Shreyaskumar R. Patel, MD: When would you consider a bigger operation, such as a joint replacement or an amputation? Would there be situations where you would do that?

Tae Won B. Kim, MD: Joint replacement is utilized when I feel that the pain is not just tumor related, but rather that they’ve had a lot of mechanical pain from the joint destruction that you see on the x-ray or MRI. I find amputation to be very rare in this situation. The only times I’ve considered amputation is in the distal extremities, where there’s basically diffuse-type disease in the foot or the hand, where you don’t have soft tissue for coverage, and you know that the morbidity of the surgery is going to be significant. Sometimes a ray resection can be functionally better for the patient than trying to save a finger that’s not salvageable.

Robert G. Maki, MD, PhD: Dr Kim, I have a question for you. Those patients with metatarsal primary, surgery there is also very difficult. The functional outcomes from that can’t be very good.

Tae Won B. Kim, MD: Your question is, do we do surgery in those cases?

Robert G. Maki, MD, PhD: Yes, exactly.

Tae Won B. Kim, MD: For localized-type disease in those patients, yes. For diffused-type disease, however, I think it’s very difficult to perform a plantar and dorsal resection, trying to get all the gross tissue out, because you end up with very significant scarring at the end of it. You can also have a lot of joint destruction and a lot of bony destruction. Trying to perform bony reconstruction in some of those locations to allow for a good functional outcome can also be difficult.

At least from my experience with ray amputations in the appropriate locations, the patients functionally do very well with a shoe filler or even no filler at all. I think this is a patient discussion to have, but before you make the decision, you’ve got to get everybody in the team involved to decide that this is the best approach.

John A. Abraham, MD: I’ll make a comment on that. The surgical approach is less dependent on the location as it is on the extent of disease. In a metatarsal region, if it’s a small, localized nodule, then there’s little risk in taking that out and the patient can do very well. Whereas some extensive, soft-tissue disease in that same region may require much more extensive surgery. I agree with Dr Kim that it’s very rare that we end up performing amputations for this disorder, but it does happen. Usually it is necessary for the much more aggressive disease with intraarticular/extraarticular components, compromise of neurovascular bundle, and destruction of the joint. When we think this is an unsalvageable limb—which is extremely rare, but happens in some cases—then we’ll start to consider amputation.

Transcript Edited for ClaritySupported by an unrestricted educational grant from Daiichi Sankyo.