Surgery for Tumours

AIMS

• Tumour removal to gain local control & minimize recurrence while maintaining functional limb

Margins

• 1 Intracapsular
  • piecemeal removal
  • Thru capsule / pseudocapsule into lesion
  • Gross tumour remains

• 2 Marginal
  • extra-capsular en bloc removal
  • plane of dissection within reactive zone
  • Entire lesion removed in one piece
  • Microscopic tumour remains
  • leaves
  • reactive non neoplastic tissue
  • micro-extensions of benign aggressive lesions
  • micro-satellites of malignant lesions
  • skip mets of hihg grade lesions
• 3 Wide
  • En bloc resection of lesion, capsule & reactive zone
  • Beyond reactive zone
  • dissection thru normal, non neoplastic, non reactive tissue thru compartment involved
  • > 7cm level on Te99 scan
  • > 5cm level on MRI
  • Tumour & cuff of Normal tissue
  • May leave skip lesions behind
  • Hence MRI
  • Remove Bx site
  • May mean amputation
• 4 Radical
  • Extracompartmental removal of all compartments that contain tumour
  • Amputation is not necessarily Radical
  • Radical resection possible with limb salvage
• Exceptions
  • 1 Skin & Subcutaneous tissue
    • Wide margin is < 5 cm
    • Radical margin is > 5 cm
  • 2 Extracompartmental lesions
    • Can’t have Radical E/O Extracompartmental lesions
    • No longidudinal barriers to extracompartmental spaces
• Defined as Radical if :
  • Radical in transverse plane
  • Longit margin at same level as origin or insertion of muscle
• Two Compartments
  • Both compartments must be removed to achieve radical resection
  • Sometimes only practical way to achieve this is Amputation
• Contamination
  • When lesion entered, wound contaminated
  • If exposed tissues not removed, margin is intracapsular
• ====
• Surgery & Recurrence rate
  • IA IB IIA IIB
  • INTRACAP 90% 90% 100%100%
  • EXTRACAP 70% 70% 90% 90%
  • WIDE 10% 30% 50% 70%
  • RADICAL 0% 0% 10% 20%
• ========
• Limb Salvage Surgery
  • Options if Bony Involvement
    • Arthrodesis
    • Allograft arthrodesis
    • Allograft arthroplasty
    • Endoprosthesis
• Technique
  • Radical or Wide Resection
  • Extra-articular resection is preferred if a tumour is adjacent to or involves a joint
  • Prophylactic AB
• °Torniquet if possible
• No Eschmarc
• Bx site excised
• Tumour &/or pseudocapsule not visualised during procedure
• Distant flaps should not be developed until the tumour has been removed
• All dead space should be eliminated, & haematoma formation should be prevented
• Surgical wound marked with clips for later DXRT planning
• Motor reconstruction by regional muscle transfer
• Adequate soft tissue cover by flap to avoid skin necrosis
• Reconstruct with
• Endoprosthesis
• Allograft
• Autograft ~ Vasc or°Vasc
• Local Graft
• Remove involved bone
• Irradiate it +++
• Re-insert it
• Van Ness Rotationplaty
• Endoprosthesis have better results
• Rotating & Hinge
• Expandable if final LLD > 2cm
• Modular
• 5yr surv 75% Modular
• 5yr surv 55% Expandable
• CInd if < 8yo
• Massive Allograft = Fail ~ 5yrs
• Collapse
• Osteoarthritis
• Van Ness
• F’n & outcome > than Prosthesis or Allograft
• ———–
• 3 Surgical Phases Benign Tumours
  • 1 Excise
  • 2 Sterilize
  • 3 Reconstruct
  • Bone
  • Soft tissue
• ———-
• Contraind Limb Salvage
• Absolute
  • 1 Can’t obtain wide margins
  • 2 Major NV involvement
    • Vessel grafts are possible
    • Nerve remains at risk
  • 3 Infection
• Relative
  • 1 Pathological Fracture
    • Haematoma spreads tumour beyond accurately defined limits
    • Amputate
  • 2 Inappropriate Previous Bx
  • 3 Signif skel immaturity
    • Pred LLD > 8cm
    • Telescoping rods availiable
  • 4 Extensive muscle involvement
    • Relative
    • Need f’ning muscle

Outcome

• Good as amputation
• Similar survival & local recurrence rates compared to amputation
• Psychologieal effect important

Complications

• Intraop & Early & Late
• Wound infection
• Allograft infection & non-union
• Prosthesis breakage
• LLD
• Lysis