Beruflich Dokumente
Kultur Dokumente
Supportive Care & Survivorship, University of Arizona Cancer CenterPhoenix, St. Josephs Hospital and Medical Center, Phoenix, Arizona
Oncology Pain & Symptom Management, Helen F. Graham Cancer Center and Research Institute, Christiana Care Health System, Newark,
Delaware
3
Clinical Associate Professor, Department of Rehabilitation Medicine, Jefferson Medical College, Philadelphia, Pennsylvania
Although relatively rare, soft tissue sarcomas cause signicant morbidity and mortality due to their advanced stage at initial diagnosis.
Rehabilitation and surgical outcomes have traditionally focused on physical parameters to assess function and recovery, emphasizing return to
ambulation, activities of daily living (ADLs) and community re-integration. Assessments of functional impairment and other quality-of-life
parameters are necessary to better understand the experience of the patient with extremity soft tissue sarcoma and thereby improve outcomes.
KEY WORDS: soft tissue sarcoma; prehabilitation; limb salvage; amputation; quality-of-life; rehabilitation
INTRODUCTION
Soft tissue sarcomas account for slightly over 20% of pediatric solid
malignancies and <1% of all adult solid malignancies [1] and are more
prevalent than malignant bone tumorsaccounting for almost 87% of
all sarcomas versus 13% being malignant bone tumors [1,2]. More than
50% occur in the extremities [3,4]. In 2014, the estimated new number
of cases of sarcomas in the United States is over 12,000 and
approximately 4700 people will die this year from these [46].
Estimated ve-year survival rate at time of diagnosis for those with
localized sarcomas is 83% and 54% if regional lymph node spread is
present. For those patients with distant metastases, the ve-year
survival rate is 16% [4,6,7]. Mean age at diagnosis of soft tissue
sarcomas was 58 and mean age at death was 65; the incidence has a
dramatic increase in people over the age of 50 [1].
*Correspondence to: Dr. Kerry Tobias, DO, Supportive Care & Survivorship University of Arizona Cancer Center Phoenix 500 W, Thomas Road,
Suite 720, Phoenix 85013, AZ. Fax: 602-406-6242.
E mail: Kerry.tobias@att.net
Received 3 June 2014; Accepted 3 October 2014
DOI 10.1002/jso.23830
Published online 21 November 2014 in Wiley Online Library
(wileyonlinelibrary.com).
616
REHABILITATION PROGRAMS
The rehabilitation course after acute surgical inpatient care and postsurgical rehab may continue with either a transfer to a comprehensive
acute rehabilitation facility, subacute rehabilitation facility,
continuation with rehabilitation at home, or initiation of outpatient
rehabilitation. Utilization of more than one of these programs may be
necessary depending on any acute medical issues that arise and
trajectory of recovery medically. Decisions regarding the location of
care are impacted by availability within a center or a community, the
cost and source of payment, and patient/family social factors.
Comprehensive rehabilitation programs seek to maximize quality of
life in sarcoma patients through recovery of physical function and
adaptation of the patient and their physical environs in order to attain
greater independence. A comprehensive team consists of a physical
therapist, prosthetist, occupational therapist, recreational therapist,
nurse, wound/ostomy care specialist, social worker, chaplain,
nutritionist, rehabilitation physician (physiatrist), and psychologist.
These teams provide care during the inpatient phase of rehabilitation in
a structured, efcient and cohesive strategy. This team can also tailor an
outpatient program to be continued by the patient when discharged from
inpatient care [10].
Rehabilitation programs in hospitals afliated with cancer centers
may provide continuity of care once a patient is discharged. Outpatient
rehabilitation programs within a cancer center provide better access to
patients for ongoing rehabilitation needs as continued surveillance and
followup appointments with their oncologists and surgeons typically
take place there. Patients often experience burnout and fatigue from the
frequency of medical appointments they must attend, especially during
the course of radiation treatments. A patient, therefore, may be more
amenable to attending outpatient rehab therapies if this care is within the
cancer center itself. Compliance with therapy will promote better
outcomes with function and recovery.
REHABILITATION PHASES
Prehabilitation
Typically, patients have not been seen or assessed by a physiatrist or
therapists much less by an entire rehabilitation team prior to surgery.
However, consideration by the surgical team for referral to a physiatrist
skilled in cancer rehabilitation can begin the process of adequate
rehabilitation prior to planned surgery. This referral and early
intervention is now referred to as prehabilitation [11]. This is
initiated prior to cancer therapy to assess: baseline level of function,
prior physical decits or weakness, evaluation of current medical status
and any comorbidities that may affect a patients tolerance to surgery
and postop course, review plan of postsurgical treatment (radiation and/
or chemotherapy), cardiovascular health and baseline endurance (e.g.,
need to take into account increased energy expenditure for level of
amputation) [11]. Pre-existing medical conditions should be assessed,
as well, in the prehabilitation phase. These can include evaluation for
pre-existing osteoporosis, underlying cardiovascular or pulmonary
disease or decits, history of deep vein thrombosis (DVT)/pulmonary
embolus (PE) and current anticoagulation status (including presence of
inferior vena cava [IVC] lter or not), anemia, and thrombocytopenia.
Consideration of a patients current stage of disease is necessary to
guide rehabilitation goals and whether a patient has metastases at
presentation or if there is a high likelihood of recurrence predicted.
Although not traditionally included when one considers
prehabilitation, attention should be paid to a patients home
environment prior to surgery and assessing feasibility of returning to
that environment with or without modications. Assessment of the
patients vocation and possibility of return to work and specic physical
tasks their job entails is benecial. Recreational activities and social
responsibilities, including child- or elder-care are important
components of their psychosocial milieu. For example, ones ability
to return to driving may signicantly promote independence and
autonomy, whereas another individual may value this less highly. The
impact of the patients possible disability upon family responsibilities
may be overwhelming. Anticipation of these issues will help
psychosocial function and promote quality of life throughout the
course of sarcoma care.
Assessment by a physical therapist, occupational therapist, and
lymphedema therapist may be enlisted as well prior to surgery if preexisting decits are noted. Then, accordingly, proper anticipation and
tailoring of the patients specic rehabilitation program may be put in
place. For instance, a lymphedema therapist may be enlisted in the
prehabilitation phase to evaluate any pre-existing lymphedema present.
Pre-surgical or pre-radiation manual lymph drainage and compression
bandaging to optimize lymph control and minimize post-operative
infection risk may be helpful. Planning for compression garment use
intraoperatively or peri-operatively may also diminish the risk of
postoperative lymphedema exacerbation.
Another example of prehabilitation can be demonstrated in a patient
with cardiovascular disease. Understanding the pre-treatment level of
function and existing tolerance for sustained exercise and activities of
daily living (ADLs) is needed. The patient may be a candidate for pre-
Postsurgical Management
Location of the sarcoma itself and involvement of surrounding
structures (muscles, fascial planes, vasculature, lymphatics, and nerves)
guide the surgery proposed and eld of excision. Discussion of the
proposed procedure(s) with the surgeon prior to surgery would be ideal
to anticipate immediate post-op decits that can be addressed by the
inpatient rehabilitation team. For instance, proximity of excision(s) to
nerve plexi lends special consideration to motor and sensory decits
likely to result and which can be addressed early on. Proximity of the
tumor to lymph nodes and whether lymphadenectomy will be a
component of proposed surgery, or radiation therapy, will drive
consideration of post-op edema control, but also the possibility of
developing long-standing, chronic lymphedema which will need to be
addressed.
Early rehabilitation post-surgery depends on immediate surgical postop condition and recovery. Type of surgery and restrictions regarding
weight-bearing and limitations in range-of-motion will be dictated by the
surgeon and affect immediate therapies that can be started. For instance, a
patient undergoing internal hemipelvectomy may have restricted weightbearing of several months; a patient with an external hemipelvectomy
will typically be ambulating within days with an assistive device.
Complex reconstructions, skin grafts, and myocutaneous ap closures
may also limit limb mobility. Brachytherapy catheters may preclude early
mobilization.
Immediate post-op issues are mainly symptom-based and couched in
controlling these adequately for comfort. A challenging early issue will
be post-surgical pain which can physically impede ability to participate
in physical therapy and perform even simple tasks such as range-ofmotion (ROM) activities and bed mobility. Chronic pain issues can
develop as well as phantom pain. In addition to deterring a patients
physical performance of therapy goals immediately post-op, pain can
also lead to depression and despondency regarding potential recovery
and, again, affect a patients participation in therapies. Fear of
overwhelming and unmanaged pain can impede a patients willingness
to move.
Other physical symptoms can be present in the immediate post-op
period, necessitating coordination between therapists, rehabilitation
specialists, nursing and the surgical team, such as: nausea, postoperative ileus, opioid-associated constipation, insomnia, and fatigue.
Fatigue may be multifactorial and due to the cancer itself, poor
nutritional status, lack of adequate sleep, and depression or difculty
coping due to body image changes and grief over loss of limb or body
part.
Weight-bearing restrictions and length of time these need to
be maintained should be claried with the surgical team. These
also need to include weight-bearing for upper extremity, as
limitations for this can signicantly affect bed mobility, transfers,
and ADLs.
Vigilant wound care and adherence to limitations must be
maintained during initial healing. After the initial dressing is
unwrapped, frequent wound inspection should occur as well as
patient education on signs of infection and inspection and care of
insensate areas. Pressure relief to reduce risk of breakdown on typical
sites (coccyx, ischii, bular heads, and heels) as well as at-risk sites
caused by special positioning, casting or bandaging is reviewed with
nursing staff, patient and caregivers.
Journal of Surgical Oncology
617
618
Procedure
Forequarter amputation
Limb salvage
Humerus
Proximal transhumeral
amputation
Distal transhumeral
Limb salvage
Forearm
Transradial amputation
Pelvic Girdle
Limb salvageinternal
hemipelvectomy
Prosthesis considerations
Transfemoral amputation
(AKA)
Limb Salvage
Tibia/Fibula
Limb salvage
Monohanded
Allograft
Femur
Orthosis options
See above
WHO
AFO
APC, allograft prosthesis composite; ROM, Range of motion; AKA, above-the-knee amputation; BKA, below-the knee amputation.
a
Gokaraju K, Sri-Ram K, Donaldson J, Parratt MTR, Blunn GW, Cannon WR, Briggs TWR.Use of a distal radius endoprosthesis following resection of a bone tumour:
A Case Report. Sarcoma, Volume 2009 (2009), Article ID 938295, 5 pages.
b
Houdek, MT, Kralovec, ME, ANdress, KL. Hemipelvectomy: High-level amputation surgery and prosthetic rehabilitation. Am. J. Phys. Med Rehabil. Vol. 93, No. 3,
March 2014, pp. 18.
c
Oren R, Zagury A, Katzir O, Kollender Y, Meller I. Principles of rehabilitation after limb-sparing surgery for cancer. In Malawer M, Sugarbaker PH (eds):
Musculoskeletal Cancer Surgery. Dordrecht/Boston/London: Kluwer Academic Publishers, 2001: 584591.
Increase (%)
MET
50
928
4065
41100
75
280
82
125
75
45
3.33.8
4.25.8
4.26.0
5.3
11.4
5.5
6.75
5.3
AK, above knee; BK, below knee; MET metabolic equivalent tasks.
a
Based on percentage increase above cost of normal (3 METs).
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CANCER RECURRENCE
Spread is via vascular system rather than lymphatic system so numeric
staging has different connotations for prognosis and severity than it does
for carcinomas. Majority of metastases occur in lungs. Recurrence rates
can range from 16% to 45%, depending on whether a patient has received
a referral to a specialized sarcoma treatment center [4].
Recurrence can occur locally at the previously resected site or may
appear in other bony structures close by or may manifest as pulmonary
metastases or both. Pain may be the rst sign of recurrence and can occur
during rehabilitation depending on the aggressive nature of the sarcoma.
It is crucial that any new pain or increased pain at previous surgical site be
assessed to discover whether this is due to recurrence versus increased
pain due to biomechanical factors on surrounding structures (i.e.,
increased stress on unused muscles required for altered gait or upper
extremity ROM), or due to development of phantom limb pain.
620
CONCLUSION
Rehabilitation of soft tissue sarcoma patients ideally begins before
any surgery takes place so an adequate assessment of pre-morbid
function, medical issues, and social and environmental habitats is
included in tailoring an adequate rehabilitation program. This then
continues in the immediate post-op period and through the continuum
of recovery whether with transfer to further inpatient rehab or
outpatient rehabilitation. Adequate cognizance of possible sequelae
and complications from surgery need to be managed as well as these
can affect an adequate rehabilitation course. These can include
continued or chronic pain or phantom limb pain, fatigue, depression,
skin breakdown, anemia, electrolyte abnormalities, bowel/bladder
dysfunction, or poorly controlled edema or lymphedema. These
complications can all severely impact rehabilitation and patients
participation in rehabilitation and may lead to long-term disability
from their surgery and cancer.
Although optimizing physical function of patients after surgical
resection for extremity soft tissue sarcomas is necessary to achieve as
much independence and premorbid activity level as possible, quality
rehabilitation programs need to look beyond the physical parameters of
measurement as represented by the Barthel Index, FIM score, MSTS,
TESS systems, etc. Physical functioning is just one aspect of recovery
and psychosocial functioning needs to be emphasized as well.
Through a model of multidisciplinary rehabilitative care, emphasis
can be placed on how patients need to function within their own specic
environments. Psychological, emotional, spiritual, vocational, and
nancial issues can be addressed by skilled members of the
rehabilitation team to help a patient achieve optimal quality of life
and function.
REFERENCES
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epidemiology of sarcoma. Clin Sarcoma Res. 2012;2:14.
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Regs Research Data, Nov 2010 Sub (19732008) Katrina/Rita
Population AdjustmentLinked To County Attributes - Total U.S.
19692009 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released
April 2011, based on the November 2010 submission.
3. Wibmer C, Leithner A, Zielonke N, et al.: Increasing incidence
rates of soft tissue sarcomas? A population-based epidemiologic
study and literature review. Ann Oncol 2010;21:11061111.
4. National Cancer Institute: PDQ1 Adult Soft Tissue Sarcoma
Treatment. Bethesda, MD: National Cancer Institute. Date last
modied 02/28/2014. Available at: http://cancer.gov/cancertopics/pdq/treatment/adult-soft-tissue-sarcoma/HealthProfessional
Accessed 05/28/2014.
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