Importance of surgical resection in the successful management of soft tissue sarcoma.

HYPOTHESIS: A systemic disease-free state necessitates a local disease-free state. This cannot be accomplished without a properly performed resection by an experienced surgical team. Successful local management of soft tissue sarcoma (STS) may lead to improved disease-free survival. An STS treatment protocol using wide local excision followed by radiation therapy is effective in achieving local tumor control and survival similar to that of multiple-modality regimens, but with lower morbidity. DESIGN: Retrospective cohort review (August 1, 1987, to May 6, 1998). SETTING: Referral to a single musculoskeletal oncologic surgeon, with surgery performed at a tertiary care medical center in a large urban area. PATIENTS: Ninety patients with STS of the trunk or extremities. INTERVENTIONS: Preoperative evaluation included surveillance computed tomographic scan of the chest, magnetic resonance imaging of primary site to assess tumor extent and to plan the surgical approach, and angiography if vascular bypass was proposed. Wide local excision of tumor was performed, with concomitant vascular bypass and/or complex plastic reconstruction as needed. Postoperative radiation therapy was given in most patients. Adjuvant chemotherapy was used selectively. MAIN OUTCOME MEASURES: Morbidity, local recurrence rates, and survival. RESULTS: Histologically negative margins were obtained in 89 (99%) of 90 patients; 86 (96%) remained free of local disease at follow-up. Five patients died of systemic metastatic disease. CONCLUSION: Excellent local control obtained with aggressive, appropriate surgery followed by radiation therapy in most patients and chemotherapy in only selective high-risk patients leads to excellent survival, with low morbidity and good functional outcome.

Axillary artery injury as a complication of proximal humeral fractures. Two case reports and a review of the literature.

Proximal humeral fractures are commonly seen in orthopedic practice. The vast majority of these fractures are nondisplaced. Infrequently, displaced proximal humeral fractures have associated neurovascular injuries. Injury to the brachial plexus is uncommon; axillary artery injury is rare. This is a report of two displaced proximal humeral fractures in elderly, intoxicated patients following low-energy trauma. Both fractures resulted in axillary artery injury requiring vascular reconstruction. Only nine similar cases were found in a review of the literature. Displaced proximal humeral fractures should be carefully evaluated for vascular injury, and arteriography should be used when necessary. If vascular reconstruction is indicated, the fracture must be internally fixed to prevent redisplacement and potential compromise of the vascular repair. Serial postoperative Doppler examinations are necessary to detect thrombus formation. With prompt diagnosis and treatment, prolonged limb ischemia and its sequelae can be prevented.