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Clinical experience with psychological aspectsin pediatric patients amputated for

malignancies

ARTICLE in TUMORI JULY 2004

Impact Factor: 1.27 Source: PubMed

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12 AUTHORS, INCLUDING:

Carlo Alfredo Clerici

Fondazione IRCCS Istituto Nazionale dei T

66PUBLICATIONS 247CITATIONS

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Maura Massimino


235PUBLICATIONS 2,706CITATIONS

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Monica Terenziani



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Filippo Spreafico



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Available from: Filippo Spreafico

Retrieved on: 07 February 2016
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Tumori, 90: 399-404, 2004

Introduction

Various malignant childhood tumors (eg, osteosarco-ma, Ewings sarcoma and, less frequently, soft tissuesarcomas of the extremities) may make limb amputationnecessary as part of the treatment. The systematic use ofmultidisciplinary integrated treatment in the last 20years and the use of preoperative chemotherapy in

particular has reduced the number of patients under-going amputation or dysarticulation: nowadays 5-20%of the patients with osteosarcoma are submitted to am-putation. However, when mutilating surgery is needed,it induces considerable stress in patients and their fami-lies. The better chances of long-term survival for thesepatients poses the problem of adapting to permanentdisability and its social and psychological consequencesin future adult life.

The aims of this study were to review the literatureon the psychological problems related to amputation inpediatric oncology and on the type of support provided,and to report on the psychological support provided at

the Pediatric Oncology Unit of the Istituto NazionaleTumori in Milan.

Material and methods

From January 1998 to June 2003 22 patients whowere candidates for limb amputation or disarticulation

were observed. Suitable psychological support was pro-vided for patients and their families.

In recent years, due to the increased request of evi-dence-based protocols, the necessity has arisen toclearly define the techniques of intervention also in thepsychosocial setting. However, we believe it is very dif-ficult to standardize into a protocol the procedures relat-ed to the support needed by these patients. Therefore, a

descriptive rather than a quantitative clinical methodwas adopted. Nevertheless, some simple guidelineswere followed in our individually tailored approach tothe talks with patients and parents.

Support was given on two different levels:

1) The medical psychology level: this involved themedical team (medical oncologists and nursingstaff), social assistants and teachers. In addition totechnical information, this first approach offered afirst line of emotional support and a restraint on theanguish associated with cancer and the prospect ofamputation.

2) The clinical psychology level: provided by a physi-cian specializing in clinical psychology, a memberof the medical team; this involved clinical talks andpsychotherapy sessions.

It is essential to underline that the foundations of op-timal communication with the family and the patient

Acknowledgments: This research was partly funded by the Associazione Bianca Garavaglia, which supported the medical psychologicalassistance provided at the Pediatric Unit of the Istituto Nazionale Tumori of Milan.

Correspondence to: Carlo Clerici, MD, Pediatric Oncology Unit, Istituto Nazionale Tumori, Via G. Venezian 1, 20133 Milan, Italy.Tel +39-02-23902588; fax +39-02-2665642; e-mail [email protected].

Received December 9, 2003; accepted March 30, 2004

CLINICAL EXPERIENCE WITH PSYCHOLOGICALASPECTS

IN PEDIATRIC PATIENTS AMPUTATED FOR MALIGNANCIES

Carlo Alfredo Clerici1,2, Andrea Ferrari1, Roberto Luksch1, Michela Casanova1, Maura Massimino1,Graziella Cefalo1, Monica Terenziani1, Filippo Spreafico1, Daniela Polastri1, Sergio Mapelli3, Primo Daolio3,

and Franca Fossati Bellani1

1Pediatric Oncology Unit, Istituto Nazionale dei Tumori, Milan; 2Department of Psychology, University of Milan-Bicocca, Milan;3Orthopedic Cancer Surgery, Istituto Gaetano Pini, Milan, Italy

Key words: amputation, childhood cancer, psychosocial adjustment, quality of life.

Aims and background: Amputation surgery in pediatric patientssuffering from malignant tumors is less common than in thepast, but has a great emotional impact on patients and theirfamilies as well as on the medical team. Studies addressingthe psychological aspects of limb amputation in childhoodcancer are still relatively limited, and the results have some-times been contradictory.

Me thods: At the Pediatric Oncology Unit of the IstitutoNazionale Tumori of Milan psychological support was provid-ed to candidates for amputation and their families, involving

medical oncologists, a clinical psychologist, and social assis-

tants. Twenty-two patients were analyzed and 16 underwentmutilating surgery.

Results: Different emotional reactions were observed. Surgeryproved to be easier to accept when the tumor caused painand functional loss. Specialist medical psychological supportwas needed in case of defense mechanisms (eg, splitting andprojection) and depressive reactions evolving into isolation orintolerance.Conclusions: The reported experience could be helpful in pro-viding adequate support to children with tumors requiring

mutilating surgery.


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should be laid from the very beginning of treatment, be-fore the need for amputation is mentioned. Duringevery talk it is important that the physician test the de-gree of understanding of the previous information re-ceived by patients and parents.

Although a protocol seems unfeasible, adequate rulesconcerning the setting, the time available and the orga-nization of the talks are needed. Particular attentionshould be paid to choosing a suitable setting where par-ticipants will not be disturbed; interruption by phonecalls, for example, should be avoided. In addition,enough time should be taken for the talks, with the pos-sibility of further talks, if necessary, to provide addi-tional information. During the talks with parents andpatients it is important that alternative treatment optionsand relative risks and benefits are presented to allowadequate informed consent but in particular to makesure that participants correctly understand all the detailsof the situation. Talks with parents and with patientsneed to be planned and performed separately.

The parents should be informed first about the needfor surgery and possibly be supported by psychologicalinterventions. When the parents have given their consentto the proposed amputation, the patient must be in-formed and prepared for the surgical procedure. This isdone using different, individually tailored strategies de-pending on the patients age and maturity: the aim ofthese talks is to help patients understand and convincethemselves of the need for this type of treatment.Through talks with relatives, the specialist seeks to iden-tify the patients personality traits, self-esteem and cog-nitive, social and physical abilities, the defense mecha-

nisms they have used in previous situations, their presentcoping skills and their need for specialist support aftersurgery. In younger patients it is best to avoid mention-ing the need for mutilating surgery too soon, since itmay cause unnecessary anguish and become intolerable.It is brought up only a few days before surgery (usually,2-3 days). This can be quite different for adolescents,who might need more time to come to terms with theclinical situation and the necessity of the mutilation.

Results

Twenty-two young patients were candidates for limb

amputation or disarticulation during the study period.Table 1 shows the characteristics of the patients. Sixteenunderwent mutilating surgery consisting of lower limbamputation above the knee in eight cases, below theknee in five cases, coxofemoral disarticulation in onecase, interscapular-humeral disarticulation in one case,and hemipelvectomy in one case. One patient did notundergo the scheduled surgery due to unexpected dis-ease progression detected at the preoperative workup.

Five adolescents (four girls, one boy; four osteosar-comas, one Ewings sarcoma) refused amputation. Oneof them underwent conservative surgical treatment(considered inadequate by our surgeons) elsewhere and

was lost to follow-up. The other four received radio-

therapy as the only local treatment. At the time of writ-ing, one patient was alive in complete remission (26months from diagnosis), one was alive with stable dis-ease (21 months from diagnosis), one relapsed locally at20 months from diagnosis while on second-line treat-ment, and the last patient developed pulmonary metas-tases 24 months from diagnosis and died.

Below we describe a number of particular case re-ports.

Case 1

V. was a 15-year old girl from Sicily with an os-teosarcoma of the right tibia. She helped out in a hair-dressers shop and was very anxious about her physicalappearance. During the first hospital stay she worriedmore about the side effects of treatment such as hairloss and the risk of scarring than about the prognosis ofher disease. On clinical reconsideration following thefirst cycles of chemotherapy, amputation was recom-mended. The patient defined the amputation as ab-solutely unacceptable. Despite several talks withphysicians, in agreement with her mother she decided toconsult various other clinical centers. Most of theseconfirmed the choice of amputation; however, she even-tually found a center that proposed conservative surgery(considered inadequate by our surgeons).

In this case, excessive denial prevented the patientfrom accepting the prospect of amputation, whichwould probably have caused an identity crisis beyondthe patients emotional resources.

Case 2

When she was 12 years old, A. was treated withchemotherapy and complete excision of an osteosarco-ma of the left tibia. At age 15 she had local recurrence ofthe disease requiring amputation. From the first talks

Table 1 - Characteristics of the patients

Candidates for amputation or disarticulation 22Gender

Male 12Female 10

Age 6-21 years (median, 15 years)Histology

Primary osteosarcoma 18Ewings sarcoma 1

Post-irradiation sarcoma 1Rhabdomyosarcoma 1Synovial sarcoma 1

Tumor siteFemur 11Tibia 5Pelvis 2Humerus 1Calcaneus 1Soft tissue of calf 1Soft tissue of foot 1

Patients who underwent mutilating surgery 16Type of surgery

Lower limb amputation above the knee 8Lower limb amputation below the knee 5Coxofemoral disarticulation 1Interscapular-humeral disarticulation 1Hemipelvectomy 1


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PSYCHOLOGICAL ASPECTS IN AMPUTATED PEDIATRIC PATIENTS 401

about surgery she surprised the physicians because sheappeared extremely relaxed about the idea of amputa-tion. When her mother despaired and asked for psycho-logical support, the patient invited her to calm down.She underwent amputation and, surprisingly, adamantlyrefused the planned chemotherapy, stating that it wouldnot add anything to what had already been done. She re-fused hospitalization and would not even talk to the doc-tors. Psychological counseling, suggested by managingphysicians and parents, initially took place at a hospitalfire exit. The patients maturity was assessed and theconclusion was that she was capable of understandingthe risks associated with incomplete compliance with thescheduled treatment. At a talk two weeks later she con-firmed her decision; the medical team accepted it and A.agreed to join a periodic follow-up program.

In this case the adolescent patient dramatically ex-pressed the need to regain some degree of control overher own life, opposing decisions made by others. Threeyears later she was still disease-free, adapting very wellto her prosthesis.

Case 3

C. was a 12-year-old boy with an osteosarcoma ofthe left leg. He was very fond of soccer, playing in ateam coached by his dad, and dreamed of becoming aprofessional when he grew up. When amputation of theleg below the knee was suggested, the patients reac-tions were dramatic. He accepted surgery only after nu-merous difficult talks. After surgery, he was depressedfor several months. Reorganization of existential plan-ning took place only after the conclusion of postopera-

tive chemotherapy: the patient quickly started rehabili-tation and used a prosthesis. During a talk he enthusias-tically reported, My dad bought me a radio-controlledcar. Its wonderful! I can take it apart and reassemble itin no time. Im not that fond of soccer anymoreIdlike to become a mechanic when I grow up.

This is a case of a process of adapting to amputationthat included a depressive phase followed by restructur-ing of the patients identity and a new investment forthe future. Unfortunately, the patient developedmetastatic pulmonary disease six months later; he un-derwent various chemotherapy regimens, but eventuallydied of the disease.

Case 4

O. was a 17-year-old girl from Southern Italy. Shehad a relapsing rhabdomyosarcoma of the left leg. Thedisease developed when she was 14 and since then shehad been treated with numerous cycles of chemotherapyand radiotherapy. She had left school several years be-fore and she drew great comfort from her friends, par-ticularly those of a folk group, with whom she dancedand sang. She paid a lot of attention to her physical ap-pearance. The disease had progressed extensively, how-ever, so much so that vast areas of muscle had been lost,exposing the underlying bone and smelling putrid. The

diseased leg was kept well bandaged and hidden from

the patient beneath a sheet. When amputation was sug-gested the parents were very worried about how O.would react and thought she would probably refusesurgery. During her talks with the doctors, she appearedgreatly anguished and she refused to give her consent.Further consultation at a different orthopedic oncologycenter confirmed the need for amputation. In the mean-time, she frequently asked the staff for details about thedisease and wanted to know what the amputation wouldbe like. A turning point was reached when O., in tears,asked, How do you accept living without a leg? Howdid the other patients make it?. In subsequent talkswith the medical staff O. was told about the experienceof other patients. She agreed to pick a date for surgery,providing she could change her mind at any time. Theanguish of the first days was replaced by severe anxietyprompted by the prospect of having to make a decision.She was virtually unable to sleep and dwelt constantlyon what was ahead of her. The last night before surgery,in the early hours of the morning, she wrote a farewellletter to her leg and after that managed to get somesleep without help. The next morning she gave herconsent and underwent the amputation. The postopera-tive course was satisfactory and the patient proudly ex-hibited the leg that is no longer there. She wanted herletter to be read by the doctors and thought her experi-ence might be useful to other patients.

In this patient, an excessively rigid denial developedinto the acceptance of her new situation only through acertain degree of idealization.

Case 5

R. was a 13-year-old girl originally from Sicily withan osteosarcoma of the right ankle. The disease requiredamputation of the right foot. The patient suffered in-tense pain and functional loss. Talks between the patientand the physicians were calm; the doctor emphasizedthe advantages of surgery, ie, remission of pain and theability to walk again without the aid of a prosthesis. Thegirl was also introduced to a young male patient whohad undergone the same amputation a few months earli-er. The boy told her about his experience and removedhis prosthesis to show her how it worked: surgery wasseen as a possibility to be considered without untowardanguish. Following surgery the patient rapidly adapted

to the prosthesis and experienced good functional re-covery.

Discussion

This study describes our experience with childrenand adolescents who require amputation, focusing onthe psychological aspects and the support provided by amultidisciplinary team composed of medical oncolo-gists, nurses, social assistants, teachers, and a medicalpsychologist. Twenty-two consecutive patients were in-cluded in the study.

Our experience confirmed that talks were generally

followed by strong emotional reactions, associated with


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a sense of impotence at being faced with a decision al-ready taken by others and the feeling of being attacked.First of all, the support measures aimed to ease thesepainful feelings.

The proposed surgery seemed easier to accept whenthe tumor caused significant pain and, more important-ly, involved the functional loss of a limb. The sharingof the decision might in this case be based on the per-ception of a clinical and physical improvement; the pa-tient would be freed of the pain and of a uselesslimb and might realistically see the prospects ofprompt rehabilitation and the possibility of functionalimprovement.

Amputation was more difficult to accept if it was pro-posed after the patient had received preoperativechemotherapy that had reduced the pain. The immediateresistance to the idea of amputation was generally asso-ciated with a rejection of the efficacy of surgery (Evencutting away the leg will be of no use), or an overesti-mation of the effects of initial treatment (What do youmean? Amputating the leg is pointless, the therapy is ef-fective, I feel much less pain and the swelling has gonedown.) hiding the anguish induced by the idea of severephysical disability and its consequences in future life.

In our patients, specialist medical psychological sup-port was needed when excessively rigid defence mecha-nisms, particularly denial, interfered with the patientsadaptation to reality and ability to express genuine con-sent or opposition to the surgical procedure. Copingwith amputation was generally a long-term process,partly because the physical and psychological changeswere associated with a disruption of the patients family

and social structure.From a psychodynamic point of view, we observedthe activation of defense mechanisms, such as splittingand projection, with variable degrees of adaptation.When splitting led to the diseased limb being investedwith all the persons positive and vital aspects, depres-sive reactions ensued (Without the leg I feel dead. Lifeis not worth living in this state), evolving into socialisolation.

When the affected limb was associated with negativeaspects, an idealization process developed, followed byreactions of omnipotence that might lead to underesti-mation of the functional loss (What was the use of

keeping the diseased leg? I feel much better now. Actu-ally, I feel a lot stronger). It was important to makesure that this did not evolve into a distorted sense of re-ality, with a diminished risk perception and inability toask for help.

Furious reactions sometimes develop, with an intol-erance of healthy people, which may compromise fami-ly, social and emotional relationships. The body mightbe felt as an object of curiosity. The uneasiness mightbe aggravated by the patient projecting his intoleranceof the disability on others (They give me strange looksbecause Im disabled; theres no respect for people whosuffer).

For patients adopting dysfunctional psychological

defense mechanisms despite effective disease control,the quality of life and social adaptability remain poorand specialist psychotherapy might be needed.

The defense mechanisms adopted by patients may al-so influence future rehabilitation and prosthetic options.If idealization prevails, the prosthesis is integrated intothe body image, facilitating omnipotence (With the arti-ficial limb I can do everything, just like before, or betterstill). Conversely, the prosthesis might be refused andexperienced as an obstacle to self-esteem, with the pa-tient offering practical explanations, such as, I prefernot to use the prosthesis ... Im used to getting alongwith crutches. It takes me less time to get into the car.Using the prosthesis makes me feel I have to depend onsomething artificial from the outside to be able to walk

Our experience should be compared with similarfindings reported in the literature. It is of note that thereis an abundance of literature on the psychosocial as-pects of adult patients undergoing traumatic (mainlywartime) or vascular amputation, but such studies areonly marginally useful in understanding the psychologi-cal aspects associated with mutilating surgery in pedi-atric oncology. In adult trauma, surgery is usually per-formed in an emergency setting associated with intensepain and involves subjects with a fully developed bodyimage. In childhood cancer, on the other hand, amputa-tion is generally performed as elective surgery. It in-volves limbs with residual functional utility and symp-tom relief may have been achieved by neoadjuvantchemotherapy. In addition, the body image is still in-complete in children and adolescents.

The first studies on the psychological aspects of mu-

tilating cancer surgery date back roughly 30 years,when childhood cancer began to receive specific treat-ment. Since then, psychological support for patients andanalyses of their quality of life have been instituted, in-volving staff with very different professional back-grounds (oncologists, psychiatrists, clinical or medicalpsychologists, childhood neuropsychiatrists, profession-al nurses)1.

Notwithstanding the numerous possible approaches,there are at least three common research areas: qualityof life, coping with the amputation, and the emotionalaspects of the disability.

The first area of research, concerning quality of life,

aims to address the effects of mutilating surgery on thepatients physical performance and subjective percep-tion of well-being. Quantitative statistical methods havebeen used to determine the incidence of psychopatho-logical conditions and the resulting difficulties in socialadaptation factors that have greater affinity with bio-logical studies than with psychological considerations.The term quality of life has become popular in recentyears; it includes heterogeneous aspects, eg the nor-mality of the subjects physiological parameters andability to perform daily activities, the presence of physi-cal or psychopathological symptoms, and adaptation inthe social, school and family settings2.

Interest in the problems of patients and families cop-


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PSYCHOLOGICAL ASPECTS IN AMPUTATED PEDIATRIC PATIENTS 403

ing with amputation stems mainly from cognitive-be-havioral research. Since the 1960s various psychosocialstudies have been performed in pediatric oncology eval-uating the aspects of coping with cancer. The greatestdifficulties arise from the lack of an unequivocal defini-tion of this concept: Folkman describes coping as theconstantly changing cognitive and behavioral effort tomanage specific external or internal demands3. How-ever, clinical experience generally suggests a continuityin the same individual between the defense mechanismsadopted in daily life and the coping skills used in life-threatening situations.

Research into the emotional and affective aspects ofamputation is psychodynamic in origin and has general-ly used the case method. This has led to the develop-ment of intervention theories and methods dealing withpatients and families faced with amputation.

The general impression from our literature analysis isthat the studies on the psychological aspects of patientsundergoing amputation for childhood cancer are inade-quate and their findings often contradictory. For exam-ple, there is no consensus on the psychological advan-tages of conservative surgery resulting in partial loss offunction compared with amputation4-6. A different lineof research investigated the role of psychological as-pects in protracted phantom limb syndrome, discussinghow it could be influenced by emotional factors7-9. Vari-ous studies have focused on quality of life assessmentand psychosocial unrest in these patients5,10,11. Otherfields of mainly cognitive-behavioral research have at-tempted to define predictive factors in coping with am-putation, including the severity of the disability, its per-

ception by the patient and family, the presence of pain,the patients gender and degree of intelligence5,12,13. Theassociation between the patients age at surgery andtheir ability to cope with amputation is still controver-sial: various authors agree that younger patients run agreater risk of interference with their personal evolu-tion, others described prompt and satisfactory coping inyoung amputated patients14,15. The time it takes to adaptto amputation may vary; anxiety and depression maypersist long after surgery16. Few studies have investigat-ed the dynamics of emotional adaptation in amputatedpatients. The condition has been compared with mourn-ing, marked by a succession of adaptive phases8.

Our experience has taught us that patients may adoptdifferent defense mechanisms, such as regression to aprevious phase of development or behavior designed toelicit care and attract attention17. Denial is common,particularly in the early stages, demanding an exhaust-ing effort to cope with an inevitable reality and some-times prompting a sense of anger. Carers therefore haveto deal with a substantial degree of aggressiveness,which is sometimes self-inflicted, resulting in depres-sion. Support aims partly at easing the anguish associat-ed with the sense of helplessness and facilitating theprocess of reorganizing future projects. Adolescents re-act dramatically to changes in their body image and to

having to depend more on others.

With regard to the psychological support required bypatients, it is of note that few studies have describedtheoretical and practical models of psychological sup-port for young patients undergoing amputation for can-cer, partially due to the limited number of cases gener-ally seen at a given cancer center. Interventional modelstherefore stem from the results of psychodynamic clini-cal trials and research in the field of general pediatricpsycho-oncology. One of the main models is the emo-tional containment postulated by the psychoanalyst WBion18. Cancer and any related disability are true lifeevents that induce a strong sense of anguish in pa-tients19; without a chance to share the experience, dwellon it and use it to evolve further, the mind is invaded byparalyzing anguish, confusion (beta elements) and theonset of defense mechanisms, eg splitting, projectionand denial. Support measures aim to reduce the pa-tients isolation, making them realize that anguish andaggressiveness can be accepted and restrained in a rela-tionship, and that these emotions are less dangerousthan pity and empathy. Various case reports describepsychological support for amputated patients based onthis model, without it being expressly quoted.

After completing medical treatment, the patient facesa change of perspective from curing a tumor to copingwith a disability. An identity crisis may develop, withthe need to formulate new projects for the future andnew life investments. During this phase, a condition de-fined by Schneider as the chronic patient triad may de-velop20,21 with dependence, regression and passivity ifthe patient converts the chronic illness into a conditionthat guarantees tangible primary benefits and secondary

psychological benefits, such as regaining a certainamount of control within the family and care and atten-tion that is mistakenly thought to arise from the pres-ence of disease.

A commonly described aspect is the fear of diseaseprogression or relapse, partly because the mutilation is aconstant reminder of the original disease. Worry maysometimes evolve into the so-called Damocles syn-drome, unless adaptive defense mechanisms are trig-gered22.

Conclusions

The apparent contradictions and shortcomings of theliterature emphasize the well-known problems involvedin merging clinical and psychological knowledge23. At-tempts to integrate the psychological sciences withmedical practice to produce quantitative observationsand statistically significant objective data may divertour attention from know-how deriving from the tradi-tion of clinical methodology.

It is an apparently obvious observation that any bodymutilation damages a patients integrity. Although diffi-cult to define with scales and questionnaires, this mustalways be borne in mind, both when recommendingsurgery and during the patients rehabilitation and cop-

ing with the disability. The identity crisis may occur on


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an intrapsychological level, revealing little on a behav-ioral level.

The patient-clinician relationship may help in thestages immediately after suggesting surgery and in theinitial restructuring of the patients identity, essential tothe integration of the amputation experience into theirlife history.

We feel that our experience could be useful for thosestudying childhood cancer that involves mutilatingsurgery. Psychological support must be provided at var-ious stages and on different levels, by the whole treat-ment team and also by staff with specific psychologicalcompetence. Its aims are to provide emotional contain-ment for the anguish associated with the prospect ofamputation, to evaluate defense mechanisms adopted by

the patient, and to treat maladaptive conditions, with thefinal purpose of integrating the experience of diseaseand amputation in a tolerable perspective of life. Thequality of life of amputated patients may vary greatlyin relation to their ability to develop and maintain an in-vestment in life and their future prospects.

We cannot claim to propose a protocol but we dowant to suggest the need for a multidisciplinary ap-proach at all centers dealing with pediatric patients withdiseases potentially requiring mutilating surgery. In ourexperience the aid of staff with specific psychologicaltraining is useful, although the leading part is played bythe oncologist, who must learn to develop proper com-munication skills. Such skills, however, are not easilyadaptable to a rigid framework or study protocol.

1. Van Dongen-Melman JE, Sanders Woudstra JAR: Psychoso-cial aspects of childhood cancer: a review of the literature.J Child Psychol Psychiatr, 27: 145-180, 1986.

2. Leplge A, Hunt S: The problem of quality of life in medi-cine. JAMA, 278: 47-50, 1997.

3. Folkman S: Personal control and stress and coping processes:a theoretical analysis. J Pers Soc Psychol, 46: 839-852, 1984.

4. Sugarbaker PH, Barofsky I, Rosenberg SA, Gianola FJ:Quality of life assessment of patients in extremity sarcomaclinical trials. Surgery, 91: 17-23, 1982.

5. Weddington WW Jr, Blindt Segraves K, Simon MA: Psycho-logical outcome of extremity sarcoma survivors undergoingamputation or limb salvage. J Clin Oncol, 10: 1393-1399, 1985.

6. Postma A, Kingma A, De Ruiter JH, Schraffordt Koops H,Veth RP, Goeken LN, Kamps WA: Quality of life in bone tu-mor patients comparing limb salvage and amputation of thelower extremity. J Surg Oncol, 51: 47-51, 1992.

7. Parkes CM: Reaction to the loss of a limb. Nurs Mirror Mid-wives J, 140: 36-40, 1975.

8. Parkes CM: Psycho-social transitions: comparison betweenreactions to loss of a limb and loss of a spouse. Br J Psychia-try, 127: 204-210, 1975.

9. Fisher K, Hanspal RS: Phantom pain, anxiety, depression,and their relation in consecutive patients with amputatedlimbs: case reports. BMJ, 7135: 903-904, 1998.

10. Boyle M, Tebbi CK, Mindell ER, Mettlin CJ: Adolescent ad-justment to amputation. Med Pediatr Oncol, 10: 301-312, 1982.

11. Tebbi CK, Petrilli AS, Richards ME: Adjustment to amputa-tion among adolescent oncology patients. Am J PediatrHematol Oncol, 11: 276-280, 1989.

12. Casari EF, Puncuh E: Amputare un arto: problemi psicologicinellosteosarcoma delladolescente. In: Argomenti di psico-oncologia, Comazzi AM, Morselli R (Eds), pp 98-106, CNR,Milano, 1988.

References

13. Tebbi CK: Psychological effects of amputation in osteosarco-ma. In: Osteosarcoma in adolescents and young adults: newdevelopments and controversies, Bennett Humphrey G,Schraffordt Koops H, Molenaar WM (Eds), pp 39-44, Kluw-er Academic Publishers, Boston, 1993.

14. Frantz CH: The child with an amputation. In: The child witha handicap, Martmer EE (Ed), pp 56-61, Thomas, Spring-field, 1959.

15. Vote PA, Burgers JM, van Putten WJ, van DobbenburghOA: Amputations in children. Clinical indications and psy-chological implications. Arch Chir Neerl, 25: 427-433,1973.

16. Simon JI: Emotional aspects of physical disability. Am J Oc-cup Ther, 25: 408-410, 1971.

17. Siller J: Psychological concomitants of amputation in chil-dren. Child Develop, 31: 109-120, 1960.

18. Bion WR: Apprendere dallesperienza. Armando, Roma,1972.

19. Di Cagno L, Gandione M, Massaglia P: Il contenimento delleangosce come momento terapeutico nel lavoro con i genitoridi bambini con patologia organica grave. In: Dalle curematerne allinterpretazione, Fava Vizziello G, Stern DN(Eds), pp 115-142, Cortina, Milano, 1992.

20. Schneider PB: La psychologie du malade chronique. FoliaPsychopractica, pp 112-119, Hoffmann La Roche SA,Basilea, 1978.

21. Comazzi AM: Riabilitazione psicologica sino alla fine. ActaBiomedica de lAteneo Parmense, 63: 461-468, 1992.

22. Koocher GP, OMalley JE: The Damocles syndrome: psy-chosocial consequences of surviving childhood cancer. Mc-Graw Hill, New York, 1981.

23. Sala G: La necessit di unopzione clinica per la ricerca psi-cologica in ambito medico. In: Ricerche di psicologia, Cesa-Bianchi M, Bosio AC (Eds), Franco Angeli, 1996-1997.

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