How to treat sarcomas: Surgery

Which surgeons operate sarcomas?

As many sarcomas grow on the limbs orthopedists are the surgeons that more commonly take care of sarcomas, but they are far from being the only ones. For example, ENT specialists can operate sarcomas on the head or neck; gynecologists ones in the uterus, general surgeons usually operate those in the abdomen, thoracic surgeons those located in the ribs or the chest inner area. Plastic and repairing surgeons are not just essential to rebuild the broken tissues, so they can look and function properly as expected, but also help with the extirpation of tumors. What is really important is not the surgeon degree or branch of specialization, but his experience, as explained below.

It is not rare, therefore, that several surgeon specialists have to operate by turns the same case. For example, a leg sarcoma that requires extirpation and rebuilding of an important artery needs that, eventually, the orthopedic surgeon steps aside to let the vascular surgeon work. From this point of view, it is impossible to exaggerate the importance that the sarcoma patient gets into the hands not of one specialist, but of a team. It is not exceptional the situation in that one case is labeled as inoperable not because it really is, but because who makes the decision faces the case alone, without the vision and help from other surgery specialists.

Radical surgery and compartmental surgery. margins

The basic concept in the surgical intervention of sarcomas is radical surgery, which should be the basic goal of any attempt to cure it. Radical surgery is understood as the removal of the whole tumor, if possible in a single piece and, above all, surrounded by a generous margin of healthy tissue of a centimeter or more. The margins are very important. If there is not such margin of healthy tissue between the tumor and the incision made by the surgeon, the chances of a relapse are significantly higher. Arms and legs are made of watertight compartments separated from each other by solid fibrous septum that acts as a wall of containment against the advance of sarcomas. A compartment usually contains muscles, vessels and nerves. If a soft tissue sarcoma is limited to a compartment, a great way to achieve a radical surgery keeping the member function would be to remove the whole compartment as a block, with the sarcoma locked inside. This technique is called compartment surgery.

Marginal surgery and intralesional surgery

Sometimes, it is just impossible to remove the tumor with that margin of healthy tissue around. This usually happens in very crowded places of anatomical structures, such as the neck or pelvis. In these cases, the surgeon must be satisfied with marginal surgery, which means cutting right along the edges of the sarcoma or a bit beyond. Marginal surgery has a relapse rate superior to the radical surgery, which may be partly offset by the use of radiotherapy. The only possible justification for performing a marginal surgery is that it is impossible to go through a radical surgery. If a patient has already undergone through a marginal surgery and it is now possible to operate on him to obtain those margins of healthy tissue around the sarcoma, it should be done without hesitation. This used to happen a lot before surgeons knew that they were actually operating on a sarcoma. He assumed it was a benign lesion until days later, the final pathology report arrived. There is no radiotherapy or chemotherapy treatment that improves both the expectations of a marginal surgery healing and the possibility of a radical one in such a way.

The intralesional surgery takes place when the surgeon cuts through the tumor, therefore, leaving the disease inside the body. These patients are intended for relapse almost surely, regardless of the medical or radiation treatment they receive after that. Intralesional should never be performed if it is possible to do a marginal or radical surgery, so a second intervention should not be avoided if there is a real chance of improving the margins. The only situation in which marginal surgery is acceptable would be in case it was impossible to remove it completely and necessary to eliminate at least part of it to save the patient’s life (if it was blocking the intestine, for example), or to reduce a severe symptom (such as a paralysis due to the compression of the spinal cord).

Conservative surgey and amputations

The concept of conservative surgery is opposed to the amputation; thus, it is only applicable to sarcomas in arms or legs. Sometimes, the only way to achieve the desired radical surgery is through amputation. This can happen, for example, when the tumor affects several compartments or when it is in places where it is almost impossible to obtain the appropriate margins due to the packaging of numerous vessels, nerves and tendons in a small space; as it happens in the hands and the feet. If the only way achieving the radical surgery is by amputation, nothing else should be tried. The cure is what is at stake and life is always more important than an arm or a leg. Moreover, nowadays there are prostheses that allow to carry out an almost normal life after the removal of a member.

However, orthopedic surgery has made huge progress over the last decade regarding conservatory surgery; which consists in getting a radical surgery (therefore, an identical possibility of healing), without removing an arm or a leg. There are not only compartmental surgery techniques but also a variety of synthetic internal prostheses able to replace veins, arteries, bones, and joints. Some other times, doctors use bones that the patient can do without (such as the fibula) or bones coming from a corpse and stored in the so-called banks of bones. Anyways, only those expert surgeons in sarcomas, imbricated in a multidisciplinary team, are in the best position to squeeze all the possibilities of conservative surgery without sacrificing a drop of healing.

Team experience improves the expectatives of the patient

Although experience is always desirable in a surgeon, here there is something different. Other tumors, such as breast, lung or prostate are so common that any surgeon of the corresponding specialty attending dozens of cases each year. In the case of the sarcomas, the difference between an expert surgeon and another who is not, is that the first one intervenes one or two dozen patients each year, while the latter just a couple. It has been proved with irrefutable statistical data that the people with sarcoma intervened in centers where they operate on more than ten cases per year get a better prognosis in the long run.

It is not just in the hands of the surgeon, which is already more than enough. Only hospitals that take care of many cases of this rare disease can afford the luxury of dedicating their attention to a full team of radiologist, surgeons, medical oncologist, pathologist and oncologist; a group of specialists that will be able to keep up with all the developments regarding sarcomas in their own field, to transmit this knowledge to their colleagues and put everything together to manage all the available tools for the diagnosis and treatment in the best way possible. The existence of these well-coordinated groups makes all the difference towards the treatment of sarcomas.

How to recognize a surgeon expert in sarcomas

If someone had been diagnosed with sarcoma and was facing a surgery or just a biopsy at the suspicion of the disease, it would be best to make sure that the surgeon in whose hands he is putting himself was an expert in sarcomas. There are two key questions in this regard: Do you treat more than ten new sarcomas every year? and is there in this center a Committee of sarcomas, formed by different specialists that come together to study each case before any intervention?

It is true that it is necessary to react quickly to a cancer diagnosis, but it is even more important to do it right since the beginning. In the case of sarcomas, this principle has an enormous importance. In many cases, it is the first treatment the one that determines what comes next, for better or worse. If someone had been diagnosed with sarcoma and was facing a surgery or just a biopsy at the suspicion of the disease, it would be best to make sure that the surgeon in whose hands he is putting himself was an expert in sarcomas. There are two key questions in this regard: Do you treat more than ten new sarcomas every year? and is there in this center a Committee of sarcomas, formed by different specialists that come together to study each case before any intervention?

No patient should feel ashamed to ask these questions and no doctor should feel annoyed by his approach. If both answers are negative, it does not mean that the surgeon is not capable of performing the intervention or the he will do it wrong at all. But that may be a sensible reason for the patient to get a second opinion from a more experienced specialist. Except for some extreme cases, waiting a week or two to get that second opinion has no influence on the probability of being cured. In most of the cases, the expert’s opinion will be the same as the first Surgeon's, to whom the patient may return full of confidence. On the contrary, in some other cases that second opinion prevents an inadequate medical intervention. 

Biopsies also count

It is important that, if you are going to ask for a second opinion, you do it as early in the diagnostic and therapeutic process as you can. It would be ideal to do so before the biopsy, at the simple suspicion that a lump might be a sarcoma. In this disease, the importance of the biopsy is much higher than the mere diagnosis. An inadequate biopsy may complicate a lot any posterior surgery. There are many exceptions but, generally, sarcomas’ biopsies should be performed with needle through the skin, avoiding cutting it with the scalpel or leaving a drainage. It is essential to carefully prevent bruising and infections. Anything different from that might favor the spread of the sarcoma or end up needing a more serious surgery than it was planned. It is also necessary to think about the plastic reconstruction from the moment of the biopsy; the part of the skin through which passes the biopsy needle must also be removed later. Therefore, it is imperative to avoid performing the biopsy through any area of the skin that is later going to be needed for plastic surgery to cover the wound. For all these reasons, ideally the biopsy will be made by the same surgeon who will be responsible for the complete removal.