Principles of Surgical Resection & Margins
Tumour resection aims to achieve oncologic control while preserving function; margin status is critical for local recurrence risk.
Historical Background
Pre-1940s → Amputation was standard treatment.
1940s sonrası → Tumour resection
1970s → Chemotherapy + Radiotherapy + Limb-sparing surgery standard of care.
Basic Principles
Wide surgical margin = most important factor for local control.
All imaging must be completed before surgery.
Surgical planning should be based on imaging close to surgery date.
Enneking’s Margin Classification
Intralesional Curettage / piecemeal debulking / Macroscopic disease remains
Marginal Shelling out via pseudocapsule- reactive zone / May leave satellite or skip lesions
Wide En bloc with cuff of normal tissue / Adequate, but skip lesions possible
Radical En bloc removal of whole compartment / No residual local disease
Natural Barriers
Bone: Cortical bone, articular cartilage
Joint: Articular cartilage, capsule
Soft tissue: Fascial septa, tendon origins/insertions
Barrier effect: Fascia, tendon sheath, vascular sheath, cartilage act as protective margins
Critical Points in Limb-Sparing Surgery
Poor biopsy incision
Major vascular involvement
Motor nerve sacrifice
Preoperative infection
Expected poor motor function after resection
➡️ These complicate but do not always contraindicate limb-sparing surgery.
Advanced Techniques
Microsurgical reconstruction
Tendon transfers, nerve/vessel grafts
Flap coverage after large resections
Role of Adjunctive Therapies
Neoadjuvant chemotherapy/radiotherapy → may shrink tumour, improve margin status.
Wide margins still required even after neoadjuvant treatment.
Practical Margin Rules
Bone tumours: ≥ 3 cm bone marrow margin on T1 MRI.
Soft tissue tumours: Aim for ≥ 2 cm margin.
References
Enneking WF. Musculoskeletal Tumor Surgery. New York: Churchill Livingstone; 1983.
Simon MA, Springfield DS. Surgery for Bone and Soft-Tissue Tumors. Philadelphia: Lippincott-Raven; 1998.
Healey JH, Lane JM. Operative Techniques in Orthopaedic Surgical Oncology. Philadelphia: Lippincott Williams & Wilkins; 1996. (For the figures and the margin classification)
Mankin HJ, Hornicek FJ. Diagnosis, classification, and management of soft tissue sarcomas. Cancer Control. 2005;12(1):5–21.
O’Donnell RJ, Springfield DS, Motwani HK, et al. Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. J Bone Joint Surg Am. 1994;76(12):1827–33.
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