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Surgical approach to soft tissue sarcomas of the extremities
Annals of Oncology 3 (Suppl. 2): S59-S61, 1992. © 1992 Kluwer Academic Publishers. Printed in the Netherlands.
Original article Surgical approach to soft tissue sarcomas of the extremities G. Pignatti & M. Campanacci Istituto Ortopedico Rizzoli, Bologna, Italy
the anatomic location of the tumor, and point out the main goals: first to provide local control of the tumor, and second to preserve as much function as possible without jeopardizing the adequacy of the procedure.
Soft tissue sarcomas (STS) are rare and form a heterogeneous group which comprises all malignant tumors of non-epithelial extraskeletal tissues with the exception of the hematopoietic system and glia. Malignant tumors of the peripheral and autonomic nervous system are included among the STS because they pose similar diagnostic and therapeutic problems [1]. Although STS may involve any anatomic site, the most common locations are the extremities. Traditionally, ablative surgery was considered to be the most effective treatment for STS. In recent years evidence has been accumulating that limited surgery combined with radiotherapy and/or adjuvant chemotherapy yield results comparable to those of more extensive surgery [2-5]. It is important to emphasize that surgical treatment is the crucial step in designating a suitable therapeutic program and depends upon meticulous preoperative examination and consequent clinical staging [6-9]. In evaluating a patient with a sarcoma and planning the surgical procedure, our first goal must be to obtain control of the primary tumor. Local recurrence of the primary tumor leads to both an increase in magnitude of the local surgery (frequently amputation) and a higher incidence of metastases. The second goal is to preserve as much function as possible without jeopardizing the adequacy of the procedure. It is well recognized that surgical management depends more on the anatomic location of the tumor than on its histologic type, malignancy grade and size [10]. A variety of limb salvage surgical procedure has been advocated, but if this approach is not feasible, demolitive surgery must be mandatory. This is not necessarily bad, as amputation is a safe operative procedure, with a short rehabilitation period and sometimes a satisfactory function. Nowadays, the introduction of new technologies and materials in the external prosthesis field has allowed us to satisfy the amputee's requirements.
We must not forget that amputation is not a definition of surgical margin and may indeed produce any of the surgical margins, including intralesional and marginal. Wide or radical surgical margins are essential in order to achieve local control of the primary tumor. Marginal excision (shelling out) is not indicated carrying a high risk of local recurrence. We recommend reexcision of the previously operated bed tumor in all patients referred to us having had a prior marginal excision. In more than 50% of patients treated with re-excision of the scar of the previous marginal surgery, viable tumor cells were histologically found in the resected specimen [11,12]. We reserve radical resection for extracompartmental lesions or for extremely large intracompartmental tumors. A radical resection is the removal of the entire compartment or compartments involved by tumor. This procedure allows us to include in the resected specimen skip metastases. Following this procedure the functional results are usually poor. For this reason, when feasible, we prefer to perform a wide excision for local control. This is the most commonly used surgical margin for sarcomas. The tumor specimen is surrounded by a continuous layer of normal tissue. As advocated by Stener, we perform a primary myectomy, without biopsy confirmation, whenever the clinical history indicates a sarcoma and a minor functional impairment is expected from the surgical excision [13]. When the tumor is adjacent to the bone, radionuclide bone scan will assist in defining the relationship of the tumor to the bone. Enneking reports that in more than 90% of the cases the bone scan is able to detect whether the bone adjacent to a STS is reactive, which means it is possibly the site of satellites of the tumor [14]. In such cases, in order to obtain a wide surgical margin it is necessary to include the periosteum or, better, a tangential section of the bone close to the
Key words: soft tissue sarcoma, surgical technique
Downloaded from http://annonc.oxfordjournals.org/ at University of California, San Francisco on March 11, 2015
Summary. Authors emphasize the primary role of surgery in the treatment of soft tissue sarcoma, confirming the recent acquisition that conservative surgery and adjuvant therapy yield results comparable to those of more extensive surgery. Subsequently, the authors delineate the general guidelines in the surgical treatment of soft tissue sarcoma, depending on
Fig. 1. a) The CT scan demonstrates a large lesion involving the vascular bundle; b) The intraoperative photograph shows the Goretex vascular by-pass.
tumor. In this second case the surgeon has to be aware of the mechanical weakening of the bone that can lead to fracture. If a tumor completely surrounds a major nerve trunk, the only way to obtain an adequate surgical margin is to sacrifice the nerve. On the other hand, when the nerve is only adjacent to but no surrounded by a sarcoma, it is possible to excise the tumor with the epineurium, which acts as a thin but continuous compartmental barrier, saving the nerve. When the tumor is located close to or involves the major vessels, it is necessary to include the vessels in the resection. The CT. scan, M.R.I, and the angiogram well demonstrate the contiguous association of the vessels to the tumor. In such cases we widely resect the tumor together with the vessels and we now perform solely arterial by-pass utilizing a Goretex graft or autologous safena vein graft (Fig. 1). Soft tissue tumors rarely grow close to or into a joint. In such cases it is necessary to perform an en-bloc resection of the joint. Following the resection we usually utilize a prosthesis or an allograft reconstruction (Fig. 2). We perform a free myocutaneous flap coverage of the defect when the preoperative study confirms the need to include in the resection of large amount of skin to achieve a wide margin. This occurs frequently, par-
ticularly in regions such as elbow and distal, knee and distal. Microsurgery has represented a great progress and contributed to drastically reduce amputations. Adequate surgery is the first and most important treatment in STS. It must be performed following precise oncological guidelines only in specialized centers. This latter message should be spread to the entire medical community to avoid the severe consequences from the usually inappropriate treatment of these tumors. Acknowledgement
This work was supported by Rizzoli Institute Research Funds. References 1. Enzinger FM. Clinicopathological correlation in soft tissue sarcomas. In van Oosterom, van Unnik (eds): Management of Soft Tissue and Bone Sarcomas. Raven Press: New York, 1986. 2. Liebel SA, Tranbaugh RF, Wara W et al. Soft tissue sarcomas of the extremities. Cancer 1982; 50: 1076-83. 3. Antman KH, Blum RH, Wilson RE et al. Survival of patients with localized high-grade soft tissue sarcoma with multimodality therapy. Cancer 1983; 51: 396-402. 4. Eilber FR, Morton DL, Eckardt J, Grant T, Weisemburger T. Limb salvage for skeletal and soft tissue sarcomas: A multidisciplinary preoperative chemotherapy. Cancer 1984; 57: 2579-84. 5. Potter DA, Kinsella T, Glatstein E et al. High-grade soft tissue sarcomas of the extremities. Cancer 1985; 58: 190-205. 6. Kinnard P. Preoperative assessment of soft tissue sarcoma of
Downloaded from http://annonc.oxfordjournals.org/ at University of California, San Francisco on March 11, 2015
Fig. 2. a) The MRI demonstrates a sinovial sarcoma growing into the knee joint; b) The surgical specimen following the extra-articular resection; c) The allograft arthrodesis reconstruction.
61 the extremities. In current concepts of diagnosis and treatment of bone and soft tissue tumors. Springer-Verlag: Berlin, Heidelberg, 1984. Enneking WF, Spanier SS, Godman MA. A system for surgical staging of musculoskeletal sarcoma. Clinical Orthop 1980; 153:106-20. Rydholm A, Rooser B. Surgical margins for soft tissue sarcoma. JBJS 1987; 69-A: 1074-8. Springfield DS. General guidelines in treatment of sarcoma. In van Oosterom, van Unnik (eds): Management of Soft Tissue and Bone Sarcomas. Raven Press: New York, 1986. 10. Markhede G, Angervall L, Stener B. A multivariate analysis of the prognosis after surgical treatment of malignant soft tissue tumors. Cancer 1982; 49: 1721-33. n. Simon MA, Enneking WE The management of soft tissue sarcoma of the extremities. JBJS 1976; 58-A: 317-27.
12. Gherlinzoni F, Bacci G, Picci P, Capanna R, Calderoni P, Campanacci M. Randomized trial for the treatment of high grade soft tissue sarcoma of the extremities: Preliminary observation. J Clin Oncol 1986; 4: 552-8. 13. Stener B. The management of soft tumors. International Orthopaedics 1978; 1: 289-98. 14. Enneking WF, Chew FS, Springfield DS, Hudson TM, Spanier SS. The role of radionuclide bone scanning in determining the resectability of soft tissue sarcoma. JBJS 1981; 63-A: 249-57. Correspondence to: Giovanni Pignatti M.D. Istituto Ortopedico Rizzoli Via Pupilli 1 40136 Bologna Italy Downloaded from http://annonc.oxfordjournals.org/ at University of California, San Francisco on March 11, 2015
Original article Surgical approach to soft tissue sarcomas of the extremities G. Pignatti & M. Campanacci Istituto Ortopedico Rizzoli, Bologna, Italy
the anatomic location of the tumor, and point out the main goals: first to provide local control of the tumor, and second to preserve as much function as possible without jeopardizing the adequacy of the procedure.
Soft tissue sarcomas (STS) are rare and form a heterogeneous group which comprises all malignant tumors of non-epithelial extraskeletal tissues with the exception of the hematopoietic system and glia. Malignant tumors of the peripheral and autonomic nervous system are included among the STS because they pose similar diagnostic and therapeutic problems [1]. Although STS may involve any anatomic site, the most common locations are the extremities. Traditionally, ablative surgery was considered to be the most effective treatment for STS. In recent years evidence has been accumulating that limited surgery combined with radiotherapy and/or adjuvant chemotherapy yield results comparable to those of more extensive surgery [2-5]. It is important to emphasize that surgical treatment is the crucial step in designating a suitable therapeutic program and depends upon meticulous preoperative examination and consequent clinical staging [6-9]. In evaluating a patient with a sarcoma and planning the surgical procedure, our first goal must be to obtain control of the primary tumor. Local recurrence of the primary tumor leads to both an increase in magnitude of the local surgery (frequently amputation) and a higher incidence of metastases. The second goal is to preserve as much function as possible without jeopardizing the adequacy of the procedure. It is well recognized that surgical management depends more on the anatomic location of the tumor than on its histologic type, malignancy grade and size [10]. A variety of limb salvage surgical procedure has been advocated, but if this approach is not feasible, demolitive surgery must be mandatory. This is not necessarily bad, as amputation is a safe operative procedure, with a short rehabilitation period and sometimes a satisfactory function. Nowadays, the introduction of new technologies and materials in the external prosthesis field has allowed us to satisfy the amputee's requirements.
We must not forget that amputation is not a definition of surgical margin and may indeed produce any of the surgical margins, including intralesional and marginal. Wide or radical surgical margins are essential in order to achieve local control of the primary tumor. Marginal excision (shelling out) is not indicated carrying a high risk of local recurrence. We recommend reexcision of the previously operated bed tumor in all patients referred to us having had a prior marginal excision. In more than 50% of patients treated with re-excision of the scar of the previous marginal surgery, viable tumor cells were histologically found in the resected specimen [11,12]. We reserve radical resection for extracompartmental lesions or for extremely large intracompartmental tumors. A radical resection is the removal of the entire compartment or compartments involved by tumor. This procedure allows us to include in the resected specimen skip metastases. Following this procedure the functional results are usually poor. For this reason, when feasible, we prefer to perform a wide excision for local control. This is the most commonly used surgical margin for sarcomas. The tumor specimen is surrounded by a continuous layer of normal tissue. As advocated by Stener, we perform a primary myectomy, without biopsy confirmation, whenever the clinical history indicates a sarcoma and a minor functional impairment is expected from the surgical excision [13]. When the tumor is adjacent to the bone, radionuclide bone scan will assist in defining the relationship of the tumor to the bone. Enneking reports that in more than 90% of the cases the bone scan is able to detect whether the bone adjacent to a STS is reactive, which means it is possibly the site of satellites of the tumor [14]. In such cases, in order to obtain a wide surgical margin it is necessary to include the periosteum or, better, a tangential section of the bone close to the
Key words: soft tissue sarcoma, surgical technique
Downloaded from http://annonc.oxfordjournals.org/ at University of California, San Francisco on March 11, 2015
Summary. Authors emphasize the primary role of surgery in the treatment of soft tissue sarcoma, confirming the recent acquisition that conservative surgery and adjuvant therapy yield results comparable to those of more extensive surgery. Subsequently, the authors delineate the general guidelines in the surgical treatment of soft tissue sarcoma, depending on
Fig. 1. a) The CT scan demonstrates a large lesion involving the vascular bundle; b) The intraoperative photograph shows the Goretex vascular by-pass.
tumor. In this second case the surgeon has to be aware of the mechanical weakening of the bone that can lead to fracture. If a tumor completely surrounds a major nerve trunk, the only way to obtain an adequate surgical margin is to sacrifice the nerve. On the other hand, when the nerve is only adjacent to but no surrounded by a sarcoma, it is possible to excise the tumor with the epineurium, which acts as a thin but continuous compartmental barrier, saving the nerve. When the tumor is located close to or involves the major vessels, it is necessary to include the vessels in the resection. The CT. scan, M.R.I, and the angiogram well demonstrate the contiguous association of the vessels to the tumor. In such cases we widely resect the tumor together with the vessels and we now perform solely arterial by-pass utilizing a Goretex graft or autologous safena vein graft (Fig. 1). Soft tissue tumors rarely grow close to or into a joint. In such cases it is necessary to perform an en-bloc resection of the joint. Following the resection we usually utilize a prosthesis or an allograft reconstruction (Fig. 2). We perform a free myocutaneous flap coverage of the defect when the preoperative study confirms the need to include in the resection of large amount of skin to achieve a wide margin. This occurs frequently, par-
ticularly in regions such as elbow and distal, knee and distal. Microsurgery has represented a great progress and contributed to drastically reduce amputations. Adequate surgery is the first and most important treatment in STS. It must be performed following precise oncological guidelines only in specialized centers. This latter message should be spread to the entire medical community to avoid the severe consequences from the usually inappropriate treatment of these tumors. Acknowledgement
This work was supported by Rizzoli Institute Research Funds. References 1. Enzinger FM. Clinicopathological correlation in soft tissue sarcomas. In van Oosterom, van Unnik (eds): Management of Soft Tissue and Bone Sarcomas. Raven Press: New York, 1986. 2. Liebel SA, Tranbaugh RF, Wara W et al. Soft tissue sarcomas of the extremities. Cancer 1982; 50: 1076-83. 3. Antman KH, Blum RH, Wilson RE et al. Survival of patients with localized high-grade soft tissue sarcoma with multimodality therapy. Cancer 1983; 51: 396-402. 4. Eilber FR, Morton DL, Eckardt J, Grant T, Weisemburger T. Limb salvage for skeletal and soft tissue sarcomas: A multidisciplinary preoperative chemotherapy. Cancer 1984; 57: 2579-84. 5. Potter DA, Kinsella T, Glatstein E et al. High-grade soft tissue sarcomas of the extremities. Cancer 1985; 58: 190-205. 6. Kinnard P. Preoperative assessment of soft tissue sarcoma of
Downloaded from http://annonc.oxfordjournals.org/ at University of California, San Francisco on March 11, 2015
Fig. 2. a) The MRI demonstrates a sinovial sarcoma growing into the knee joint; b) The surgical specimen following the extra-articular resection; c) The allograft arthrodesis reconstruction.
61 the extremities. In current concepts of diagnosis and treatment of bone and soft tissue tumors. Springer-Verlag: Berlin, Heidelberg, 1984. Enneking WF, Spanier SS, Godman MA. A system for surgical staging of musculoskeletal sarcoma. Clinical Orthop 1980; 153:106-20. Rydholm A, Rooser B. Surgical margins for soft tissue sarcoma. JBJS 1987; 69-A: 1074-8. Springfield DS. General guidelines in treatment of sarcoma. In van Oosterom, van Unnik (eds): Management of Soft Tissue and Bone Sarcomas. Raven Press: New York, 1986. 10. Markhede G, Angervall L, Stener B. A multivariate analysis of the prognosis after surgical treatment of malignant soft tissue tumors. Cancer 1982; 49: 1721-33. n. Simon MA, Enneking WE The management of soft tissue sarcoma of the extremities. JBJS 1976; 58-A: 317-27.
12. Gherlinzoni F, Bacci G, Picci P, Capanna R, Calderoni P, Campanacci M. Randomized trial for the treatment of high grade soft tissue sarcoma of the extremities: Preliminary observation. J Clin Oncol 1986; 4: 552-8. 13. Stener B. The management of soft tumors. International Orthopaedics 1978; 1: 289-98. 14. Enneking WF, Chew FS, Springfield DS, Hudson TM, Spanier SS. The role of radionuclide bone scanning in determining the resectability of soft tissue sarcoma. JBJS 1981; 63-A: 249-57. Correspondence to: Giovanni Pignatti M.D. Istituto Ortopedico Rizzoli Via Pupilli 1 40136 Bologna Italy Downloaded from http://annonc.oxfordjournals.org/ at University of California, San Francisco on March 11, 2015