Sarcomas of the flexor fossae in children: Is amputation necessary?

• Published in: Journal of pediatric surgery Vol. 27; no. 8; pp. 964 - 967
• Main Authors: Philippe, Paul G., Rao, Bhaskar N., Rogers, David A., Fontanesi, James, Bowman, Laura, Parham, David, Shapiro, David, Lobe, Thom E., Fleming, Irving
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.08.1992
• Subjects: Adolescent; Adult; Amputation; Child; Child, Preschool; Combined Modality Therapy; Elbow - surgery; Female; Humans; Knee - surgery; Leg - surgery; Male; Neoplasm Recurrence, Local - surgery; Reoperation; Rhabdomyosarcoma - drug therapy; Rhabdomyosarcoma - radiotherapy; Rhabdomyosarcoma - surgery; Sarcoma - drug therapy; Sarcoma - radiotherapy; Sarcoma - surgery; Soft Tissue Neoplasms - drug therapy; Soft Tissue Neoplasms - radiotherapy; Soft Tissue Neoplasms - surgery; children; Sarcomas; flexor fossae
• ISSN: 0022-3468; 1531-5037
• DOI: 10.1016/0022-3468(92)90541-E

Successful management of sarcomas of the extremities in children implies not only achievement of local control but also satisfactory function and maintenance of the growth potential. The popliteal and antecubital fossae, because of their complex neurovascular anatomy, all of which is essential, make resection with satisfactory margins difficult. We reviewed our experience with 14 patients (3 to 20 years old; median, 13 years) with soft tissue sarcomas arising in the popliteal (11 patients) or antecubital (3 patients) fossae. There were four rhabdomyosarcomas (3 alveolar, 1 embryonal) and 10 other sarcomas, the most frequent being synovial sarcoma (5 patients). Chemotherapy was given to all patients with rhabdomyosarcomas. The one patient presenting with metastatic disease was treated, after biopsy of the primary, by chemotherapy and radiation and survived 21 months. In three patients, the primary management was an above-the-knee amputation and two of three survived (3 and 43 months). In 10 patients a wide local excision of the primary tumor was performed. Radiation therapy was administered to five, either as external beam (3 patients) or as brachytherapy (2 patients). In this group, there were no local recurrences. Four patients remain free of disease (4 months to 18 years) and one developed pulmonary metastasis. Among the five non-irradiated patients, three developed local recurrences, requiring above-the-knee amputation for disease. The fourth patient relapsed in the lung and only one of the five is free of disease at 36 months. Of the 8 patients not treated with amputation, one acquired a leg length discrepancy, which required correction, and one has a minimal extension deficit of the knee. These data suggest that: (1) preservation of a functional limb is possible for a majority of soft tissue sarcomas in these areas; (2) invasion of a major neurovascular bundle warrants a primary amputation; and (3) the addition of radiation therapy is an essential component of the therapy. Modern techniques of radiation, such as hyperfractionation or interstitial implantation, may also decrease the related morbidity.