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Bone sarcomas: Overview of management, with a focus on surgical treatment considerations

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Intralesional surgery is generally to be avoided

Intralesional surgery should not be performed on high-grade bone sarcomas because it will lead to a high risk of local recurrence regardless of whether the patient receives perioperative radiation therapy or chemotherapy. If intra­lesional surgery has been performed for a high-grade sarcoma at an outside institution, re-excision of the tumor bed is recommended, as it has reduced the rate of recurrence following intralesional surgery. 13 For low-grade chondrosarcomas, intralesional curettage (ie, violating the margin of the tumor by scraping it out thoroughly) with use of an adjuvant (freezing, phenol, methylmethacrylate, or argon beam) may be adequate and has been reported to have a low rate of recurrence. 14

Preoperative planning

The resection procedure involves careful preoperative planning, typically guided by an MRI reviewed by a musculoskeletal tumor radiologist. General anesthesia is usually preferred because it can be used for a lengthy procedure, ensures complete muscle relaxation over the duration of the procedure, and allows for immediate postoperative nerve assessment. If neurovascular structures are not encased (ie, not more than 50% surrounded in the case of arteries or motor nerves), these structures are spared. If arteries are encased, arterial resection with reverse interpositional vein graft, synthetic graft, or vein allograft allows for bypass of the vessel and leaves the encased structure with the resection specimen for en bloc resection. In Ewing sarcoma, if the tumor is adjacent to but not encasing the neurovascular structures, the radiation oncologist is consulted about whether there is a preference for pre- or postoperative radiation therapy.

Limb salvage for Ewing sarcoma was originally with radiation only, but subsequently limb-salvaging surgery has been shown in several studies to have lower rates of local failure. 6,15–18 Whether primary radiation or surgery is performed after the initiation of chemotherapy is generally determined by a discussion between the surgeon and radiation oncologist about the feasibility of a negative margin with surgery and the inherent functional loss with resection. There are particular concerns about radiation in younger patients, who have a relatively high rate of postradiation sarcoma. 18

In osteosarcoma and chondrosarcoma, radiation has been found not to be effective, so resection with a negative margin is especially important for preventing local recurrence.

RECONSTRUCTION

Allograft or metallic prosthesis?

Figure 2. Anteroposterior radiograph (A) and anteroposterior MRI (B) showing the bone destruction and soft-tissue mass (arrows) of an aggressive osteosarcoma of the proximal tibia at the time of diagnosis. Anteroposterior (C) and lateral (D) radiographs after surgical resection and recon­struction in the same patient. The postoperative radiographs demonstrate the use of an allograft-prosthetic composite (APC) after resection with a negative margin.

For reconstruction after bone sarcoma resection, it is common to use costly modular metallic prosthetic joint replacements. We have found, however, that the most effective and easiest way to reconstruct the extensor mechanism sometimes is to use an allograft-prosthetic composite (APC) with a unicortical plate across the host bone–allograft junction. In the case of proximal tibial resection, for example, the APC consists of a proximal tibial allograft with soft-tissue patellar tendon and a rotating-hinge modular knee replacement prosthetic ( Figure 2

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