus. Clin Orthop Relat Res 2006; 447: pp. 132-137
- 93. Marulanda G.A., Henderseon E., Cheong D., et al: Proximal and total humerus reconstruction with the use of an aortograft mesh. Clin Orthop Relat Res 2010; 468: pp. 2896-2903
- 94. Wittig J.C., Bickels J., Kellar-Graney K.L., et al: Osteosarcoma of the proximal humerus: long-term results with limb-sparing surgery. Clin Orthop Relat Res 2002; 397: pp. 156-176
- 95. Abdeen A., Hoang B.H., Athanasian E.A., et al: Allograft-prosthesis composite reconstruction of the proximal part of the humerus: functional outcome and survivorship. J Bone Joint Surg Am 2009; 91: pp. 2406-2415
- 96. Aponte-Tinao L.A., Ayerza M.A., Muscolo D.L., et al: Allograft reconstruction for the treatment of musculoskeletal tumors of the upper extremity. Sarcoma 2013; 2013: pp. 925413
- 97. Gebhardt M.C., Roth Y.F., and Mankin H.J.: Osteoarticular allografts for reconstruction in the proximal part of the humerus after excision of a musculoskeletal tumor. J Bone Joint Surg Am 1990; 72: pp. 334-345
- 98. De Wilde L.F., Plasschaert F.S., Audenaert E.A., et al: Functional recovery after a reverse prosthesis for reconstruction of the proximal humerus in tumor surgery. Clin Orthop Relat Res 2005; 430: pp. 156-162
- 99. Pritchard D.J., and Dahlin D.C.: Neoplasms of the elbow. In Morrey B.F. (eds): The elbow and its disorders. Philadelphia: WB Saunders, 1985. pp. 713-735
- 100. Athwal G.S., Chin P.Y., Adams R.A., et al: Coonrad-Morrey total elbow arthroplasty for tumours of the distal humerus and elbow. J Bone Joint Surg Br 2005; 87: pp. 1369-1374
- 101. Weber K.L., Linn P.P., and Yasko A.W.: Complex segmental elbow reconstruction after tumor resection. Clin Orthop Relat Res 2003; 415: pp. 31-44
- 102. Dean G.S., Holliger E.H., and Urbaniak J.R.: Elbow allograft for reconstruction of the elbow with massive bone loss. Long term results. Clin Orthop Relat Res 1997; 341: pp. 12-22
- 103. Kocher M.S., Gebhardt M.C., and Mankin H.J.: Reconstruction of the distal aspect of the radius with use of an osteoarticular allograft after excision of a skeletal tumor. J Bone Joint Surg Am 1998; 80: pp. 407-419
- 104. Scoccianti G., Campanacci D.A., Beltrami G., et al: The use of osteo-articular allografts for reconstruction after resection of the distal radius tumour. J Bone Joint Surg Br 2010; 92: pp. 1690-1694
- 105. Lackman R.D., McDonald D.J., Beckenbaugh R.D., et al: Fibular reconstruction for giant cell tumor of the distal radius. Clin Orthop Relat Res 1987; undefined: pp. 232-238
- 106. Bickert B., Heitmann Ch, and Germann G.: Fibulo-scapho-lunate arthrodesis as a motion-preserving procedure after tumour resection of the distal radius. J Hand Surg Br 2002; 27: pp. 573-576
- 107. Natarajan M.V., Chandra Bose J., Viswanath J., et al: Custom prosthetic replacement for distal radial tumours. Int Orthop 2009; 33: pp. 1081-1084
- 108. Hatano H., Morita T., Kobayashi H., et al: A ceramic prosthesis for the treatment of tumours of the distal radius. J Bone Joint Surg Br 2006; 88: pp. 1656-1658
- 109. Seradge H.: Distal ulnar translocation in the treatment of giant-cell tumors of the distal radius. J Bone Joint Surg Am 1982; 64: pp. 67-73
- 110. Minami A., Kato H., and Iwasaki N.: Vascularized fibular graft after excision of giant-cell tumor of the distal radius: wrist arthroplasty versus partial wrist arthrodesis. Plast Reconstr Surg 2002; 110: pp. 112-117
- 111. Pho R.W.: Malignant giant-cell tumor of the distal end of the radius treated by a free vascularized fibular transplant. J Bone Joint Surg Am 1981; 63: pp. 877-884
- 112. Campbell C.J., and Akbarnia B.A.: Giant-cell tumor of the radius treated by massive resection and tibial bone graft. J Bone Joint Surg Am 1975; 57: pp. 982-986
- 113. Athanasian W.A.: Bone and soft tissue tumors. In (eds): , 6th edition. New York: Churchill Livingstone, 2010. pp. 2142-2195