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01 Surgical Management of Sarcoma
The guiding principle of surgical intervention is complete removal of the primary tumor with maximum retention of function and minimum possibility of local recurrence. Classically, in extremity tumours, this has been accomplished by ablative surgery (amputation). Today, the increasing use of limb salvage procedures has become possible because of effective adjuvant radiation therapy(see below). Neo- adjuvant chemotherapy may contribute in some instances by reducing tumor edema and size and by eradicating micrometastases. As a result, it becomes even more essential that a multi-disciplinary treatment team plan the overall management recommendations from the beginning.
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Excision Type |
Synonymous terms |
Comments |
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Intralesional Excision* |
curettage, debulking or piecemeal removal |
This procedure may be appropriate for some benign tumors, but never for malignant tumors |
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Marginal excision* |
'shell-out' |
This procedure transgresses the pseudo-capsule (zone of reaction), microscopic tumor is left behind and opened tissue planes are contaminated.
Local recurrence is 100% in high-grade lesions and high in lower grade entities. |
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Wide excision* |
intra-compartmental excision**
wide local excision |
The neoplasm is removed outside its reactive zone, with an adequate but variable amount of "normal" tissue attached to it. In soft tissue sarcomas, unless the margin is extremely wide, there remains a likelihood of local recurrence. |
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Radical Excision* |
extra-compartmental excision** |
the tumor and surrounding tissues are removed by dissecting along planes that are separated from the tumor and its tissue of origin by at least one involved anatomical structure in both longitudinal and transverse planes. |
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*The procedure amputation may fit into any one of these four categories as inadequate (or adequate) surgical treatment.
** For musculoskeletal lesions |
- Surgery (PLANNED wide local excision) is the most important component of curative therapy, except in the rare case.
- Inoperable tumors are incurable. Ewing's sarcoma and rhabdomyosarcoma may be possible exceptions with some patients who have had inoperable disease being cured with multi-modality therapy including chemotherapy and less local excision and/or radiation therapy.
- Imaging and diagnostic procedures should precede PLANNED wide local excision.
- Radical surgery does not imply adequate surgery. Very careful pre-operative assessment is required before attempting wide excision.
- Even the presence of demonstrable pulmonary metastases need not preclude curative treatment - these can be resected surgically with the proper indications.
- In the case of extensive lytic destruction of weight bearing bones with pain, fracture or impending fracture – rigid internal fixation may be considered as part of the management after considering the diagnosis and extent of disease. In patients over 40, the most common cause of a such a lesion is metastatic disease – BUT primary bone tumors do still occur. Curative management may be seriously compromised if hasty surgery is planned without consideration of the clinical setting.
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