Next Article in Journal
Does the Location of Oral Lesions in Oral Lichen Planus Allow Predicting the Outcome of Its Histopathological Examination?
Previous Article in Journal
Lipopolysaccharide-Binding Protein (LBP) and Inflammatory Biomarkers in SARS-CoV-2 Hospitalized Patients
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JCM
Volume 14
Issue 12
10.3390/jcm14124074
jcm-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Secondary Amputation After Failed Limb-Salvage Surgery Shows Comparable Long-Term Oncological Outcomes to Primary Amputation in Extremity Sarcoma: A 5-Year Follow-Up Study

by
Ortal Segal
1,*,†,
Guy Ben Arie
1,*,†,
Solomon Dadia
2,
Ofer Marimsky
3,
Assaf Albagli
4,
Yair Gortzak
1,
Amit Benady
2 and
Ben Efrima
4
1
National Department of Orthopaedic Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
2
Levin Center for 3D Printing and Surgical Innovation, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
3
Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv 6423906, Israel
4
Department of Foot and Ankle, Orthopaedic Surgery Division, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
*
Authors to whom correspondence should be addressed.
†
These authors contributed equally to this work.
J. Clin. Med. 2025, 14(12), 4074; https://doi.org/10.3390/jcm14124074
Submission received: 31 March 2025 / Revised: 3 May 2025 / Accepted: 2 June 2025 / Published: 9 June 2025
(This article belongs to the Section Orthopedics)
Versions Notes

Abstract

Aims: Extremity sarcomas (ES) are rare, aggressive malignancies requiring complex surgical decisions. While limb-salvage surgery (LSS) is the preferred treatment to preserve functionality, local disease progression can necessitate secondary amputation. The oncological outcomes of secondary amputation compared to primary amputation remain uncertain, particularly with long-term follow-up. This study aimed to compare overall survival (OS), metastasis-free survival (MFS), local recurrence-free survival (LRFS), and postoperative complications between ES patients undergoing primary amputation (V1) and those requiring secondary amputation after failing LSS (V2), with a minimum follow-up of five years. Methods: A retrospective review was conducted at a national sarcoma center, including 71 patients treated between 2007 and 2017. Patients were categorized into V1 (n = 28) and V2 (n = 43) groups. Clinical and oncological data were collected from medical records and imaging, including tumor stage, surgical margins, and postoperative complications. All patients were followed up for a minimum of five years or until death. Kaplan–Meier survival analysis was performed to evaluate OS, MFS, and LRFS. Results: OS was 25% in the V1 group and 39.5% in the V2 group (p = 0.6). MFS (10.5 months, p = 0.2) and LRFS (27.4 vs. 34.4 months, p = 0.6) were comparable between groups. Postoperative complications occurred in 34.9% (V1) and 32.1% (V2) of patients, with infections being the most common complication. Patients with complications exhibited shorter MFS (p = 0.029). Negative surgical margins were achieved at 96.4% (V1) and 97.6% (V2). Conclusions: Secondary amputation following failing LSS demonstrates similar oncological outcomes to primary amputation, even with a minimum follow-up of five years. These findings support LSS as the preferred initial approach for ES patients. Postoperative complications associated with reduced MFS underscore the need for rigorous postoperative protocols. A multidisciplinary approach remains essential for optimizing long-term outcomes.

1. Introduction

Sarcomas are rare and aggressive malignant tumors, accounting for approximately 1% of all adult cancers. More than 50% of sarcomas occur in the extremities, with over 70% located in the lower limbs. The prognosis for extremity sarcomas (ES) depends on several factors, including patient age, preexisting medical conditions, tumor size and grade, histological subtype, lymph node involvement, and metastasis. Overall, sarcomas have a poor prognosis, with a five-year survival rate of around 50%. A key factor for optimizing overall survival (OS) is tailoring patient-specific surgical treatment that incorporates achieving negative surgical margins while maximizing limb functionality.
Limb amputation (AS) for ES was introduced in the 19th century, and, for many years, was the gold standard of treatment. However, it was associated with high mortality rates and poor functional outcomes. With the advent of multidisciplinary approaches, including neoadjuvant and adjuvant chemotherapy, radiotherapy, advanced imaging, and improved surgical techniques, the treatment paradigm has shifted toward limb-salvage surgery (LSS), which sometimes has its complications, such as local disease progression. Today, AS is generally reserved for cases where obtaining tumor-free margins with LSS is impossible, where limb functionality cannot be preserved, for palliative care, or for secondary amputation in LSS patients suffering from local disease progression.
The current consensus advocates LSS as the primary option. However, some studies argue that this trend may have shifted too far, and the possibility of secondary amputation after LSS and its risks should be factored into the decision-making process. With ongoing advancements in treatment, it is essential to reassess the surgical decision-making process periodically. Our study hypothesized that LSS resulting in local disease progression and subsequent secondary amputation yields different oncological outcomes compared to primary amputation. This single-center study, conducted at a national sarcoma center over the course of a decade, aims to compare OS, local recurrence-free survival (LRFS), metastasis-free survival (MFS), and complication rates between primary and secondary AS. Additionally, the study evaluates the impact of surgical margins and type of amputation on prognosis.

2. Materials and Methods

2.1. Patient Selection

This retrospective study was conducted between January 2007 and December 2017 at a national sarcoma center and was approved by the institutional review board. A total of 71 consecutive patients were included. The inclusion criteria were sarcoma patients over the age of 18 who were treated with either primary amputation surgery or secondary amputation as a result of local disease progression after LSS. Patients under 18 years of age and those who had undergone amputation for other types of tumors were excluded. All patients were evaluated by a multidisciplinary cancer board consisting of oncologists, radiologists, pathologists, and orthopedic surgeons specializing in surgical oncology. A high-volume orthopedic surgeon with expertise in surgical oncology performed all of the surgeries.

2.2. Preoperative Evaluation

Preoperative evaluation included pathological confirmation of the diagnosis, with sarcoma subtypes broadly categorized as either soft tissue or bone sarcomas, as determined by biopsy. Preoperative imaging, including CT or MRI of the affected limb, was conducted to assess tumor location, size, composition, and proximity to vital structures. Staging was performed using either total-body CT or PET-CT.

2.3. Postoperative Evaluation

Follow-up evaluations included clinical examinations and imaging, either total-body CT or PET-CT. During the first year, these were conducted at intervals of 3–6 months and then annually, continuing for five years or until the patient passed away.

2.4. Methods

Patient demographics were collected, and medical records were reviewed. Preoperative imaging was analyzed to assess tumor location and size. Tumors were categorized into four groups based on location: below the knee (BK), above the knee and below the pelvis (AK), hip and pelvis (PEL), and upper limb (UL). PET-CT or total-body CT was used to assess the presence and location of preoperative metastasis.
Tumor staging was performed using the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, and tumors were classified into stages I–IV. The use of neoadjuvant chemotherapy and radiotherapy was also documented. Patients were divided into two surgical groups: primary amputation (V1) and secondary amputation (V2). The type of amputation was also recorded. Pathology reports were used to evaluate surgical margins, which were classified according to the R classification (R0, R1, and R2). Postoperative data were analyzed, including OS, MFS, LRFS, metastasis location, and complications. The primary outcome was to compare OS, MFS, LRFS, metastasis location, and complications between the V1 and V2 groups. Outcome data were collected by independent assessors who were blinded as to whether each amputation was primary or secondary.

3. Results

A total of 71 patients (28 in group V1 and 43 in group V2) were included in this study, with a mean follow-up time of 41 ± 42 months. Patient demographics and primary tumor locations are detailed in Table 1.
This table presents the baseline demographics and tumor characteristics of the study cohort, including age, gender, tumor type, and location. Data are stratified by primary amputation (V1) and secondary amputation (V2) groups.
Preoperative staging, presence of preoperative metastasis, and details regarding adjuvant and neoadjuvant treatments are reported in Table 2. No statistically significant differences were found in the two groups’ prevalence or location of metastasis.
Regarding amputation procedures, 9 patients underwent below-knee amputation (BKA) (17.8% in V1 and 16.3% in V2), while 23 patients had above-the-knee amputation (AKA) (35.7% in V1 and 30.2% in V2). Disarticulation was performed in 35 patients (42.9% in V1 and 53.5% in V2), and four patients had forequarter amputation (14.3% in V1 only).
Negative (R0) surgical margins were achieved in 96.4% of V1 patients and 97.6% of V2 patients. Two patients, one from each group, had positive surgical margins.
This table summarizes preoperative staging and treatment details, including tumor stage, presence of metastases, and use of neoadjuvant or adjuvant therapies. Comparisons between the primary amputation (V1) and secondary amputation (V2) groups are included.
Postoperative complications were observed in 24 patients (34.9% in the V1 group and 32.1% in the V2 group). The most common complication in both groups was postoperative infection, accounting for 56% of complications in V1 and 60% in V2. A detailed breakdown of postoperative complications is provided in Table 3. The mean time to complication onset was 6.9 ± 12.6 months, with a group-specific mean of 9.5 ± 16 months in V1 and 5.2 ± 10 months in V2. Local recurrence was observed in four patients (7% in V1 and 3.6% in V2). Among patients with initial metastasis-free staging, 23 developed postoperative metastases (36% in V1 and 30% in V2), with the lung being the most common metastatic site. Table 3 also provides details on the locations of postoperative metastasis.
The overall survival (OS) rate was 33.8% (25% in V1 and 39.5% in V2), with a mean time to death of 23.4 ± 23.3 months (22.5 ± 18.6 months in V1 and 23.9 ± 27 months in V2). No statistically significant differences were observed between primary and secondary amputation in terms of metastasis-free survival (MFS), OS, time to death, complication rates, or local recurrence-free survival (LRFS). The type of amputation, whether primary or secondary, did not influence the time to recurrence or time to death. The preoperative staging did not affect the time to death or time to metastasis, and postoperative complications were not associated with differences in time to death. These comparative postoperative outcomes are summarized in Table 3.

4. Discussion

Advances in surgical techniques, neoadjuvant and adjuvant therapies, improved imaging modalities, and implant technology have significantly shifted the treatment paradigm for ES, moving from radical limb amputations to LSS. Research consistently shows that LSS leads to superior functionality and an enhanced quality of life for patients. However, approximately 14% of patients who undergo LSS eventually require secondary amputation. This raises the question of whether secondary amputation results in a worse prognosis compared to primary amputation [1,2,3,4,5]. The key finding of this study is that there were no significant differences in complication rates, incidence of new metastases, or local recurrence between the two groups. Furthermore, OS, LRFS, and MFS did not differ significantly, which is consistent with existing literature [6,7,8,9,10]. Notably, preoperative staging did not impact survival outcomes, whereas patients who experienced postoperative complications had significantly shorter MFS.
While LSS is increasingly favored for treating ES, there is conflicting evidence regarding its superiority over AS in terms of OS in specific clinical settings. He et al.’s meta-analysis demonstrated that patients who underwent LSS had significantly better OS compared to those treated with AS [7]. Similarly, Abdelgawad et al. found that LSS was associated with notably higher OS than AS. However, Han et al.’s meta-analysis reported a favorable odds ratio for AS, suggesting that AS may offer better survival in certain cases [8]. In our cohort, the OS rate for amputations was 33.8%, with the V1 group at 25% and the V2 group at 39.5% (p = 0.6) showing no significant survival advantage for AS. These findings reflect the ongoing debate but support the value of LSS in improving long-term survival while preserving functionality in ES patients, even with the risk of local disease progression and secondary amputation.
Postoperative metastasis and local disease progression are critical considerations when determining the optimal surgical approach for ES. The choice between LSS and AS hinges on balancing oncological control with functional outcomes. According to Kirilova et al., 30% of patients who underwent AS for ES developed metastases [4]. In contrast, Kaneuchi et al. reported metastasis rates of 28% in LSS patients and 36% in AS patients, while Baysal et al. found similar metastasis rates in AS patients [11,12]. In our study, metastasis occurred postoperatively in 36% of patients in the V1 group and 30% in the V2 group, with no statistically significant difference between the two groups. The mean MFS was 10.5 months. This aligns with previous studies, which indicated that the risk of metastasis is comparable between LSS and AS [13,14,15]. Additionally, it underscores that within the first-year post-surgery, the rates of metastasis are comparable for both primary and secondary amputations.
The emergence of lung metastases following amputation may be influenced by factors such as immunosuppression from surgical stress and the effects of wound-healing cytokines. Given that 93% of our cohort presented with advanced disease (stage III or above), a possible explanation could be the presence of preoperative micrometastases [16,17,18,19]. The importance of detecting micrometastases has been discussed extensively in the literature. Some authors have suggested that circulating tumor DNA (ctDNA) could help identify micrometastases more effectively, potentially guiding neoadjuvant and adjuvant treatment strategies. However, the specific role of ctDNA testing in the management of ES still needs to be determined [17].
Local disease progression after LSS has been reported to range from 15% to 20% in the literature [20,21,22,23,24,25,26]. Abdelgawad et al. highlighted significantly higher local disease progression rates in LSS compared to AS, reinforcing concerns about the oncological outcomes associated with limb-salvage techniques. In contrast, in our study, no statistically significant difference in local recurrence between V1 and V2 was found (p = 0.6). Given the absence of significant differences in both metastasis and local recurrence between V1 and V2, surgical decision-making should prioritize functional preservation and the achievement of clear surgical margins. Our finding demonstrated that only one patient in each group had positive surgical margins, indicating that free surgical margins are obtainable in both V1 and V2 groups; therefore, LSS should be attempted if possible.
The difference in MFS between primary and secondary amputation patient groups is not extensively detailed in the literature. However, several studies provide relevant insights into oncological outcomes and the associated survival rates of these two surgical approaches [27,28]. Kirilova et al. and Erstad et al. reported no statistically significant differences in metastatic disease between patients undergoing primary amputation and those receiving secondary amputation [4,28]. Similarly, our study’s mean difference in MFS between the V1 and V2 groups was not statistically significant (p = 0.23), highlighting that disease advancement after LSS resulting in secondary amputation will not compromise the oncological outcomes. This suggests that LSS remains a preferable option due to its preservation of functional status without compromising survival.
Notably, patients who experienced postoperative complications exhibited shorter MFS (p = 0.029). This could be attributed to factors such as a pro-inflammatory state, the survival of residual tumor cells, poor overall health, and delays in initiating adjuvant therapy. Importantly, no significant difference in postoperative complications was observed between the V1 and V2 groups, underscoring that LSS can be attempted, even with the risk of secondary amputation due to local disease progression, without reducing MFS. For surgeons in both groups of patients, a higher level of vigilance is warranted when postoperative complications arise, as these may correlate with early metastasis. In such cases, early imaging might be beneficial. Furthermore, patients should be informed that the presence of postoperative complications may be associated with a poorer overall prognosis.
Our finding that postoperative complications, mainly infections, were associated with shorter MFS contrasts with the results of Jeys et al., who reported improved survival in patients with wound infections after surgery for high-grade localized osteosarcoma [29]. They attributed this to a possible anti-tumor immune response triggered by infection. In contrast, our cohort included heterogeneous sarcoma subtypes, predominantly with advanced-stage disease, where immunosuppression, delays in adjuvant therapy, or systemic inflammation may have contributed to earlier metastasis. These divergent findings underscore the need for further research to clarify the immunologic and therapeutic dynamics following postoperative complications in sarcoma patients.
This study has several limitations that should be considered when interpreting the results. First, as a retrospective single-center study, it is subject to inherent biases, such as selection bias and reliance on incomplete or inconsistently recorded medical data, which may affect the accuracy of the findings. Additionally, the relatively small sample size of 71 patients may limit the statistical power to detect smaller but clinically meaningful differences between primary and secondary amputation groups. Patients undergoing secondary amputation may represent a more complex and advanced disease cohort, which could influence the outcomes. Furthermore, the mean follow-up period may be insufficient to capture long-term outcomes such as OS, MFS, and LRFS. Another limitation is the lack of functional and quality-of-life assessments, which are important considerations in the decision between LSS with a risk of secondary amputation and primary amputation. The inclusion of multiple sarcoma subtypes adds heterogeneity to the sample, potentially obscuring subtype-specific outcomes. Finally, because the study was conducted in a single high-volume national sarcoma center, the findings may not be generalizable to other healthcare settings with different resources or expertise. These limitations suggest the need for further multicenter studies with larger sample sizes and longer follow-up periods to validate these findings and explore functional outcomes.
In conclusion, secondary amputation following failing limb-salvage surgery (LSS) demonstrated comparable overall survival (OS), metastasis-free survival (MFS), and local recurrence-free survival (LRFS) to primary amputation in patients with extremity sarcoma (ES). These results indicate that secondary amputation, performed after LSS and subsequent local disease progression, does not result in worse outcomes compared to primary amputation. This supports prior studies advocating for LSS over primary amputation as the initial approach. Additionally, postoperative complications were associated with shorter MFS, highlighting the need for more rigorous postoperative staging protocols for patients experiencing immediate postoperative complications.

5. Clinical Relevance

  • Postoperative complications: postoperative complications were associated with reduced MFS, underscoring the need for careful monitoring.
  • Secondary amputation: outcomes for secondary amputation after failing LSS are comparable to primary amputation, affirming LSS as a strong initial treatment.

Author Contributions

Conceptualization, O.S. and A.B.; methodology, B.E.; validation, O.S.; formal analysis, A.B. and B.E.; resources, G.B.A. and Y.G.; data curation, G.B.A. and A.A.; writing—original draft preparation, G.B.A.; writing—review and editing, O.M. and B.E.; project administration, S.D. These authors are equal first authors and contributed equally to this work. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of Tel-Aviv Sourasky Medical Center. Protocol code: 0516-20-TLV. Date of approval: 4 March 2024.

Informed Consent Statement

The informed consent for this study were waived due to the retrospective study.

Data Availability Statement

The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author.

Conflicts of Interest

No external funding was received for this work. All authors declare have no conflicts of interest.

References

  1. Dangoor, A.; Seddon, B.; Gerrand, C.; Grimer, R.; Whelan, J.; Judson, I. UK guidelines for the management of soft tissue sarcomas. Clin. Sarcoma Res. 2016, 6, 20. [Google Scholar] [CrossRef] [PubMed]
  2. Casali, P.G.; Abecassis, N.; Bauer, S.; Biagini, R.; Bielack, S.; Bonvalot, S.; Boukovinas, I.; Bovee, J.V.; Brodowicz, T.; Broto, J.M.; et al. Soft tissue and visceral sarcomas: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann. Oncol. 2018, 29 (Suppl. S4), iv51–iv67. [Google Scholar] [CrossRef] [PubMed]
  3. Gronchi, A.; Miah, A.B.; Dei Tos, A.P.; Abecassis, N.; Bajpai, J.; Bauer, S.; Biagini, R.; Bielack, S.; Blay, J.Y.; Bolle, S.; et al. Soft tissue and visceral sarcomas: ESMO-EURACAN-GENTURIS Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann. Oncol. 2021, 32, 1348–1365. [Google Scholar] [CrossRef]
  4. Kirilova, M.; Klein, A.; Lindner, L.H.; Nachbichler, S.; Knösel, T.; Birkenmaier, C.; Baur-Melnyk, A.; Dürr, H.R. Amputation for Extremity Sarcoma: Indications and Outcomes. Cancers 2021, 13, 5125. [Google Scholar] [CrossRef]
  5. Daso, G.; Chen, A.J.; Yeh, S.; O’Connell, J.B.; Rigberg, D.A.; de Virgilio, C.; Gelabert, H.A.; Ulloa, J.G. Lower Extremity Amputations Among Veterans: Have Ambulatory Outcomes and Survival Improved? Ann. Vasc. Surg. 2022, 87, 311–320. [Google Scholar] [CrossRef] [PubMed]
  6. Webster, J.B.; Crunkhorn, A.; Sall, J.; Highsmith, M.J.; Pruziner, A.; Randolph, B.J. Clinical Practice Guidelines for the Rehabilitation of Lower Limb Amputation: An Update from the Department of Veterans Affairs and Department of Defense. Am. J. Phys. Med. Rehabil. 2019, 98, 820–829. [Google Scholar] [CrossRef]
  7. He, X.; Gao, Z.; Xu, H.; Zhang, Z.; Fu, P. A meta-analysis of randomized control trials of surgical methods with osteosarcoma outcomes. J. Orthop. Surg. Res. 2017, 12, 5. [Google Scholar] [CrossRef]
  8. Han, G.; Bi, W.Z.; Xu, M.; Jia, J.P.; Wang, Y. Amputation Versus Limb-Salvage Surgery in Patients with Osteosarcoma: A Meta-analysis. World J. Surg. 2016, 40, 2016–2027. [Google Scholar] [CrossRef]
  9. Blay, J.Y.; Honoré, C.; Stoeckle, E.; Meeus, P.; Jafari, M.; Gouin, F.; Anract, P.; Ferron, G.; Rochwerger, A.; Ropars, M.; et al. Surgery in reference centers improves survival of sarcoma patients: A nationwide study. Ann. Oncol. 2019, 30, 1143–1153. [Google Scholar] [CrossRef]
  10. Callegaro, D.; Miceli, R.; Bonvalot, S.; Ferguson, P.; Strauss, D.C.; Levy, A.; Griffin, A.; Hayes, A.J.; Stacchiotti, S.; Le Pechoux, C.; et al. Development and external validation of two nomograms to predict overall survival and occurrence of distant metastases in adults after surgical resection of localized soft-tissue sarcomas of the extremities: A retrospective analysis. Lancet Oncol. 2016, 17, 671–680. [Google Scholar] [CrossRef]
  11. Kaneuchi, Y.; Yoshida, S.; Fujiwara, T.; Evans, S.; Abudu, A. Limb salvage surgery has a higher complication rate than amputation but is still beneficial for patients younger than 10 years old with osteosarcoma of an extremity. J. Pediatr. Surg. 2022, 57, 702–709. [Google Scholar] [CrossRef] [PubMed]
  12. Baysal, Ö.; Sağlam, F.; Sofulu, Ö.; Yiğit, O.; Şirin, E.; Erol, B. Indications of amputation after limb-salvage surgery of patients with extremity-located bone and soft-tissue sarcomas: A retrospective clinical study. Acta Orthop. Traumatol. Turc. 2021, 55, 154–158. [Google Scholar] [CrossRef] [PubMed]
  13. vonKonow, A.; Ghanei, I.; Styring, E.; von Steyern, F.V. Late local recurrence and metastasis in soft tissue sarcoma of the extremities and trunk wall: Better outcome after treatment of late events compared with early. Ann. Surg. Oncol. 2021, 28, 7891–7902. [Google Scholar] [CrossRef] [PubMed]
  14. Lindner, L.H.; Litière, S.; Sleijfer, S.; Benson, C.; Italiano, A.; Kasper, B.; Messiou, C.; Gelderblom, H.; Wardelmann, E.; Le Cesne, A.; et al. Prognostic factors for soft tissue sarcoma patients with lung metastases only who are receiving first-line chemotherapy: An exploratory, retrospective analysis of the European Organization for Research and Treatment of Cancer-Soft Tissue and Bone Sarcoma Group (EORTC-STBSG). Int. J. Cancer 2018, 142, 2610–2620. [Google Scholar] [CrossRef]
  15. Marulli, G.; Mammana, M.; Comacchio, G.; Rea, F. Survival and prognostic factors following pulmonary metastasectomy for sarcoma. J. Thorac. Dis. 2017, 9 (Suppl. S12), S1305–S1315. [Google Scholar] [CrossRef]
  16. Gherzi, L.; Ferrari, M.; Pardolesi, A. Lung metastases from sarcoma: Multidisciplinary approach—A narrative review. ASJ 2021, 2, 38. [Google Scholar] [CrossRef]
  17. Tsoi, K.M.; Gokgoz, N.; Darville-O’Quinn, P.; Prochazka, P.; Malekoltojari, A.; Griffin, A.M.; Ferguson, P.C.; Wunder, J.S.; Andrulis, I.L. Detection and utility of cell-free and circulating tumour DNA in bone and soft-tissue sarcomas. Bone Jt. Res. 2021, 10, 602–610. [Google Scholar] [CrossRef]
  18. Tirotta, F.; Sayyed, R.; Jones, R.L.; Hayes, A.J. Risk factors for the development of local recurrence in extremity soft-tissue sarcoma. Expert Rev. Anticancer Ther. 2022, 22, 83–95. [Google Scholar] [CrossRef]
  19. Diaz Casas, S.E.; Villacres, J.M.; Lehmann Mosquera, C.; Mora, M.G.; Lozano, I.M.; Aristizábal, J.Á.; Rodríguez, R.S.; Torres, C.A.D.; Pedraza, R.S. Prognostic factors associated with tumor recurrence and overall survival in soft tissue sarcomas of the extremities in a Colombian reference cancer center. Curr. Oncol. 2024, 31, 1725–1738. [Google Scholar] [CrossRef]
  20. Stevenson, M.G.; Musters, A.H.; Geertzen, J.H.B.; van Leeuwen, B.L.; Hoekstra, H.J.; Been, L.B. Amputations for extremity soft tissue sarcoma in an era of limb salvage treatment: Local control and survival. J. Surg. Oncol. 2018, 117, 434–442. [Google Scholar] [CrossRef]
  21. Stauss, R.; Aigner, A.; Richter, A.; Suero, E.; Altemeier, A.; Savov, P.; Ettinger, M.; Omar, M. The prognostic significance of surgical resection margins for local recurrence, distant metastasis, and overall survival in sarcoma. J. Surg. Oncol. 2023, 128, 1160–1170. [Google Scholar] [CrossRef] [PubMed]
  22. Kantidakis, G.; Litiere, S.; Neven, A.; Vinches, M.; Judson, I.; Blay, J.-Y.; Wardelmann, E.; Stacchiotti, S.; D’Ambrosio, L.; Marréaud, S.; et al. New benchmarks to design clinical trials with advanced or metastatic liposarcoma or synovial sarcoma patients: An EORTC-Soft Tissue and Bone Sarcoma Group (STBSG) meta-analysis based on a literature review for soft-tissue sarcomas. Eur. J. Cancer 2022, 176, 70–80. [Google Scholar] [CrossRef]
  23. Crago, A.M.; Lee, A.Y. Multimodality Management of Soft Tissue Tumors in the Extremity. Surg. Clin. N. Am. 2016, 96, 977–992. [Google Scholar] [CrossRef]
  24. Lebas, A.; LeFevre, C.; Waissi, W.; Chambrelant, I.; Brinkert, D.; Noel, G. Complications and Risk Factors in Patients with Soft Tissue Sarcoma of the Extremities Treated with Radiotherapy. Cancers 2024, 16, 1977. [Google Scholar] [CrossRef]
  25. Grünwald, V.; Litière, S.; Young, R.; Messiou, C.; Lia, M.; Wardelmann, E.; van der Graaf, W.; Gronchi, A.; Judson, I.; EORTC STBSG. Absence of progression, not extent of tumour shrinkage, defines prognosis in soft-tissue sarcoma—An analysis of the EORTC 62012 study of the EORTC STBSG. Eur. J. Cancer 2016, 64, 44–51. [Google Scholar] [CrossRef] [PubMed]
  26. Pasquali, S.; Pizzamiglio, S.; Touati, N.; Litiere, S.; Marreaud, S.; Kasper, B.; Gelderblom, H.; Stacchiotti, S.; Judson, I.; Tos, A.P.D.; et al. The impact of chemotherapy on survival of patients with extremity and trunk wall soft tissue sarcoma: Revisiting the results of the EORTC-STBSG 62931 randomised trial. Eur. J. Cancer 2019, 109, 51–60. [Google Scholar] [CrossRef]
  27. Harati, K.; Goertz, O.; Pieper, A.; Daigeler, A.; Joneidi-Jafari, H.; Niggemann, H.; Stricker, I.; Lehnhardt, M. Soft Tissue Sarcomas of the Extremities: Surgical Margins Can Be Close as Long as Radiotherapy is Administered. World J. Surg. 2017, 41, 2824–2831. [Google Scholar]
  28. Erstad, D.J.; Ready, J.; Abraham, J.; Ferrone, M.L.; Bertagnolli, M.M.; Baldini, E.H.; Raut, C.P. Amputation for Extremity Sarcoma: Contemporary Indications and Outcomes. Ann. Surg. Oncol. 2018, 25, 394–403. [Google Scholar] [CrossRef]
  29. Jeys, L.M.; Grimer, R.J.; Carter, S.R.; Tillman, R.M.; Abudu, A. Post operative infection and increased survival in osteosarcoma patients: Are they associated? Ann. Surg. Oncol. 2007, 14, 2887–2895. [Google Scholar] [CrossRef] [PubMed]
Table 1. Patient demographics and tumor characteristics.
Table 1. Patient demographics and tumor characteristics.
CategoryV1V2Totalp-Value
Total Patients284371-
Gender20 M/8 F32 M/11 F52 M/19 F0.8
Mean Age (Years)47 ± 2654 ± 2451 ± 250.3
Primary Tumor Location—Below the Knee9 (32.10%)14 (32.60%)23 (32.4%)-
Primary Tumor Location—Above the Knee9 (32.10%)21 (48.80%)30 (42.2%)-
Primary Tumor Location—Pelvis6 (21.90%)8 (18.60%)14 (19.7%)-
Primary Tumor Location—Upper Limb4 (14.30%)0 (0%)4 (5.6%)-
Tumor Type—Bone Sarcoma16 (57.1%)20 (46.5%)36 (50.7%)-
Tumor Type—
Soft Tissue Sarcoma		12 (42.9%)23 (53.5%)35 (49.3%)-
Table 2. Preoperative staging and treatment details.
Table 2. Preoperative staging and treatment details.
CategoryV1V2Totalp-Value
Stage I or II3 (10.70%)1 (2.30%)4 (5.6%)0.4
Stage III15 (53.60%)26 (60.50%)41 (56.3%)0.4
Stage IV10 (35.70%)16 (37.20%)26 (36.6%)0.4
Preoperative Metastasis—Total10 (35.7%)14 (32.5%)24 (33.8%)0.8
Preoperative Metastasis—Lungs10 (35.7%)10 (23.2%)20 (28.1%)0.2
Preoperative Metastasis—Other: Abdomen or Bone1 (1.4%)5 (11.6%)6 (8.4%)0.2
Neoadjuvant/Adjuvant Chemotherapy20 (71.4%)29 (67.4%)49 (69.0%)0.8
Neoadjuvant/Adjuvant Radiotherapy8 (28.5%)20 (46.5%)28 (39.4%)0.1
Table 3. Surgical outcomes and postoperative complications.
Table 3. Surgical outcomes and postoperative complications.
CategoryV1V2Total/Notesp-Value
Postoperative Complications34.90%32.10%24 patients
(most common—infection)		0.6
Time to Complication (Months)9.5 ± 165.2 ± 10Mean: 6.9 ± 12.60.5
Postoperative Metastasis36%30%Most common location—lungs (32.4% overall)0.8
MFS (Months)10 ± 7.610.8 ± 15.8Mean: 10.5 ± 12.70.2
Local Recurrence (LR)7%3.60%4 (5.6%)-
LRFS (Months)27.4 ± 26.634.4 ± 36.1Mean: 31.7 ± 32.60.6
Overall Survival (OS)25%39.50%33.80%0.3
Time to Death (Months)22.5 ± 18.623.9 ± 27Mean: 23.4 ± 23.30.6
This table outlines the surgical outcomes and postoperative complications, including rates of infection, local recurrence, and metastasis. It also details the time to complication onset and compares outcomes between the primary (V1) and secondary (V2) amputation groups. MFS—Metastasis Free Survival, LRFS—Local Recurrence Free Survival.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Segal, O.; Ben Arie, G.; Dadia, S.; Marimsky, O.; Albagli, A.; Gortzak, Y.; Benady, A.; Efrima, B. Secondary Amputation After Failed Limb-Salvage Surgery Shows Comparable Long-Term Oncological Outcomes to Primary Amputation in Extremity Sarcoma: A 5-Year Follow-Up Study. J. Clin. Med. 2025, 14, 4074. https://doi.org/10.3390/jcm14124074

AMA Style

Segal O, Ben Arie G, Dadia S, Marimsky O, Albagli A, Gortzak Y, Benady A, Efrima B. Secondary Amputation After Failed Limb-Salvage Surgery Shows Comparable Long-Term Oncological Outcomes to Primary Amputation in Extremity Sarcoma: A 5-Year Follow-Up Study. Journal of Clinical Medicine. 2025; 14(12):4074. https://doi.org/10.3390/jcm14124074

Chicago/Turabian Style

Segal, Ortal, Guy Ben Arie, Solomon Dadia, Ofer Marimsky, Assaf Albagli, Yair Gortzak, Amit Benady, and Ben Efrima. 2025. "Secondary Amputation After Failed Limb-Salvage Surgery Shows Comparable Long-Term Oncological Outcomes to Primary Amputation in Extremity Sarcoma: A 5-Year Follow-Up Study" Journal of Clinical Medicine 14, no. 12: 4074. https://doi.org/10.3390/jcm14124074

APA Style

Segal, O., Ben Arie, G., Dadia, S., Marimsky, O., Albagli, A., Gortzak, Y., Benady, A., & Efrima, B. (2025). Secondary Amputation After Failed Limb-Salvage Surgery Shows Comparable Long-Term Oncological Outcomes to Primary Amputation in Extremity Sarcoma: A 5-Year Follow-Up Study. Journal of Clinical Medicine, 14(12), 4074. https://doi.org/10.3390/jcm14124074

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop