Sarcoma in the Forearm and Hand: Clinical Outcomes of 26 Cases and Microsurgical Reconstruction for Limb Salvage

Introduction: Sarcomas in the forearm and hand are very rare, accounting for <1% of all upper limb tumors and clinical outcomes after surgery and adjuvant therapies have been unclear. The forearm and hand present specific challenges due to their unique anatomical structure. There is little soft tissue and each compartment is narrow so that important structures exist in close proximity. Anatomic constraints make it difficult to achieve wide surgical margins. The aim of the current study was to examine oncological outcome, microvascular reconstruction and functional evaluation in patients who underwent wide resection for sarcoma.

Methodology and Material: A retrospective review was performed in 26 patients who were treated for soft tissue (18) or osseous sarcoma (9). The most common pathologic subtype of soft tissue sarcoma was malignant fibrous histiocytoma, while chondrosarcoma was most common in the hand. Tumor staging was based on the Enneking guidelines. At initial presentation, 1 patient was considered as stage IA, 6 as stage IB, 11 as stage IIA, 7 as stage IIB, and 1 as stage III based on the presence of lung metastasis. The mean period of follow-up was 87 months and ranged from 12 to 204 months.

Results: All 17 patients with sarcoma in the forearm were treated with limb-salvage and needed microvascular reconstruction. Flap survival was excellent, although three patients had vascular complications requiring immediate rescue surgery. Local recurrence occurred in 4 patients, 3 of which had previously undergone inadequate resection in other hospitals. Three patients had distant recurrence and one died of disease at 38 months after surgery. The 3-year disease specific survival rate in 17 patients was 100% and 5-years in 9 patients was 88%. The mean Enneking functional score for the upper limb was 25 (83%) and ranged from 20 to 30 points at a mean follow-up period of 37 months.

Conclusions: Although sarcomas in the forearm and hand often metastasize to the lung, the overall survival rate is excellent. Wide marginal resection during initial surgery is the most predictive factor for tumor control. Careful pre-operative planning with anticipation of all resected structures can improve patient outcome. Multiple options exist for bony and soft tissue reconstruction of the upper limb, with the choice dependent upon tumor type, wound characteristics, surgeon preference and the patients’ functional requirements. Microvascular cutaneous, myocutaneous or osteocutaneous flap reconstruction is essential for limb salvage and provides reliable, safe coverage with reasonable preservation of function.