Lower-Extremity Soft-Tissue Sarcoma Functional Outcome and Quality of Life after Treatment

Background
\nSoft-tissue sarcomas (STS) represent approximately 1% of all solid malignancies in adults. More than 50% of STSs are localized in the extremities. The aim of extremity STS treatment is survival and limb salvage with the best possible quality of life (QoL) and functional outcome.
\nThere has been increasing interest to report the health-related quality of life (HRQL) and functional outcome after treatment. Measures should be valid, reliable, accurate, and clinically meaningful for the population in question.
\nA few studies have focused on patient-related factors or assessment using multiple metrics in analyzing long-term functional outcome and HRQL in surgically treated lower-extremity STS patients.
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\nMaterials and methods
\nThe dissertation is based on four papers that are focused on different aspects of functional outcome and HRQL in lower-extremity STS. The first paper was a pilot study in which the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumor Society (MSTS) score were translated to Finnish language according to accepted guidelines.
\nThe second paper was a systematic literature review that was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results on measurement types, measures, and time of measurement of functional outcome were compiled from the included studies. Validity of the used measures was reported.
\nThe third paper was a cross-sectional validation study that was based on STS limb-salvage patients. Assessments of functional outcome and HRQL were performed using the TESS, the QLQ-C30 Function and QoL modules, the 15D, and the MSTS score. The TESS was repeated twice at a 2- to 4-week interval.
\nThe fourth paper was a cross-sectional study in which functional outcome and HRQL analysis were performed using STS limb-salvage patients. The TESS, QLQ-C30, and 15D measures were used. Functional outcome and HRQL data were collected prospectively and other data retrospectively.
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\nResults
\nFinnish versions of the TESS and the MSTS questionnaires were translated and culturally adapted. No problems or difficulties were reported by the patients in completing the Finnish versions of TESS or MSTS questionnaires.
\nThe systematic literature review search found 3461 publications, of which 37 met the inclusion criteria. The measurement types used were clinician-reported outcomes (n=27), patient-reported outcomes (PRO) (n=20), and observer-reported outcomes (n=2). The most frequently used measures were the TESS (n=16) and the MSTS (1993) (n=12) scores. Three of the ten previously reported measures provided validated functional outcome scores. 
\nThe TESS questionnaire’s ceiling effect was noted, as 21% of the patients scored maximum points. The intraclass correlation coefficient between first and second administration of the TESS was very high (0.96). The results of exploratory factor analysis together with high Cronbach’s α (0.98) supported a unidimensional structure. The TESS correlated moderately with the MSTS score ( = 0.59, p < 0.001) and strongly with the mobility dimension in the 15D HRQL instrument ( = 0.76, p < 0.001) and physical function in QLQ-C30 ( = 0.83, p < 0.001).
\nA total of 141 patients undergoing limb-salvage surgery were included in the fourth study. Based on our sample, lower functional outcome was statistically significantly associated with older age, higher body mass index (BMI), and need for reconstructive surgery and radiotherapy. Lower HRQL was statistically significantly associated with older age, higher BMI, and reconstructive surgery.
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\nConclusion
\nTranslation and cultural adaptation of questionnaires should be performed according to internationally accepted guidelines. The current thesis is the first to validate the TESS distinctly for lower-extremity STS patients. In addition, the thesis demonstrates that the TESS measure is valid and reliable in Finnish.
\nBased on the systematic review, several different methods exist for assessing functional outcome in patients with lower-extremity sarcoma. The most frequently used measure is a validated TESS. The postoperative functional outcome in patients with lower-extremity STSs seems to increase back to the preoperative baseline level during long-term follow-up evaluation. Post-treatment functional outcome of patients with lower-extremity STS is affected by BMI, age, and need for reconstructive surgery and radiotherapy. The most significant predictors affecting HRQL are BMI, age, and need for reconstructive surgery. Although tumor- and treatment-related factors had an impact, patient-related factors such as age and BMI were the most consistent and significant determinants of both functional outcome and HRQL.

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