How should orthopaedic oncologists prevent unplanned resections of soft tissue sarcomas by general practitioners?

Unlike other orthopaedic fields, the disease encountered in the field of musculoskeletal oncology can be life-threatening. It is therefore necessary for orthopaedic oncologists to have a sound grasp of their discipline, and to have skill and expertise when managing their patients. In recent years, there has been a tendency for patients with musculoskeletal sarcomas to be treated at specialist clinics, and therefore orthopaedic general practitioners have fewer opportunities to gain experience in musculoskeletal oncology. However, it is extremely likely that patients with a serious sarcoma will first visit a local clinic and consult a general practitioner. Therefore it is obvious that the prognosis of such patients would be significantly affected by the initial responses of the general practitioner they consult. Against this background, the main theme for the 45th Annual Musculoskeletal Tumor Meeting of the Japanese Orthopaedic Association in 2012 is ‘‘Reconfirmation of basic knowlege of orthopaedic oncology – The importance of a good working relationship between general practitioners and specialists’’. In the last 40 years, the clinical outcomes for musculoskeletal sarcoma have markedly improved due to the establishment of neoadjuvant chemotherapy and the development of surgical techniques based on imaging modalities such as CT and MRI. For example, the current 5-year survival rate for patients with osteosarcoma is 60–80% in comparison with 10–15% in 1970. Furthermore, in the light of studies focusing on the surgical margin, a concept that has undergone remarkable development in Japan, orthopaedic oncology specialists now recommended that musculoskeletal sarcomas should be excised with an adequate safety margin. Currently, Limb salvage procedures are indicated for more than 80% of patients undergoing surgery for musculoskeletal sarcomas. However, over the last 20 years, the potentially favorable outcome in the majority of such patients has not been realized. In my view, clinical outcomes for patients with musculoskeletal sarcomas in the extremities are still less than satisfactory. Strict assessment of the acquired surgical margin of excised tumors is undoubtedly an innovation that originated in Japan. According to the new guideline for safety margins based on difference in tumor malignancy stipulated by the Surgical Society for the Musculoskeletal Sarcoma in 2010, the current safety margins are 2 cm or more for high-grade sarcoma and 1 cm or more for low-grade sarcoma. Moreover, those based on the response to preoperative chemotherapy are classified as marginal or more for marked responders, 2 cm or more for partial responders, and 5 cm or more for poor responders. Although the safety margins for lesions with skip and lymph node metastasis are still unresolved, a serial trial to minimize the safety margin seems to have nearly achieved its goal. Prosthetic replacement for reconstruction after resection of musculoskeletal sarcomas has shown marked progress with the modular type of prosthesis. Use of a metal prosthesis is undoubtedly one of the main methods for reconstruction of massive bone and joint defects. Further minor changes in model or better new materials for prosthesis manufacture, such as the Howmedica Modular Resection System (HMRS) and the Global Modular Resection System (GMRS), are expected in the future. However, it is recognized that biological reconstruction achieves better longterm function than a prosthesis. As well as the surgical margin, prosthetic replacement also seems to have nearly K. Mochizuki (&) Department of Orthopaedic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan e-mail: [email protected]