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PubMed2005

Surgical considerations for management of distal extremity soft tissue sarcomas.

PURPOSE OF REVIEW: This review focuses on the surgical management of soft tissue sarcomas of the hands and the feet. With recent advances in limb salvage surgery and radiotherapy delivery, local control of soft tissue sarcoma in the extremity has become optimized, and the associated functional results of this treatment have taken on extreme importance. Techniques to limit the amount of normal tissue resected and to reconstruct the resulting defects are critical to the final functional result. RECENT FINDINGS: Several features of soft tissue sarcoma unique to the hand and foot have been reported. Certain histologic subtypes of soft tissue sarcoma have been noted to arise preferentially in the hand and the foot, such as epithelioid sarcoma, clear cell sarcoma, and synovial sarcoma. Patients with hand and foot sarcomas have been described as having improved overall survival, but this is likely a result of the smaller size of tumors arising in these locations. Reconstruction of bone defects using various techniques, vascular reconstruction, tendon transfers, and soft tissue reconstruction using regional flaps in the hand and free flaps in the foot have resulted in good functional outcomes. Amputation and early prosthetic fitting still have a role in management of some soft tissue sarcomas, most frequently in the foot. SUMMARY: Limb salvage remains the standard of care for extremity soft tissue sarcomas. Given the fact that patients have good oncologic and functional outcomes with limb salvage in tumors in the hand and foot, surgical oncologists should have this goal for each patient.

Extremities↗
PubMed2007

Photon extremity absorbed dose and kerma conversion coefficients for calibration geometries.

Absorbed dose and dose equivalent conversion coefficients are routinely used in personnel dosimetry programs. These conversion coefficients can be applied to particle fluences or to measured air kerma values to determine appropriate operational monitoring quantities such as the ambient dose equivalent or personal dose equivalent for a specific geometry. For personnel directly handling materials, the absorbed dose to the extremities is of concern. This work presents photon conversion coefficients for two extremity calibration geometries using finger and wrist/arm phantoms described in HPS N13.32. These conversion coefficients have been calculated as a function of photon energy in terms of the kerma and the absorbed dose using Monte Carlo techniques and the calibration geometries specified in HPS N13.32. Additionally, kerma and absorbed dose conversion coefficients for commonly used x-ray spectra and calibration source fields are presented. The kerma values calculated in this work for the x-ray spectra and calibration sources compare well to those listed in HPS N13.32. The absorbed dose values, however, differ significantly for higher energy photons because charged particle equilibrium conditions have not been satisfied for the shallow depth. Thus, the air-kerma-to-dose and exposure-to-dose conversion coefficients for Cs and Co listed in HPS N13.32 overestimate the absorbed dose to the extremities. Applying the conversion coefficients listed in HPS N13.32 for Cs, for example, would result in an overestimate of absorbed dose of 62% for the finger phantom and 55% for the wrist phantom.

Body Burden↗
PubMed2006

Combined functional task practice and dynamic high intensity resistance training promotes recovery of upper-extremity motor function in post-stroke hemiparesis: a case study.

BACKGROUND AND PURPOSE: Weakness is a significant impairment in persons with post-stroke hemiparesis, yet traditional clinical perspectives caution against strengthening in neurological populations. Significant correlations between weakness and functional movement have been demonstrated, however, a clear relationship between increased strength and functional improvement has been elusive. This case study describes a combined program of dynamic, high-intensity resistance training and functional task practice for the upper-extremity in adult hemiparesis. CASE DESCRIPTION: The patient was a 65-year-old, right hand dominant woman who presented to the Neural Control of Movement Laboratory at the Palo Alto VA Rehabilitation Research and Development Center 16 weeks following clipping of an unruptured aneurysm with consequent dense right hemiparesis. She received 7 weeks of acute rehabilitation according to CARF guidelines (ie, at least 3 hours of two or more disciplines, 6 days per week). Her baseline research evaluation revealed significant upperextremity deficits at the ICF body structure/function level including: weakness, shoulder pain, mild resistance to passive movement, and need for moderate to maximal assistance in many activities of daily living including bathing and dressing. The Stroke Impact Scale score reporting her perspective indicated she had recovered from her stroke only 50%. The hybrid resistance training-functional task practice intervention, detailed in this report, was delivered 3 times per week for 6 weeks with each session lasting 75:00. OUTCOMES: The subject revealed marked improvements in isometric and dynamic force production in 5 key upper-extremity actions: elbow flexion, elbow extension, shoulder flexion, shoulder abduction, and shoulder external rotation. Strength gains were accompanied by increased EMG activation immediately postintervention and by a combination of increased activation and apparent hypertrophic effects at 6 month follow up. Marked improvements were noted in all clinical and functional measures and in an elbow trajectorytracking task which served as a surrogate measure of motor control. DISCUSSION: Improvements in strength and positive outcome effects at the physiological, clinical, and functional levels were observed in this subject following the experimental hybrid upper-extremity rehabilitation intervention described. Importantly, no deleterious effects were observed including exacerbation of spasticity or musculoskeletal compromise. Observations of improved EMG activation in this case study suggest that improvements in motor activation underlie these strength gains and can likely be attributed to working at a high intensity level.

Activities of Daily Living↗
PubMed2004

Refinements of free tissue transfer for optimal outcome in lower extremity reconstruction.

Advances in microsurgery have revolutionized the management of severe lower extremity soft tissue injuries. However, the final optimal result, such as cosmesis, is only of secondary concern as limb salvage is the ultimate goal in reconstruction. In a continuous effort to obtain the best possible outcome for patients, several refinements of free tissue transfers in lower extremity reconstruction have been made. Over the past 2 years, 14 patients (8 males: 6 females; ages 14 to 65 years) underwent lower extremity reconstructions with free muscle flaps (7 gracilis, 3 rectus abdominus, and 4 latissimus dorsi) and split-thickness skin grafts for various soft tissue defects. All patients have obtained excellent cosmetic and reconstructive outcomes with an average of 1-year follow-up. Based on our results, the following refinements are recommended: (1) selection of donor muscle flap appropriate to the size and contour requirements of the defect; (2) meticulous flap inset into the defect; and (3) if necessary, final flap debulking by tangential excision for optimal contouring.

Adolescent↗
PubMed2004

Teleconsultation by using the mobile camera phone for remote management of the extremity wound: a pilot study.

To assess the feasibility of remote management of extremity wound by using a mobile camera phone to transfer clinical images and online communication, teleconsultations were carried out on 60 patients between January and August 2003 for 82 extremity wounds presented to the emergency room between residents and consultant plastic surgeons. A questionnaire about wound descriptors (gangrene, necrosis, erythema, and cellulitis/infection), as well as clinical opinions regarding treatment with antibiotics or debridement, was filled out. In this study, 3 surgeons were able to make 80%, 76%, 66%, and 74% agreement, respectively, in the remote diagnosis regarding presence of gangrene, necrosis, erythema, and cellulitis/infection. Recognition of gangrene had the highest agreement percent (80%), sensitivity (85%), and specificity (93%). There were 68% to 90% of image sets that could be made with equivalent diagnoses of wound descriptors and 83% of wounds managed as per the remote treatment recommendation regarding whether to use antibiotics or to perform debridement. The preliminary results showed that the camera phone is valuable and bears potential for remote management of the extremity wound.

Adolescent↗
PubMed2004

Handgrip strength as a diagnostic tool in work-related upper extremity musculoskeletal disorders in women.

The aim of this study was to determine if handgrip strength might be used as a diagnostic tool in musculoskeletal disorders of the upper extremities in women working in an industrial environment. The setting was an electronic factory with four groups of women (n = 101) in a factory assembling electronic components. Handgrip strength was measured using a Jamar hydraulic hand dynamometer. The study investigated grip strength in managers-engineers, cable wiring, circuit board assembly, integrated circuits women at 90 degrees elbow flexion and 180 elbow extension. Women seeking or receiving medical care for musculoskeletal disorders of the upper extremities or neck showed significant declines (p < 0.01) in handgrip strength and these also related to the type of work and the level of perceived physical exertion. Women in the managerial-engineering group showed fewer musculoskeletal disorders of the upper extremity compared with the other groups and also had significantly stronger handgrip. Our findings encourage us to recommend hand dynamometer testing as a useful diagnostic tool to determine loss of handgrip strength.

Adult↗
PubMedDate not supplied

Microvascular transplantation of a free omental graft to the distal extremity in dogs.

OBJECTIVE: To assess the survival of a free omental graft applied to an experimentally created wound on the distal extremity in dogs. STUDY DESIGN: A free omental graft was evaluated as a primary method of treatment for dogs with distal extremity wounds in an experimental model. ANIMALS OR SAMPLE POPULATION: Five adult intact female mixed breed dogs weighing 21.8 kg to 25.0 kg. METHODS: A free omental graft was harvested from the abdomen and transferred to a wound bed overlying the medial aspect of the tibia. A microvascular anastomosis was performed between the graft vessels and vessels at the recipient site. Daily clinical assessment of graft viability was performed. Angiography and 99mTechnetium labeled macroaggregated albumin (99mTc MAA) scintigraphic perfusion scans were performed on either day 4, 5, or 7. Postmortem collection of tissues for histopathologic analysis was performed immediately after imaging. Total operative time and graft ischemia time were evaluated for effects on graft survival. RESULTS: Two of seven grafts survived to the end of the study, three of seven grafts failed because of ischemia, and two of seven grafts failed because of self-trauma. There was no clinically significant morbidity associated with the abdominal portion of the procedure. Because of the small number of surviving grafts, the effects of operative time and graft ischemia time could not be statistically evaluated. CONCLUSIONS: Microvascular transplantation of a free omental graft can result in a viable tissue covering of a distal extremity wound, however, the failure rate is unacceptably high. CLINICAL RELEVANCE: A free omental graft may not have sufficient durability to be an acceptable wound covering by itself. Further studies combining omentum with a skin graft or other tissues may result in a clinically useful technique.

Anastomosis, Surgical↗
PubMed2006

Effects of turn angle and pivot foot on lower extremity kinetics during walk and turn actions.

This study examined lower extremity joint moments during walk and turn with different turn angles and pivot feet. Seven young adults (age 21+/-1.3 yrs) were asked to walk at a self-selected speed (1.35+/-0.15 m/s) and to turn to the right using right (spin turn) and left (step turn) pivot feet at turn angles of 0 degrees (walking straight), 45 degrees, and 90 degrees. Video and forceplate systems were employed for kinematic and kinetic data collection. Inverse dynamics approach was used to compute joint moments using segmental kinematics, ground reaction forces, and moments. The participants decreased their forward speed by increasing the ankle plantar flexion moment as the turn angle increased. The peak ankle plantar flexion moment during the braking phase increased with increasing turn angle for both spin and step turns. Ankle invertor moments were observed only in spin turns, suggesting that more ankle muscles are involved in spin turns than in step turns. The turn angle had a significant effect on the transverse plane moment profiles at the different lower extremity joints. The results suggest that the loading patterns of different anatomical structures in the lower extremity are affected by both turn angle and pivot foot during walk and turn actions.

Adult↗
PubMed2006

Interventions for the prevention and management of neck/upper extremity musculoskeletal conditions: a systematic review.

Considered from medical, social or economic perspectives, the cost of musculoskeletal injuries experienced in the workplace is substantial, and there is a need to identify the most efficacious interventions for their effective prevention, management and rehabilitation. Previous reviews have highlighted the limited number of studies that focus on upper extremity intervention programmes. The aim of this study was to evaluate the findings of primary, secondary and/or tertiary intervention studies for neck/upper extremity conditions undertaken between 1999 and 2004 and to compare these results with those of previous reviews. Relevant studies were retrieved through the use of a systematic approach to literature searching and evaluated using a standardised tool. Evidence was then classified according to a "pattern of evidence" approach. Studies were categorised into subgroups depending on the type of intervention: mechanical exposure interventions; production systems/organisational culture interventions and modifier interventions. 31 intervention studies met the inclusion criteria. The findings provided evidence to support the use of some mechanical and modifier interventions as approaches for preventing and managing neck/upper extremity musculoskeletal conditions and fibromyalgia. Evidence to support the benefits of production systems/organisational culture interventions was found to be lacking. This review identified no single-dimensional or multi-dimensional strategy for intervention that was considered effective across occupational settings. There is limited information to support the establishment of evidence-based guidelines applicable to a number of industrial sectors.

Cost-Benefit Analysis↗
PubMed1998

Percutaneous drainage of fluid collections in the extremities.

PURPOSE: To analyze the results of percutaneous drainage of fluid collections in the extremities. MATERIALS AND METHODS: From 1990-1997, 28 patients aged 14-90 years underwent percutaneous drainage of 33 fluid collections in the extremities; two patients underwent multiple drainages. Fluid collections were in the hip-groin area (n = 16), thighs (n = 6), buttocks (n = 6), knees (n = 3), calf (n = 1), and axilla (n = 1). Three intraarticular collections were included. The patients who had undergone prior procedures were eight who had undergone surgical drainage, 10 who had undergone needle aspiration, and one who had undergone surgical débridement. The two most common guidance methods of catheter placement were ultrasound localization and fluoroscopy. RESULTS: The average drainage duration was 18.2 days (range, 1-93 days). The estimated cavity sizes were 4-733 cm3. Purulent fluid was drained in 13 patients. Staphylococcus aureus was the most commonly identified organism (n = 9). Nine patients had postoperative lymphoceles; five of these patients underwent sclerotherapy. Two (7%) patients had two complications, one of which was major. Failure occurred in four (16%) of 25 patients; two needed repeat drainage for recurrence, and two needed subsequent surgery. Success could not be determined in three patients who were lost to follow-up. CONCLUSION: Percutaneous drainage of fluid collections in the extremities is an effective alternative to open-incision drainage in inpatients and outpatients.

Adolescent↗
PubMed2004

A Phase I trial of TNFerade biologic in patients with soft tissue sarcoma in the extremities.

PURPOSE: TNFerade is a second-generation replication-deficient adenovector carrying a transgene encoding human tumor necrosis factor alpha under control of a radiation- induced promoter. The objective of this study was to assess the tolerance of combining TNFerade and radiation therapy in patients with soft tissue sarcomas of the extremity. EXPERIMENTAL DESIGN: TNFerade was administered in combination with single-daily fractionated radiation therapy in 14 patients with soft tissue sarcoma of the extremities. Three escalating dose levels of TNFerade (4 x 10(9) -4 x 10(11) particle units) were planned, given in 1 log increments by intratumoral injections, twice weekly during week 1 and once weekly during weeks 2-5 of radiation therapy. RESULTS: TNFerade was well tolerated with no dose-limiting toxicities noted. Grade 1-2 chills (50.0%), fever (43.0%), fatigue (36.0%), and flu-like symptoms (21.0%) were the most common side effects. Serum-tumor necrosis factor alpha levels were low in all of the patients (<15 pg/mL). No patients had virus-detected blood, sputum, or urine cultures. Of the 13 evaluable patients, 11 received TNFerade preoperatively, and 2 received the treatment for palliation. Eleven patients (85%) showed objective or pathological tumor responses (2 complete and 9 partial), and 1 had stable disease. Partial responses were achieved despite some of these tumors being very large (up to 675 cm(2)). Of the 11 patients who underwent surgery, 10 (91%) showed a pathological complete response/partial response. CONCLUSION: TNFerade + radiation therapy was well tolerated in the treatment of patients with soft-tissue sarcoma of the extremity. The high number of objective responses observed warrants additional studies of this approach in a larger controlled prospective trial.

Adenoviridae↗
PubMed2003

Motor evoked potentials in predicting recovery from upper extremity paralysis after acute stroke.

OBJECTIVE: The use of motor evoked potentials (MEPs) in predicting recovery after stroke still appears to be somehow equivocal. We assessed the prognostic value of MEPs with respect to arm and hand motor recovery in acute stroke patients. METHODS: This cohort study included 43 consecutive acute stroke patients with complete paralysis of the upper extremity. MEPs of the abductor digiti minimi muscle (ADM) and the biceps brachii muscle (BB) were obtained within 10 days after stroke onset. The upper limb subset of the Fugl-Meyer Motor Assessment was used to evaluate the motor performance at regular intervals until 6 months after stroke. RESULTS: The follow-up was complete in 40 patients (2 patients died and 1 patient had a recurrent stroke); 14 patients showed motor recovery of the arm and their mean 26-week arm motor score was 17.93 (range 3-30, SD 11.68); hand motor recovery occurred in 11 patients and their mean 26-week hand motor score was 11.09 (range 4-14, SD 4.10). Stepwise logistic regression revealed prognostic models for both arm and hand motor recovery based on BB MEPs (odds ratio 7.69, confidence interval, CI, 1.16-50.95) and ADM MEPs (odds ratio 16.20, CI 2.51-104.40), respectively. CONCLUSIONS: The predictive significance of MEPs with respect to motor recovery of the upper extremity was obvious in our homogeneous sample of patients. This agrees with the paradigm that motor recovery after infarction is strongly dependent on a critical residual sparing of the corticospinal function. In this context, the test properties of MEPs in predicting motor recovery are discussed. The added value of MEPs with respect to motor recovery of the upper extremity should be regarded as established for patients with initial paralysis, especially since clinical examination alone lacks the possibility to detect the potential for motor recovery in these cases.

Adolescent↗
PubMed2006

Exercise-induced deep vein thrombosis of the upper extremity. 2. A case series in children.

Upper-extremity deep venous thrombosis (UEDVT) is an increasingly important clinical problem in children. These events are classified as primary or secondary, with the latter being the most common and usually associated with the presence of a central venous line. Among primary UEDVT, the so-called Paget-Schroetter syndrome, effort-related or exercise-induced upper-extremity thrombotic event represents an extremely rare finding that has never been described in a pediatric series. The objective of the second part of this two-part article is to report the first pediatric series in a group of adolescents with this condition from a single center, describing their clinical features, management, and outcome. A retrospective chart review of 6 patients seen between December 2003 and April 2005 was conducted, with a median follow-up of 9 months (range 2-17). Four females and two males, all Caucasian, were enrolled with a median age of 16 years (range 14-17). In all cases, strenuous exercise was present in the month preceding diagnosis and mild trauma was present in only one case (weight lifting). At presentation, all patients had objective swelling of the affected limb for a median of 4 days (range 2-14), and 4 patients had UEDVT of the dominant arm. Thrombophilia investigation revealed that 50% had a combined prothrombotic state at presentation, and all patients were/are being treated with anticoagulation for 6 months (low-molecular-weight heparin followed by warfarin). Continuation of the initial symptoms was present in all cases but one at the 3-month clinic follow-up (last case has yet to reach 3 months of follow-up), and residual moderate to severe postthrombotic syndrome was present in all 3 cases followed for more than 12 months. Of those 3 patients followed for more than 1 year, 2 patients recurred despite having complete resolution of the thrombus after 6 months of anticoagulation, and the third patient underwent surgery with clinical improvement. Adolescents with UEDVT treated only with anticoagulation seem to have a poor outcome.

Adolescent↗
PubMed2003

Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula.

BACKGROUND: In patients in chronic hemodialysis via upper extremity arteriovenous fistula in whom ipsilateral internal thoracic artery graft was used for myocardial revascularization, hemodynamic interference between the fistula and the graft during dialysis can be hypothesized. METHODS AND RESULTS: In 5 patients undergoing chronic hemodialysis via upper extremity arteriovenous fistula, ipsilateral to an internal thoracic to left anterior descending graft mammary flow was studied by means of transthoracic echo-color Doppler at baseline and during hemodialysis. Flow in the contralateral mammary artery was used as control. Transthoracic echocardiography was performed in concomitance with flow evaluation to assess eventual modifications of left ventricular segmental wall motion. Immediately after hemodialysis pump start there was a marked reduction of peak systolic and end-diastolic velocities and time average mean velocity and flow in the ITA ipsilateral to the fistula, whereas no substantial hemodynamic modification was evident in the contralateral artery. Dialysis-induced reduction of ipsilateral ITA flow was accompanied by evidence of hypokinesia of the anterior left ventricular wall. Three cases also experienced clinical angina. CONCLUSIONS: Hemodynamically evident flow steal and consequent myocardial ischemia develop during hemodialysis in patients with upper extremity arteriovenous fistula and ipsilateral internal thoracic artery to coronary graft. These data have major implications for patients' management, both for nephrologists and cardiac surgeons.

Arteriovenous Shunt, Surgical↗
PubMedDate not supplied

Lower extremity deep venous thrombosis: vascular laboratory quality assurance without correlation between ultrasound and venography.

Venography is rarely available for comparison with ultrasonography (US) as a means for quality assurance (QA) in the detection of lower extremity venous thrombosis. New QA methods must be implemented. We compared results of multiple serial studies performed in the same extremity as a QA indicator. From a 3-year sample of close to 9,000 venous tests, we obtained a subset of 44 patients who had 331 tests in 71 lower extremities throughout the years. A positive or negative study preceded or followed by another positive or negative study was considered as a confirmed study. A negative or positive study not preceded or followed by a negative or positive study was considered as unconfirmed. Explanations were then sought to explain unconfirmed results. There were 169 (51%) and 124 (37%) confirmed positive and negative studies, respectively, and 13 (4%) and 25 (8%) unconfirmed positive and negative studies, respectively. Of the 13 unconfirmed positive tests, 2 were preceded by negative tests, 3 were preceded and followed by negative tests, and 8 were followed by negative tests. Of these 13 tests, 4 documented extensive venous thrombosis. Of the 25 unconfirmed negative tests, 11 followed treatment for venous thrombosis, 6 had recurrent thrombosis with intermittent lysis, and 8 were followed by positive tests. Considering the low probability of extensive thrombosis being a false-positive test, positive predictive value was 95% (173/182). Excluding 11 negative tests following treatment for venous thrombosis, negative predictive value was 90% (124/138) and accuracy was 93% (297/320). US versus US and literature US versus venography comparisons of these statistics were similar.

Female↗
PubMedDate not supplied

Upper extremity ischemia from developmental failure of brachial artery-a case report.

Advances in medicine and technology have increased brachial artery utilization for diagnostic and interventional radiology. Hence, detection and assessment of variations in upper extremity vasculature are important regardless of the low surgical intervention rate in the upper extremity. Anomalies of the upper extremity artery are infrequently reported, and anomalies of the brachial artery are even less common. Presented here is a case of developmental failure of the brachial artery. A segment about 2.1 cm from its origin was treated with bypass surgery. This is presented as an uncommon variation of the brachial artery.

Blood Vessel Prosthesis Implantation↗
PubMed1985

Perioperative blood transfusions are associated with increased rates of recurrence and decreased survival in patients with high-grade soft-tissue sarcomas of the extremities.

One hundred fifty-six patients with high-grade soft-tissue sarcomas of the extremities treated on prospective randomized trials were analyzed to determine the impact of perioperative blood transfusions on tumor recurrence and patient survival. A significant increase in the incidence of tumor recurrence and decrease in survival were associated with the receipt of blood transfusions at the time of definitive surgical therapy of the sarcoma. Actuarial 5-year continuous disease-free survival was 70% in patients who had not been transfused compared to 48% in patients who received one or more transfusions (P = .007). Overall 5-year survival was also substantially decreased in patients receiving transfusions (85% compared to 63%; P = .0035). A direct relationship existed between the number of transfusions administered and the decrease in disease-free and overall survival; the larger the number of transfusions the worse the prognosis (P less than .0001 and P = .0001, respectively). A large number of other prognostic factors were included in the analysis including the age, sex, race of the patient, histology of the primary lesion, anatomic site of the primary lesion, final surgical margins, size of the tumor, type of surgery required, the use of chemotherapy, actual time in the operating room under anesthesia, the exact anesthetic agent used, and the individual surgeon who performed the operation. Accounting for all of these factors a strong association continued to exist between the receipt of blood transfusion and poor patient prognosis. We have previously shown that adjuvant chemotherapy is of benefit to patients with high-grade extremity sarcomas, and 132 (84.6%) of 156 patients in this series received chemotherapy. In patients receiving chemotherapy, blood transfusions were associated with increased recurrence (P less than .0001) and decreased survival (P = .0001). The only other significant independent prognostic variable in these patients was the size of the primary tumor. An analysis of all patients, stratified for tumor size, revealed an impact of transfusions on increasing recurrence (P = .007) and decreasing survival (P = .016). An analysis of the subpopulation of patients with large tumors (greater than 150 mL) gave the same results (P = .03 and .015, respectively). It thus appears that the receipt of blood transfusions is associated with increased tumor recurrence and decreased survival in patients with high-grade soft-tissue sarcomas of the extremities.(ABSTRACT TRUNCATED AT 400 WORDS)

Actuarial Analysis↗
PubMed1989

Results of intensive therapy in children with localized alveolar extremity rhabdomyosarcoma: a report from the Intergroup Rhabdomyosarcoma Study.

Preliminary analyses of treatment results and prognostic factors from the first Intergroup Rhabdomyosarcoma Study (IRS I) suggested that alveolar histology and extremity site were among factors associated with an adverse outcome in clinical group I patients whose tumors had been completely resected. A high incidence of alveolar histology among the extremity tumors compounded the problem. These findings prompted an amendment to IRS II shortly after the study opened. Therapy for patients with alveolar extremity tumors in groups I and II was changed to more intensive repetitive pulse vincristine, dactinomycin, and cyclophosphamide (VAC) for 2 years. The outcome of 44 patients who received intensive therapy on IRS II is compared with a control series of 30 patients who were treated on IRS I. The control patients received standard VAC therapy for 2 years or VA for 1 year. Half of group I control patients received local radiotherapy, whereas none was given to group I intensive therapy patients. In both studies group II patients received radiotherapy to the primary tumor site and to identified positive regional lymph nodes. Compared with the control group, patients given more intensive therapy had a longer disease-free survival (DFS) (69% v 43% at 3 years), but this was of marginal significance (P = .06). The overall survival difference (77% v 57% at 3 years) was not significant (P = .23). Despite the limited statistical evidence, there is some indication that intensive therapy improved the prognosis of children with localized alveolar rhabdomyosarcoma (RMS).

Antineoplastic Combined Chemotherapy Protocols↗