Current concepts review. The surgical staging of musculoskeletal sarcoma.

Abstract

The concept of staging malignant tumors arose in re sponse to the need for meaningful assessment of various methods of treatment in end-result studies. Its purpose was to ensure that lesions of comparable prognostic import were used to evaluate methods of management, so that one form of treatment was not inadvertently biased by inclu sion of a preponderance of favorable lesions while another method was adversely weighted on the basis of lesions with unfavorable predictors. The first staging system was developed for carcinoma of the cervix . The predictors were local invasion, regional metastases to lymph nodes, and distant metastases to other organs. In the ensuing years the importance of the concept of staging has been widely recognized and adopted internationally . Staging systems based on the natural history of the tumor have been de veloped for almost all histogenic types of various malig nant neoplasms. Conspicuous by its absence has been a staging system for sarcomas of connective-tissue deriva tion. An adequate surgical procedure has been recognized as the effective means of treating the majority of primary musculoskeletal sarcomas . Historically , amputation has been employed liberally. The recent demonstration that certain chemotherapeutic agents are capable of suppres sing or even eradicating microdisease8”° has encouraged an enthusiastic proliferation of innovative therapies for many of these highly malignant tumors 12,14,t8,Almost all of these therapies were designed to supplant or replace so-called standard surgical procedures, and have as their aim control of micrometastases and preservation of a functional extremity . The trend toward conservatiVe, limb-saving surgery (usually performed under an umbrella of adjunctive chemotherapy, irradiation, or immunoactive agents) presents the surgeon and the patient with a seem ingly attractive array of treatment options, the long-term effectiveness of which are unknown. Many of these extremity-preserving options include a surgical procedure that by itself is known to carry substantial risk of recur rence and hence an increased risk of metastasis. Although