Surgical Technique for Transhumeral Amputation due to Sarcoma

Indications for Amputation

The National Comprehensive Cancer Network recommends that transhumeral amputation should only be performed when complete tumor resection would leave the limb non-functional or when the patient prefers it, after evaluation by a soft tissue sarcoma expert surgeon 1, 2, 3
Amputation should be considered when the total resection of the tumor would leave the limb without useful function (e.g., extensive compromise of major neurovascular structures that cannot be preserved) 1, 2, 3
The American College of Surgeons suggests that amputation may be considered due to the patient's explicit preference after a complete discussion of options 1, 2, 3

The National Comprehensive Cancer Network guidelines state that mandatory evaluation by a surgeon experienced in soft tissue sarcomas is required before proceeding with amputation 1, 2, 3
Consideration of neoadjuvant therapy (preoperative radiotherapy 45-50 Gy or chemotherapy) for borderline resectable tumors that could allow for conservative surgery 4, 5
Preoperative evaluation for rehabilitation (physical and occupational therapy) is necessary 2, 3

The level of amputation should be proximal to the tumor with a margin of normal tissue, typically at the level of the proximal humerus or shoulder disarticulation 1, 2
The dissection should be performed through uninvolved tissue planes 1, 2, 6, 3
The biopsy site should be excised en bloc with the final surgical specimen 2, 6, 3
If the tumor is near or displaces major vessels or nerves, these do not need to be resected if the adventitia or perineurium is removed and the underlying neurovascular structures are not involved with macroscopic tumor 1, 2, 6, 3

Both the surgeon and the pathologist should document the surgical margins when evaluating the resected specimen 1, 2, 6, 3
R0 resection (without microscopic residual disease) is the goal 6, 3
Microscopically positive margins are associated with a higher rate of local recurrence and lower disease-free survival 1, 4

Adjuvant radiotherapy should be considered for close soft tissue margins (< 1 cm) 1, 4
Adjuvant radiotherapy should also be considered for microscopically positive margin in bone, major blood vessels, or nerve 1, 4, 6, 3

Rehabilitation should continue until maximum function is achieved 2, 4, 3
Multidimensional and patient-tailored physical rehabilitation programs should be implemented perioperatively 7