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Surgical Margins

Ovid: Oncology and Basic Science

Editors: Tornetta, Paul; Einhorn, Thomas A.; Damron, Timothy A.
Title: Oncology and Basic Science, 7th Edition
> Table of Contents > Section I
– Evaluation and Management of Musculoskeletal Oncology Problems > 4
– Treatment Principles > 4.1 – Surgical Margins

Surgical Margins
Robert Quinn
Appropriate surgical planning for the treatment of
musculoskeletal tumors requires proper histologic diagnosis and
staging. The type of surgical margin most appropriate for a given tumor
is, to a large extent, dictated by the appropriate stage.
  • The pathologic definitions in Table 4.1-1 are essential to the understanding of surgical margins.
Surgical Margins
  • The surgical procedures and margins are defined in Table 4.1-2.
Surgical Procedures
Principles of Selecting the Appropriate Surgical Procedure
  • Selection of the most appropriate surgical margin is dependent upon the overall treatment goals of the patient.
  • Table 4.1-3 shows some example tumor types according to surgical stage for each type of surgical procedure.
  • If the goal of treatment is to establish
    the best chance of cure, then the most appropriate margin is that which
    will provide the lowest risk of local recurrence.
    • Life-threatening malignancy: successful limb salvage is a secondary goal, and margins should not be


      compromised in an effort to save a limb or improve its function.

    • Most aggressive benign tumors: rarely
      life- or limb-threatening, and these are often best treated with a less
      aggressive procedure, accepting a low rate of local recurrence in
      exchange for improved functional outcome
Table 4.1-1 Terms Pertaining to Surgical Margins
Term Definition
Reactive zone Area, or potential area,
between the tumor and normal tissue; it may be composed of variable
amounts of pseudocapsule, satellite tumor lesions, and reactive tissue,
including edema
Satellite lesion Nodules of isolated tumor within the reactive zone
Skip lesion Nodule of isolated tumor
within the same compartment as the primary tumor but separated by an
interval of normal tissue beyond the reactive zone
Table 4.1-2 Definitions of Surgical Procedures Related to Margins
Procedure Definition
Intralesional Procedure performed within the
capsule or pseudocapsule of the tumor. This is generally a curettage
type of procedure for bone tumors and piecemeal excision for soft
tissue tumors. By definition, macroscopic disease is left behind. An
intralesional margin is obtained when the plane of dissection passes
within the lesion.
Extended intralesional Procedure performed
intralesionally but extended beyond the confines of the tumor reactive
zone into normal tissue by use of mechanical or other adjunctive means.
This usually applies to low-grade aggressive bone lesions, where the
outer border of a standard curettage is extended mechanically with
aggressive use of curettes, a high-speed bur, or both, into normal
surrounding bone. The bone margin may also be extended by the use of
chemical (phenol), electrical, or laser cauterization, thermal effect
of curing bone cement, and freezing effect of liquid nitrogen.
Marginal Procedure performed within the reactive zone of the lesion. This is typically an en bloc
type of resection for soft tissue tumors such as excision of a lipoma.
For intraosseous bone tumors, a marginal excision would be an “extended
curettage.” For surface bone tumors, a marginal excision would be
accomplished by simple excision of the lesion without any surrounding
tissue. A marginal margin is obtained when the plane of dissection
passes through the reactive zone. Microscopic disease may be left
behind where portions of the tumor itself extend into the reactive zone
or where satellite lesions are present. A marginal resection or
amputation risks leaving satellite lesions behind.
Wide Procedure performed entirely
through normal tissue beyond the reactive zone. It reflects not the
amount of normal tissue that makes up the margin but simply the
presence of some amount of normal tissue between the reactive zone and
the plane of dissection. A wide procedure only risks leaving skip
lesions behind.
Radical Procedure in which the entire compartment of origin is removed
Contaminated margin If, during the process of
performing a wide or radical resection, the tumor is inadvertently
entered and local normal tissue exposed, the area is at increased risk
for local recurrence of the tumor. If the at-risk tissues are then
removed with a wide margin, the ultimate margin is said to be a
contaminated wide margin. If the at-risk tissues are not removed, the
ultimate margin is intracapsular.
Types of Surgical Procedures
  • Figures 4.1-1 and 4.1-2 illustrate the respective planes of dissection that would be performed with these types of resections and amputations.
Intralesional Procedure
  • Debulking or curettage of a tumor from within the tumor itself
  • This type of procedure may be performed for diagnosis (i.e., with an open biopsy), for cure, or for palliation.
    • Biopsy
      • When surgery is to be performed for
        sarcomas with curative intent, the carefully planned biopsy is an
        acceptable initial intralesional procedure.
      • An intralesional margin obtained following resection is generally unplanned and unlikely to be curative.
    • Palliation
      • An intralesional procedure might be
        performed in the presence of metastatic disease where the primary goal
        of surgery is palliation and the secondary goal is tumor removal.
      • Example: Impending pathologic fracture of the femur
      • Primary goal of the procedure is stabilization


        with an intramedullary rod, but intralesional curettage of the tumor is performed for two reasons:

        • To allow further strengthening of the construct by replacing tumor with polymethylmethacrylate
        • To afford potentially greater efficacy of adjuvant radiation or chemotherapy
Table 4.1-3 Surgical Margins as a Function of Tumor Stage
Musculoskeletal Tumor Society Stage Example Typical Desired Surgical Margin
Bone Tumor Soft Tissue Tumor
Benign 1 (latent) Enchondroma, nonossifying fibroma, solitary eosinophilic granuloma, unicameral bone cyst Lipoma, ganglion, giant cell tumor of tendon sheath Intralesional
Benign 2 (active) Aneurysmal bone cyst, chondroblastoma, osteoblastoma Hemangioma, myxoma Marginal
Benign 3 (aggressive) Giant cell tumor Fibromatosis (desmoid type) Extended intralesional curettage (bone) or wide (soft tissue or expendable bone)
Malignant IA/B Low-grade osteosarcoma, conventional chondrosarcoma Low-grade soft tissue sarcoma* Wide
Malignant IIA/B High-grade osteosarcoma, Ewing sarcoma High-grade soft tissue sarcoma Wide
Malignant III High-grade osteosarcoma, Ewing sarcoma High-grade soft tissue sarcoma Wide with metastatectomy for cure if resectable
soft tissue tumors that may be considered low-grade sarcomas by some,
such as atypical lipomatous tumor (low-grade well-differentiated
lipoma-like liposarcoma), are most often excised with a marginal margin.
Figure 4.1-1
Magnetic resonance imaging of a soft tissue sarcoma in the adductor
compartment of the thigh demonstrating potential surgical margins.
Dissection along line a would constitute an intralesional margin, along line b would be a marginal resection, and along line c would be a wide margin. A radical margin would entail removal of the entire adductor compartment.
Residual Disease and Risk of Recurrence
  • By definition this type of procedure
    leaves behind macroscopic, or at least microscopic, disease. This is
    acceptable for benign nonaggressive lesions (stage 1 or 2), but it is
    not desirable for aggressive benign or malignant lesions except when
    palliation is the goal.
  • For many benign bone and soft tissue
    tumors (enchondroma, nonossifying fibroma, eosinophilic granuloma),
    this procedure will result in a very small risk of local recurrence.
  • For most malignancies, this procedure will result in a high rate of local recurrence.
Marginal Procedure
  • A more aggressive excision performed
    through the reactive zone to minimize the amount of residual
    microscopic tumor, but leaving the potential for both satellite and
    skip lesions
  • For soft tissue tumors an en bloc excision (“shell-out” procedure) is performed.
  • For more aggressive benign tumors of bone
    (aneurysmal bone cyst, chondroblastoma, osteoblastoma) and even some
    low-grade chondrosarcomas, acceptance of a marginal margin by way of an
    extended intralesional curettage will result in a measurable risk of
    local recurrence but not high enough to warrant the additional
    morbidity of obtaining a wide margin except occasionally in expendable
    bones such as the fibula, rib, or ilium.
    • Extended intralesional curettage
      procedure: A marginal curettage is performed, and the margin is then
      extended into the reactive zone or even into normal tissue mechanically
      with a bur and~hor using cytostatic or cytocidal agents such as liquid
      nitrogen, phenol, laser, or alcohol.
    Figure 4.1-2
    Magnetic resonance imaging of a high-grade osteosarcoma of the distal
    tibia illustrating margins possible obtained at different levels of
    amputation: intralesional (a), marginal (b), and wide (c). A radical margin would be obtained with a knee disarticulation.
  • P.53

  • Amputations that achieve marginal margins
    • May be performed as a palliative procedure
    • May result from unsuccessful attempt at a wide margin amputation
    • May be performed with plans to use adjunctive treatment to minimize recurrence
Wide Margins
  • When the plane of dissection passes
    through normal tissue some distance beyond the reactive zone,
    theoretically eliminating satellite lesions but potentially leaving
    skip lesions behind
  • Cure: Appropriate margin to achieve cure
    for majority of bone and soft tissue sarcomas, for occasional isolated
    bone metastases (such as renal carcinoma), and for some particularly
    aggressive benign tumors such as desmoid-type fibromatosis
  • Palliation: Occasionally wide resection
    will also be performed for the treatment of metastatic disease when the
    tumor is felt to be poorly responsive to other adjuvant measures.
Amputation With Wide Margins
  • Performed with curative intent when limb salvage is not indicated
  • When limb-sparing surgery would leave an
    extremity with compromised vascularity or limited function inferior to
    that which would be obtained with a prosthesis
  • If a patient would prefer amputation in
    deference to the more complex nature of a reconstructive procedure and
    the potential associated complications
Radical Resection
  • Removal of the entire compartment(s)
    involved by the tumor, including the entire bone for bone tumors and
    the entire muscle compartment from origin to insertion for soft tissue
    tumors or soft tissue extension from bone tumors
  • Radical resections are largely of
    historical importance but were thought to be necessary in some cases to
    eliminate both satellite and skip lesions. In practice, skip lesions
    are rare, probably represent metastatic disease, and can generally be
    recognized on imaging studies provided the entire compartment is
    visualized. Hence, prophylactic removal of the entire compartment
    without evidence of skip lesions is rarely indicated.
    • If the skip lesion is in close proximity to the primary, both will generally be resected with a single wide margin.
    • If the skip lesion is more remote from
      the primary, two separate wide resections will generally suffice and
      often allow better functional outcome than a radical resection.
Suggested Reading
WF, Maale GE. The effect of inadvertent tumor contamination of wounds
during the surgical resection of musculoskeletal neoplasms. Cancer 1988;62(7):1251–1256.
Enneking WF, Spanier SS, Goodman MA. A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res 1980;(153):106–120.
WF, Spanier SS, Malawer MM. The effect of the anatomic setting on the
results of surgical procedures for soft parts sarcoma of the thigh. Cancer 1981;47(5):1005–1022.
Rydholm A. Surgical margins for soft tissue sarcoma. Acta Orthop Scand Suppl 1997;273:81–85.
Rydholm A, Rooser B. Surgical margins for soft-tissue sarcoma. J Bone Joint Surg [Am] 1987;69(7):1074–1078.
Virkus WW, Marshall D, Enneking WF, et al. The effect of contaminated surgical margins revisited. Clin Orthop Relat Res 2002;(397):89–94.
Wolf RE, Enneking WF. The staging and surgery of musculoskeletal neoplasms. Orthop Clin North Am 1996;27(3):473–481.

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