High Grade Sarcomas Arising from the Shoulder Girdle
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1 High Grade Sarcomas Arising from the Shoulder Girdle James C. Wittig, MD Associate Professor of Orthopedic Surgery Chief, Orthopedic Oncology Mount Sinai Medical Center
2 General Information Shoulder Girdle is the 3rd most frequent site to be affected by a sarcoma Proximal humerus is more commonly affected than the scapula Proximal humerus is the third most frequent site for an osteosarcoma (15% of all osteosarcomas) Clavicle is very rare site for developing a sarcoma James C. Wittig, MD
3 General Information Proximal humerus: osteosarcoma, chondrosarcoma, Ewing s s sarcoma Scapula: chondrosarcoma, Ewing s s Sarcoma, osteosarcoma, metastatic renal cell carcinoma Most (90%-95%) 95%) high grade sarcomas arise from the metaphysis of the proximal humerus or scapula and present as extracompartmental tumors (extend beyond the bony cortices of the proximal humerus or scapula) James C. Wittig, MD
4 Metaphyseal Origin and Extraosseous Extension James C. Wittig, MD
5 Metaphyseal Origin and Extraosseous Extension James C. Wittig, MD
6 Limb Salvage Historically a forequarter amputation was performed for high grade sarcomas of the proximal humerus and scapula Early 1970s Marcove et al initiated limb sparing surgery and published their results in 1977; Local tumor control was the same as that achieved with a forequarter and a functional hand and elbow were preserved James C. Wittig, MD
7 Limb Salvage Today, 95% of high grade shoulder girdle sarcomas are treated with limb sparing surgery Increasing use of preoperative (induction) chemotherapy and radiotherapy Improvements in surgical techniques and prosthetic designs Advanced imaging modalities (CT, MRI) Better understanding of the local growth and biological behavior of sarcomas James C. Wittig, MD
8 Historical Earliest treatment until the 1970s was a forequarter amputation Debilitating and disfiguring Chronic phantom limb pain James C. Wittig, MD
9 Historical 1977 Marcove et al published their results with limb sparing surgery for 17 patients Standard Tikhoff -Linberg resection for scapula tumors (Extraarticular total scapula resection, lateral clavicle, rotator cuff, deltoid, trapezius, rhomboids, portion of latissimus) Extended-Tikhoff Linberg for proximal humerus tumors James C. Wittig, MD
10 Tikhoff-Linberg Limb-Sparing Resection Clavicle Ewing s Sarcoma Tikhoff-Linberg Type Resection (extraarticular total scapulectomy) Glenoid Humeral Head James C. Wittig, MD
11 Tikhoff-Linberg Inferior Angle of Scapula Deltoid James C. Wittig, MD
12 Extended Tikhoff-Linberg Deltoid Overlying Proximal Humerus Tumor James C. Wittig, MD
13 Modified-Extended Tikhoff-Linberg Pathological study of specimens revealed that it was safe to perform an osteotomy medial to the coracoid process Resections of smaller magnitude Body of scapula remained to facilitate reconstruction James C. Wittig, MD
14 Early Reconstruction Options Proximal humerus stabilized to clavicle or rib (earliest) Flail shoulder Poor strength and stability Traction neuropraxia (brace or sling for support) Poor cosmesis James C. Wittig, MD
15 Early Results James C. Wittig, MD
16 Reconstruction Options Intramedullary rod stabilized to clavicle or rib Hardware failure Painful unstable shoulder Frequent wound complications Traction neuropraxia Poor cosmesis James C. Wittig, MD
17 Wound Complications from IM Rod James C. Wittig, MD
18 Reconstruction Options James C. Wittig, MD
19 Other Reconstruction Options Free vascularized fibulas for fusions: prolonged immobilization, fractures, infections, high complication rates, if succeed lose rotation below shoulder level Allografts and allo-prosthetic composites: abandoned, high infection and fracture rates (performed for intraarticular resections high local recurrence rates); function not better than prostheses despite an intraarticular resection James C. Wittig, MD
20 Rotator Cuff Deltoid Overlies Proximal Humerus Metaphysis of Proximal Humerus Metaphysis of Scapula Capsule James C. Wittig, MD
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23 Local Growth of Sarcomas Sarcomas grow locally in a centripetal manner and form ball like masses Obey fascial borders and grow along the path of least resistance Investing fascial layers of muscles form compartmental borders and form a barrier to tumor penetration; sarcomas rarely penetrate beyond adjacent fascial borders (compartmental borders) Adjacent muscles and their fascial layers are compressed into a pseudocapsule that contains microscopic tumor nodules (satellite nodules) James C. Wittig, MD
24 Compartments of the Shoulder Girdle A compartment refers to a fascial boundary to tumor extension (investing fascial layers of muscles that immediately surround a bone) Space that is bound by fascial borders Functional Anatomic Compartment exists around the proximal humerus and scapula James C. Wittig, MD
25 Compartments of the Shoulder Girdle Proximal humerus: : deltoid, lateral subscapularis and lateral portion of the remaining rotator cuff, coracobrachialis, axillary nerve and circumflex vessels Scapula: Rotator cuff muscles The glenoid and proximal humerus reside within the same functional compartment The subscapularis is a crucial boundary: protects the axillary vessels and brachial plexus from tumor involvement along with the axillary sheath The muscles that form the compartmental borders also form the pseudocapsule of the tumor. Resection of these muscles with the tumor essentially confers a compartmental resection of the tumor James C. Wittig, MD
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27 Local Growth of Proximal Humerus Sarcomas James C. Wittig, MD
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30 Local Growth of Scapular Sarcomas James C. Wittig, MD
31 Extraarticular vs Intraarticular Resection High grade shoulder girdle sarcomas (extracompartmental) routinely contaminate the glenohumeral joint (grossly and microscopically) and readily spread to the apposing articular surface Proximal humerus: deltoid and overlying rotator cuff form the pseudocapsule (satellite nodules) and must be resected for an adequate margin (compartmental resection) Proximal humerus: axillary nerve involved by tumor and must be removed Retention of the glenoid confers no functional benefit with axillary nerve and abductor muscle involvement Extraarticular resection permits medialization, stabilization James C. Wittig, MD and soft tissue coverage
32 Mechanisms of Local Tumor Spread for Sarcomas of the Shoulder James C. Wittig, MD
33 Spread along Biceps Joint Contamination Metaphyseal Origin and Centripetal Growth James C. Wittig, MD
34 Spread Along Rotator Cuff Fracture Intracapsular James C. Wittig, MD
35 Deltoid=Pseudocapsule Fracture and Joint Contamination Satellite Nodule in Deltoid James C. Wittig, MD
36 Soft Tissue Component Across Joint James C. Wittig, MD
37 Soft Tissue Component Across Joint Subscapularis Muscle James C. Wittig, MD
38 Deltoid Involved Tumor Crossing Joint Across Joint James C. Wittig, MD
39 Deltoid Involvement Joint Contamination James C. Wittig, MD Deltoid Involvement
40 Classification of Shoulder Girdle Resections Based on local growth of sarcomas Biological behavior and grade Response to adjuvants Tumor extent James C. Wittig, MD
41 Goals of Resection Oncologically safe procedure Minimal risk of local recurrence (local recurrence in this region is usually treated with a forequarter amputation and local recurrence may adversely effect survival) James C. Wittig, MD
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43 Classical Tikhoff-Linberg James C. Wittig, MD
44 Modified Tikhoff-Linberg James C. Wittig, MD
45 Extended Tikhoff-Linberg James C. Wittig, MD
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47 Goals of Reconstruction Restore shoulder girdle stability Painless shoulder Preserve a functional hand and elbow Maintain motion (rotation) below shoulder level where most activities of daily living are performed A reliable means of reconstruction that will permit prompt resumption of chemotherapy and allow early return to activity/functional use James C. Wittig, MD
48 Methods of Reconstruction Bony Reconstruction Modular Segmental Proximal Humerus Prosthesis Total Scapula Prosthesis (if specific muscles preserved) Nonconstrained Constrained Soft Tissue Reconstruction Static and Dynamic Methods of Soft Tissue Reconstruction James C. Wittig, MD
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51 Radiological Imaging Plain Radiograph MRI CT Angiogram Venogram Bone Scan Thallium Scan CT of Chest James C. Wittig, MD
52 Estimating Response to Induction Chemotherapy Plain Radiograph Arteriogram ( Gold( Standard ) CT scan Quantitative Thallium Scan Quantitative Bone Scan James C. Wittig, MD
53 Estimating Resectability Clinical Triad for an Unresectable Tumor Intractable Neurogenic Pain Motor Loss Venogram demonstrating an obliterated axillary vein Final Decision made after intraoperative Exploration!!! James C. Wittig, MD
54 Resectable Tumor James C. Wittig, MD
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56 Unresectable Tumor James C. Wittig, MD
57 Biopsy Inappropriately Performed Biopsies are Leading Cause for Amputations!!!!! Away from NV Structures James C. Wittig, MD
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59 Proximal Humerus Resection and Reconstruction James C. Wittig, MD
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71 Pectoralis Major Pectoralis Minor Deltoid Overlying Tumor Biceps Short Head Neurovascular structures in Axillary Sheath James C. Wittig, MD
72 Subscapularis Overlying Tumor Musculocutaneous Nerve Deltoid Axillary Nerve Posterior Humeral Circ Vessels Biceps Short Head Latissimus Dorsi James C. Wittig, MD
73 Ligation of Circumflex Vessels and Axillary Nerve Tumor Deep to Subscapularis and Deltoid Axillary Vessels and Brachial Plexus James C. Wittig, MD
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93 Scapulectomy and Total Scapula Reconstruction James C. Wittig, MD
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104 Total Scapula Reconstruction Crucial Periscapular Muscles A Total Scapula Reconstruction is recommended if the axillary nerve and specific periscapular muscles can be preserved Deltoid Trapezius Serratus Anterior Rhomboids Latissimus These are essential for soft tissue coverage, stabilizing and suspending the prosthesis and for providing the necessary muscle force couples to power the prosthesis James C. Wittig, MD
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108 Scapular Design Non-Constrained Components (Earlier Versions) Gore-tex aortic graft for capsular reconstruction Modular Proximal Humerus Axillary Border Superior Border Dacron Tape Gore-tex Aortic Graft Sutured to Scapula Neck James C. Wittig, MD
109 Constrained Total Scapula Prosthesis Facilitate intraoperative attachment Rotator cuff substituting (fixed fulcrum; passively stabilize humeral head in glenoid; improve active motion) Enhance stability James C. Wittig, MD
110 Body Constrained Components Down-sized compared to normal Holes for Myodesis Vacant area scarring of muscles Glenoid Bipolar hip Captured polyethylene liner James C. Wittig, MD
111 Constrained Total Scapula ***SNAP James C. Wittig, FIT MDESIGN***
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113 Prevents Superior Humeral Migration! James C. Wittig, MD
114 Motion Holes for Myodesis of Periscapular Muscles James C. Wittig, MD
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133 Results 89 Patients with high grade sarcomas arising from the shoulder girdle who underwent prosthetic reconstruction 74 proximal humerus 15 scapula Follow-up years (median: 10 years) Most common dx: osteosarcoma, chondrosarcoma and Ewing s s sarcoma James C. Wittig, MD
134 Results Overall Local Recurrence: <5% No patient required a forequarter amputation Subgroup of patients with osteosarcomas (n=43): No local Recurrences 10 patients with pathological fractures: No local recurrence 65% are prolonged survivors James C. Wittig, MD
135 MSTS Scoring System Pain (5=No Pain) Emotional Acceptance (5=Cosmetically acceptable) Function (3-4: All ADLs but can not participate in high level athletic activities) Hand positioning (3-4: Not unlimited but can position above shoulder) Dexterity (5: Normal Hand Dexterity) Lifting Ability (3-4: Virtually Normal) Score: 24-27/30 27/30 points James C. Wittig, MD
136 Results All survivors are pain free with a stable shoulder All can carry out ADLs with operative extremity No braces required Virtually normal hand and elbow function; Biceps strength: Grade 4+ MSTS score of (80%-90%) Abd/FF: IR: Normal; ER: to Neutral (Improved with latissimus dorsi transfer) Kaplan-Meier Survival at 10 years: 95%-100% James C. Wittig, MD
137 Complications Transient Nerve Palsy: 12% (All in patients who received preoperative chemotherapy) Skin Necrosis and Wound Infection: 2% (No prosthesis required removal) Aseptic loosening: 1%-2% 1 glenohumeral dislocation of a total scapula No instability with proximal humerus reconstructions No traction neuropraxia James C. Wittig, MD
138 Summary Extraarticular resection including the muscles that form the pseudocapsular layer is a reliable method of resection for high grade shoulder girdle tumors that present with an extraosseous component. It provides an oncologically safe margin. Reconstruction with proximal humerus and total scapular prostheses and with static and dynamic methods of soft tissue reconstruction provides a durable method of reconstruction and restores a functional, pain free and stable extremity James C. Wittig, MD
139 Thank You! James C. Wittig, MD
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