Surgical management of very large musculoskeletal sarcomas

The management of almost all sarcomas in the musculoskeletal system includes surgery, although chemotherapy and radiotherapy also may play an important role in the treatment. The surgical treatment comprises complete resection of the tumor with a margin of normal tissue. This can be accomplished by local resection and then reconstruction of the resultant deficit, or amputation. Resection of the tumor without amputation, that is, limb-salvage surgery, can be accomplished in 80% of cases and is generally preferred by the patient. The very large, neglected, or aggressive tumor, however, can make resection with a wide margin impossible or very difficult. Many large tumors will require amputation in order to be sure that the entire tumor is removed, as the priority is saving the patient's life, with limb preservation secondary. Even an amputation may be very difficult when the pelvic or shoulder girdle is involved. Sometimes the surgeon may agree to do a marginal resection when the patient or family absolutely refuses amputation, but they must be made to understand that this may compromise survival. In cases where there is circumferential skin involvement or projected loss, some unusual techniques, such as amputation-replantation can be done, especially in the upper limb, where in spite of gross shortening, function can be much better than any prosthesis. Even if there are metastases present, sometimes amputation or even local resection is offered as palliation if the patient's life is made miserable by a large fungating tumor. Local resection of a huge tumor can be a formidable challenge to the surgeon, and the margin may consist of a few millimeters of compressed muscle. Good skin cover may be a major problem, and free tissue transfer may be necessary if local flaps are not possible. In all cases, one must ask if the resection-reconstruction with all its complications and risk to the patient of recurrence is really better than an amputation.