EXTENDED FORE QUARTER AMPUTATION AND CHEST WALL RESECTION FOR TREATMENT OF EXTENSIVE MALIGNANT TUMOURS AROUND THE SHOULDER

Abstract

Resection of the upper limb together with the shoulder girdle is known as forequarter amputation. In selected patients, this type of resection may have to be extended to a resection including parts of the thoracic wall in order to achieve local tumour control in advanced stages of neoplasms. Although, forequarter amputation alone is well described, reports on its combination with parts of the chest wall only consist of few case reports, while larger experiences and systematic reviews of its obstacles and complications are missing.

A series of six patients, five females and one male with, average age 58 years (range 41 to74 years), undergoing forequarter amputation with partial chest wall resection has been treated for malignancies around the shoulder at the Medical University of Vienna since 1993, thereby, to our best knowledge, presenting the largest series published to date. Patient data of all departments involved were retrospectively analysed and patients were followed-up according to standard oncological protocols. The underlying disease was malignant schwannoma in two, undifferentiated sarcoma in two, osteosarcoma in one and squamous cell sarcoma in one. A vast tumour of the shoulder and axillar space, uncontrollable pain, lymphedema, partial loss of function of the affected limb and ulceration indicated treatment.

All patients underwent radical amputation of the upper limb and all structures of the shoulder girdle including two to seven ribs. Chest wall reconstruction was achieved by a PTFE patch alone or in combination with a Stratos^®-implant. Myo-cutaneous reconstruction was performed by a pedicled (n=3) or a free myo-cutaneous forearm flap (n=3). There were no cases of peri-operative mortality. In two patients full forearm flap necrosis occurred and indicated two revisions in each with coverage by a free flap. One patient suffered vascular complications and underwent five revisions. Average follow-up was 14 months (range 5 to 35 months). Median survival was 8.5 months, with three patients still alive at the time of this investigation. Three patients died of systematic metastatic disease between 5 and 35 months after surgery. Two patients were successfully supplied with myo-electrical prostheses.

The key issues for surgical management of the resulting defect were

1. the restoration of mechanical chest wall stability,

2. a sufficient myo-cutaneous flap, preferably a free pedicled flap as it seemed more efficient than the free extremity flap and

3. the management of concomitant complications such as paralysis of the phrenic nerve, chylothorax and post-operative pain.

Although forequarter amputation is a mutilating operation and in advanced stages of disease certainly can only temporarily limit disease progression, in selected cases, it may remain an option in vast tumours of the shoulder girdle.