Indications and outcomes of palliative major amputation in patients with metastatic cancer

Background: Patients with stage IV cancer often experience diminished quality of life and pain. Although palliative amputation (PA) can reduce pain, it is infrequently performed because of the morbidity associated with amputation and the limited life expectancy in this population. Here, we describe the indications for PA in patients with stage IV carcinoma or sarcoma and discuss their clinical courses and outcomes. We hypothesized that PA would be associated with reduced pain and improved quality of life in these patients. Methods: We retrospectively reviewed medical records of all patients who underwent major amputation (proximal to the ankle or wrist) for metastatic sarcoma or carcinoma from January 1995 to April 2021. We excluded patients who underwent amputation for indications other than palliation. Cox proportional hazards regression analysis was used to determine factors associated with survival after PA. Results: Twenty-six patients underwent PA (11 for carcinoma, 15 for sarcoma). The most common indications for PA were pain (all patients) and fungating tumor (16 patients). PA was the initial surgery in 7 patients. Forequarter amputations were the most common procedure (6 patients). All patients reported reduced pain after PA, with the mean (+/- standard deviation) visual analog pain score (on a 10-point scale) decreasing from 5.7 +/- 2.9 preoperatively to 0.43 +/- 1.3 postoperatively (p < 0.001). The mean preoperative ECOG score was 1.9 +/- 0.2 compared with 1.3 +/- 0.1 postoperatively (p < 0.001). Fourteen patients were fitted for prostheses (6 upper extremity, 8 lower extremity). Two patients had local recurrence, both within 6 months after PA. The mean survival time after PA was 13 +/- 12 months, and mean follow-up was 28 +/- 29 months. Mean survival time after PA was not significantly different between patients with sarcoma (11 +/- 11 months) versus carcinoma (15 +/- 14 months) (p = 0.51). Adjuvant chemotherapy was positively associated with survival; no other factors were associated with survival. Conclusions: PA was associated with significantly reduced pain in all patients with stage IV cancer. PA should be considered for those with intractable pain, fungating tumors, or symptoms that diminish quality of life. Level of evidence: Level III.