title: Palliative forequarter amputation for metastatic carcinoma to the shoulder girdle region: indications, preoperative evaluation, surgical technique, and results.
abstract: OBJECTIVE
  Uncontrolled metastatic carcinoma of the shoulder girdle is a difficult oncologic problem. This study reviews our experience with palliative forequarter amputation with emphasis on patient selection criteria, preoperative radiologic assessment, surgical technique, epineural postoperative analgesia, and clinical outcome.
  
  
  METHODS
  Eight patients who underwent palliative forequarter amputation for metastatic carcinoma between 1980 and 1999 were analyzed retrospectively. Diagnoses included breast carcinoma (n = 3), squamous cell carcinoma (n = 2), hypernephroma (n = 2), and carcinoma of unknown origin (n = 1). All patients presented with severe, intractable pain and a useless extremity. Venography demonstrated obliteration of the axillary vein in each of the patients in whom this procedure was performed. Exploration of the brachial plexus confirmed tumor encasement and unresectability in all patients. Epineural catheters for bupivacaine infusion were placed for postoperative pain control.
  
  
  RESULTS
  All patients experienced dramatic pain relief and improved mobility and overall function. Life-threatening hemorrhage and sepsis were alleviated. There were no instances of phantom limb pain or adverse psychological reactions, and no complications related to epineural analgesia.
  
  
  CONCLUSIONS
  Palliative forequarter amputation is relatively safe and reliable and provides effective pain relief for selected patients with unresectable metastatic carcinoma to the axilla and bony shoulder girdle in whom radiotherapy and/or chemotherapy has not been effective. The triad of pain, motor loss, and an obliterated axillary vein is indicative of brachial plexus infiltration and unresectability.
authors.affiliation: Department of Orthopedic Oncology, Washington Cancer Institute at the Washington Hospital Center, Washington, DC 20010, USA. wittigj@aol.com
authors.forename: J C
authors.initials: JC
authors.lastname: Wittig
authors.forename: J
authors.initials: J
authors.lastname: Bickels
authors.forename: Y
authors.initials: Y
authors.lastname: Kollender
authors.forename: K L
authors.initials: KL
authors.lastname: Kellar-Graney
authors.forename: I
authors.initials: I
authors.lastname: Meller
authors.forename: M M
authors.initials: MM
authors.lastname: Malawer
mesh_terms: D000328:Adult; D000368:Aged; D000671:Amputation, Surgical / Q000379:methods*; D001917:Brachial Plexus; D001943:Breast Neoplasms / Q000473:pathology; D002294:Carcinoma, Squamous Cell / Q000556:secondary / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010148:Intractable Pain / Q000628:therapy*; D010166:Palliative Care; D018579:Patient Selection; D010524:Peripheral Nervous System Neoplasms / Q000556:secondary* / Q000601:surgery*; D012782:Shoulder / Q000601:surgery*