SLR - December 2020 - Sahar Zaidi

Patient Reported Functional Outcomes in a Cohort of Hand and Foot Sarcoma Survivors Treated with Limb Sparing Surgery and Radiation Therapy

Reference: Ahmed SK, Kaggal S, Harmsen WS, Sawyer JW, Houdek MT, Rose PS, Petersen IA. Patient-reported functional outcomes in a cohort of hand and foot sarcoma survivors treated with limb sparing surgery and radiation therapy. J Surg Oncol. 2020 Oct 30. doi: 10.1002/jso.26258. PMID: 33125739.

Level of Evidence: Level IV

Scientific Literature Review

Reviewed By: Sahar Zaidi, DPM
Residency Program: Montefiore Medical Center – Bronx, NY

Podiatric Relevance: The ability to identify a rare sarcoma and direct timely referral in the lower extremity is paramount to patient care as a podiatric physician. The standard of care has moved from amputation to limb sparing and radiation therapy (LSS+RT) for several sarcomas based on their clinical and histological characteristics. There are historic studies that compare functional outcomes of LSS+RT when it comes to extremity sarcoma, however hand and foot sarcomas are often grouped together skewing results. This study aimed to capitalize on that limitation by obtaining and describing patient reported outcomes following LSS+RT rather than amputation in hand and foot sarcomas. 

Methods: Thirty hand and 24 foot sarcomas were identified treated at the Mayo clinic from 1991-2015. Survivors > 18 years of age without subsequent amputation of the extremity were asked to complete self assessed functional surveys. Hand surveys consisted of the Michigan hand outcomes (MHQ) and the Toronto upper extremity salvage score (TESS). For the foot, the foot and ankle outcomes survey (FAOS) and the Toronto lower extremity salvage score survey (TESS) were used. The results were based off the TESS questionnaires as this was the survey utilized in previous studies. All answers were converted to scaled scores from zero to 100. Tumor control and survival rates were defined using standard oncology scales utilizing time from initial sarcoma diagnosis. 

Results: The most common sarcomas were synovial sarcomas and Leiomyosarcomas. All patients had limb sparring procedures and all patients received radiation therapy. Five-year local tumor control and overall survival rates were 88 percent and 93 percent. Twelve patients were excluded due to subsequent amputation or death. There were 14 hand and 14 foot sarcomas that returned surveys. For hand sarcoma survivors, the mean TESS score was 89.4. For foot sarcomas the mean TESS score was 92.4. The mean FAOS score was 46.19 for core outcome and mean shoe comfort FAOS score was 53.1. The authors reported no correlation between survey outcome and patient factor or treatment factor.

Conclusions: The authors’ study is the largest cohort study to specifically look at foot and hand sarcomas and patient reported functional outcomes. The study reinforces the idea that LSS+RT can lead to excellent oncologic and functional outcomes as reported by patients. The authors give credence to patient quality of life and make a valuable distinction between discussing amputation of a lower leg versus foot as well as upper extremity versus hand. Although the sample size of the study is small, given the rare nature of the diagnosis it is acceptable. The authors note the surveys used in this study as well as historical studies do not fully assess functional disability to a patient. This opens the door for further research to be conducted on standardized surveys addressing the missing categories. With this evidence-based study, physicians have an empathetic way to discuss a debilitating diagnosis with their patients while providing necessary support to maintain their quality of life. 

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