|Year : 2015 | Volume
| Issue : 2 | Page : 78-81
Pattern of malignant extremity tumors: A review of 58 patients
MK Abubakar1, KM Adamu1, AA Mamuda1, AA Sheshe2
1 Department of Surgery, Orthopedic, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of General Surgery Units, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||16-Jun-2015|
Dr. M K Abubakar
Department of Surgery, Orthopedic Unit, A.K.T.H, P.M.B, 3452, Kano
Source of Support: None, Conflict of Interest: None
Background: Malignant extremity tumors are relatively common in the orthopedic and general surgery units. However there is no study that describes the pattern and outcome in our Kano north central Nigeria. The Objective of this study was to determine the pattern of malignant extremity tumors and the outcome of management.
Patients and Method: All malignant extremity tumors that were managed between 1 st January 2008 and 31 st December 2012 in the Orthopedics and General Surgery units of Aminu Kano Teaching Hospital, Kano were recruited for the study. Information was extracted from records of these patients.
Results: Of the 58 patients in the sturdy, 32 (55.2%) were males and 26 (44.8%) were females. The age range was 2-80 years. The mean age of the patients was 32.08 years. 41 (70.6%) patients had lower limb malignancies while 17 (29.3%) had upper limb malignancies. Soft tissue sarcoma has the highest prevalence (37.9%). Excision biopsy or wide local excision (53.4%) and amputation or disarticulation (51.7%) was the commonest surgical procedure done.
Conclusion: Lower extremity malignancies are the commonest. They are commoner in males. Soft tissue sarcoma and malignant skin tumors are more common than malignant bone tumors of the extremities.
Keywords: Amputation, disarticulation, malignant extremity tumor, soft tissue sarcoma
|How to cite this article:|
Abubakar M K, Adamu K M, Mamuda A A, Sheshe A A. Pattern of malignant extremity tumors: A review of 58 patients. Arch Int Surg 2015;5:78-81
| Introduction|| |
Extremity tumors are diverse and multivariate depending on tissue of origin. Malignant extremity tumors may be primary or secondary. Malignant tumors arise from tissues of ectodermal, mesoderm, or endodermal origin and have the potential to spread or invade to other parts of the body. Thus, may give rise to malignant melanoma or squamous cell carcinoma in the skin. Soft tissue sarcoma may develop from muscles, blood vessels, nerves, or tendon; while osteogenic sarcoma arises from bone. Musculoskeletal tumors are rare.  Soft tissue sarcoma has an annual incidence of 2 per 100,000, while primary bone tumors have an annual incidence of 1 per 100,000.  There is a general male preponderance. Primary malignant tumors may be curable if the patient presents early and prompt intervention instituted.
Despite advances in treatment modalities, surgery still remains the main treatment modality. However, the trend now is to strive for limb salvage procedures. The objective of this study is to determine the pattern of distribution of malignant extremity tumors and the outcome of management of these malignancies.
| Patients and Methods|| |
The study is a retrospective one that involved retrieval of folders belonging to patients with malignant extremity tumors and subsequent extraction of data from the patient's records. All patients that had surgery done for histologically diagnosed malignant tumors of upper or lower extremities, seen and managed by the orthopedic and general surgery unit from 1 st January 2008 to 31 st December 2012 were included for the study. Patients with benign tumors or incomplete records were excluded.
Information extracted from the records includes demographic characteristics, disease chronology, tumor distribution, histological diagnosis, type of surgery, anesthesia, and status at follow-up. Data were analyzed using Epi-info 7.1.4 version software.
| Result|| |
Records of 63 patients were retrieved; however, only 58 patients had adequate information for the study. Thirty-two were males and 26 were females. The ages of the patient ranged from 2 to 80years. The mean age was 32.08 ± 4.07 years. The regional distribution of the tumors is given in [Table 1]. The duration of tumor as noticed by the patient at presentation was <6 months in nine (15.5%) patients, 7-12months in 18 (31%) patients, 13-18 months in six (10.3%) patients, 19-24 months in six (10.3%) patients, and 19 (32.7%) patients presented after 24 months of commencement of symptoms. The histological diagnosis is presented in [Table 2].
The surgical intervention carried out depends on the stage of the tumor. Wide local excision in our study means a margin of excision was at least 5 cm from the visible tumor margin. [Table 3] shows the various surgical interventions done.
Twenty-four patients had surgery done under spinal anesthesia, 30 had general anesthesia, while 14 patients had surgery using local anesthesia. Five patients had multiple surgeries done. This explains why the total number of procedure is 68 against the 58 patients that were studied. The average duration of hospital admission for the 58 patients was 4 weeks.
Of the 58 patients in the study, 12 (20.6%) made full recovery. Twenty patients had various morbidities as a result of the surgical intervention as follows: 15 (25.8%) patients had residual amputation stump tumor, three (5.1%) patients had foot drop, and two (3.4%) patients had wrist drop. Ten (17.2%) patients died during the cause of treatment, two (3.4%) patients were discharged against medical advice, seven (12%) patients were lost to follow-up as there was no record indicating that they were either seen, discharged, or referred after at least one follow-up visit, and 7 (12%) patients were referred for radiotherapy. The outcome is presented in [Figure 1].
| Discussion|| |
Of the 58 patients in this study, the ratio of male to female was 1.2:1. This correlates with the preponderance of male over female of both soft tissue sarcoma and bone tumor as reported by Yusuf et al.,  and Wamisho et al.  This is also consistent with other studies carried out globally. , The peak distribution of both soft tissue sarcoma and malignant bone tumor of the extremity was 21-40 years followed by 0-20 years. This is consistent with the generally higher incidence of soft tissue sarcoma and bone tumors in the younger age group. The findings of ourstudy agree with the findings of Mohammed and Isa  who found a peak age incidence of osteosarcoma in the 3 rd decade.
In our study, the lower limb accounted for the highest incidence (41, 70.6%) of tumors. This is consistent with studies carried out by Gerrand et al.  Gogi and Ramanujam also showed a higher incidence of soft tissue sarcoma in the lower limb. It also conforms to the finding of other authors , who had higher incidence of bone tumors in the lower extremity. The higher incidence of lower extremity tumor conforms to most global studies. ,, From the literature review we did not get any study to compare side distribution of extremity malignancies. So there is no direct reason to explain why right side tumor is more common than left side tumors in both extremities.
We found that majority of our patients presented late from the time of initial symptoms. Most of the patients present after 6 months. The delay in presentation could be attributed to the painless nature of most musculoskeletal tumors. Other reasons include initial presentation to other facilities including alternative medical practitioner, ignorance, and poverty. There was significantly more delay before presentation among females probably because females have to obtain permission before they go to hospital. This correlates with what Schnur et al., found in their study.  Symptoms interval ranges from 1 month to more than 2 years in osteosarcoma. This is similar to what Goyal et al.,  and Ilaslan et al.,  reported in their studies.
Thirty-two patients had spinal anesthesia for their surgery. All had lower limb malignancies. Thirty patients had general anesthesia, while eight patients had local anesthesia. Our choice of anesthesia was guided by the location of the tumor, clinical state of the patient, and the preference of the patient. All these considerations were made with the collaboration of the anesthetics. Five patients had multiple surgeries where the initial excision was followed by amputation. Principally all patients had surgery. Patients with histological confirmation of metastasis had either chemotherapy or were referred for radiotherapy. Excision biopsy or wide local excision was carried out in tumors that were small, well-circumscribed, and intracompartmental. Seven patients had debulking or incision biopsy and subsequently chemotherapy. Fifteen patients had amputation, while five had disarticulation done. These have been recommended as a standard way of treatment of soft tissue sarcoma, bone tumor, and skin cancers. ,
As depicted in [Table 2], we found a higher incidence of soft tissue sarcoma compared to osteosarcoma. The types of soft tissue sarcoma we got were: Rhabdomyosarcoma, fibrosarcoma, synovial cellsarcoma, and angiosarcoma. In the skin, malignant melanoma and squamous cellcarcinoma were seen in 14 and 12 patients, respectively. Incidentally, two patients had clinical and histological features suggestive of malignancy that could not be attributed to a specific site, hence defined as malignancy of undefined origin.
Twelve (20.68%) of our patients made full recovery without any residual morbidity. Twenty (34.48%) had morbidity after treatment. Ten (17.24%) patients died during the cause of treatment. We could not account for the outcome of management in 16 patients as they were either lost to follow-up, discharged against medical advice, or never returned to us having been referred for radiotherapy.
| Conclusion|| |
Malignant extremity tumors are among the commonest musculoskeletal tumors. The lower limb accounted for the highest incidence. They are commoner in males. Soft tissue sarcoma and malignant skin tumors are more common than malignant bone tumors of the extremities. Most of our patient present late. This may be due to the fact that most tumors are initially painless so patients may not be disturbed at the early phase. There is the need to educate the public on importance of early presentation.
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[Table 1], [Table 2], [Table 3]