Moving the Needle in Undifferentiated Pleomorphic Sarcoma: Surgical Oncology Goals

In this episode of OncChats: Moving the Needle in Undifferentiated Pleomorphic Sarcoma, the following experts discuss the surgical approach to soft tissue sarcomas, emphasizing the importance of multidisciplinary care, precise biopsy techniques, achieving negative margins, and the advancements in limb salvage procedures that have minimized the need for amputation:

• J. Dominic Femino, MD, an orthopaedic surgeon with Keck Medicine of USC and chief of the USC Musculoskeletal Oncology Center
• Lee Zuckerman, MD, an orthopaedic surgeon with Keck Medicine of USC
• Mark Agulnik, MD, a medical oncologist with the USC Norris Comprehensive Cancer Center, part of Keck Medicine of USC
• Andrew Lim, MD, a radiation oncologist with Keck Medicine of USC

Femino: Dr Zuckerman, you are an orthopedic surgical oncologist, and surgery remains a primary curative approach for soft tissue sarcomas. What are your primary technical goals of surgery when you treat these patients with undifferentiated pleomorphic sarcoma of the extremities?

Zuckerman: Yes, thank you for the question. Taking care of a patient with sarcoma starts when you initially see them, so I’m going to focus a little bit on that, and part of that is the importance of being taken care at a sarcoma center where you have this multidisciplinary approach, especially for these newer treatments. But on the evaluation of a patient, someone who comes into your office who has a soft tissue mass that’s more than 3 cm or deep to the fascia, regardless of size, deserves some form of advanced imaging to help with your diagnosis and to plan your biopsy. The biopsy itself can be extremely important, and whether that’s done by a surgeon or by an interventional radiologist, it should be done under the supervision of the surgeon who’s going to do the resection, because in many cases, the biopsy tract is considered contaminated and we’re going to resect it at the time of surgery. It can also matter for when the patient is getting preoperative radiation, for planning of how we’re going to take this out and what type of reconstruction techniques we’re going to make.

Once the biopsy is performed, it’s also very important to have a pathologist at your institution who can identify that this is a UPS so that [patients] can get on the proper treatment. Once they’ve undergone their neoadjuvant therapy, we’re going to want to do a resection of the tumor that involves negative margins. What that means is we want to see on the pathology that there is normal tissue between the edge of the tumor and the edge of the specimen. [The question of how] much of a margin is debatable. Ideally, we’re getting at least a couple of mm, as wide a margin as possible. But when we’re performing limb salvage surgery, these tumors may be pressed up against a blood vessel or a nerve, so we may be taking a very minimal margin, or sometimes what some people call a planned positive margin, which is really when we’re resecting a thin layer, such as the adventitia off a vessel or the epineurium off a nerve, and that’s going to be our margin. We do that when the tumor is pressing up against these structures, but we can still perform limb salvage for the surgery. And so, from the initial evaluation of the patient to the final surgery where we’re performing this, there are many complicated steps that we have to take in order to hopefully provide cure for these patients.

Femino: And are you able to salvage the limb most of the time, or does this involve an amputation?

Zuckerman: At this point, [most] of the time we’re able to save someone’s arm or leg. [That is a] question that goes with the surgeon also, because we always can offer an amputation, but that’s a discussion with the surgeon of what the patient prefers and different factors with it. For the most part, someone who specializes in sarcoma can save the person’s extremity the majority of the time. At this point in my career, I perform very few amputations. Even if the tumor involves certain blood vessels or certain nerves, there are methods to save the patient’s limb. The function may not be as ideal, obviously, if we have to sacrifice a nerve, but the techniques that we’ve developed over the past several years really make limb salvage the standard surgical option for these tumors.

Check back tomorrow for the next episode in the series.