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Musculoskeletal tumor surgery may yield better function and QOL

Lumps >5 cm should be considered malignant until proven otherwise.

Issue: November 2004

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Obtaining a successful outcome from surgical treatment of sarcoma depends on defining the patient’s and surgeon’s definitions of success, and then performing a procedure that produces a better quality of life for the patient. “A successful sarcoma operation removes the tumor, gets complete local control, restores the patient to function, has very few complications,” said Robert J. Grimer, FRCS, orthopedic consultant at the Royal Orthopaedic Hospital in Birmingham, England.

Grimer delivered the Hunterian Lecture at the British Orthopaedic Association Annual Congress, reviewing factors related to tumor surgery outcome, such as tumor size and type, resection techniques and prognostic factors. Paraphrasing a statement by John Hunter, the Scottish surgical pioneer for whom the lecture was named, Grimer said: “Some cancers may be cured by surgery; deciding which cancers is difficult. But, if the cancer is new and is not invading nearby tissue, there is no harm in removing it. Very sound advice.”

Although orthopedic surgeons who are generalists do not typically perform surgery in most cancer cases, they need to know how to identify tumors early and when to refer their patients with osteosarcomas, Ewing’s sarcomas and other musculoskeletal tumors to a specialist. Most of the nearly 2000 patients with sarcomas treated at Grimer’s hospital were referred, he said.

Grimer emphasized early treatment. “Getting them while they’re small is important … Any lump that is >5 cm should be considered to be a sarcoma until proven otherwise … The bigger the tumor the worse the prognosis.” The average size of tumors he treats is 10 cm.

The chances a patient with a 25-cm tumor will be cured are six times worse than for a patient with <5-cm tumor. “If you see someone in your clinic with a lump that’s bigger than a golf ball, please think this could be a sarcoma,” he said.

When planning treatment, include a wide enough margin to minimize cancer recurrence locally, remembering that the patient’s goals for an active, satisfactory lifestyle postop may be best met through limb amputation, Grimer said. “Surgery is still needed to heal sarcomas. Resection of tumors is essential. … Surgery doesn’t just resect the tumor, it restores function.”

A database of sarcoma surgeries Grimer established in 1986 has shown that among 14,136 patients, the local recurrence risk was 9% with wide excision. Intralesional excision, which he advised against, had a 34% recurrence risk. It was 19% with marginal excision.

Key prognostic factors were the presence of metastases at diagnosis, tumor size, its ability to be resected, and responsiveness of the tumor to chemotherapy, particularly in cases of osteosarcomas and Ewing’s sarcomas. According to the database, for the last 20 years the overall cure rate for patients without metastases at diagnosis was approximately 52%. “If you have metastases at diagnosis, you only have a one in 10 chance of being cured,” he said.

For more information:

• Grimer RJ. Hunterian Lecture: Successful surgery for sarcomas. Presented at the British Orthopaedic Association Annual Congress. Sept. 15-17, 2004. Manchester, England.