Around 50 years back, sarcoma was synonymous with amputation (cutting the limb), but with the improvements in chemotherapeutic regimes, surgical techniques, and imaging modalities, limb salvage surgeries have become the standard of care for patients with sarcoma. Limb salvage surgery (LSS) technically means removing the tumor en bloc (in one piece) with a cuff of normal tissue while preserving the limb along with its function. Although there are more than 60 subtypes of sarcomas, they can broadly be grouped into two categories- Sarcoma of the bone and sarcoma of soft tissues (muscle, nerve, fat, blood vessels, etc)
In LSS for bone sarcomas, part of the bone involved with sarcoma is removed surgically (rather than cutting the whole limb) and the defect is reconstructed with an artificial implant (mega prosthesis), thereby saving the limb. Since most of the bone sarcomas occur in children who have yet not achieved their full height, removal of cancerous bone also removes (in the majority of cases) the growth plate (part of the bone that grows with age to give length to the bone). Reconstructing such bone defects in growing children with conventional mega prosthesis gives the additional problems of unequal limb lengths at skeletal maturity. To circumvent this problem, nowadays it is possible to reconstruct the defect with an expandable implant which can be made to grow as the child grows.
Not only that, in some cases we can even avoid putting artificial metal prostheses. In those cases, the cancerous bone so removed is given a very high dose of radiation so as to kill all the cancer cells and the sterilized bone so formed is fixed back to the parent bone with the help of plates and screws, a technique commonly called Extra Corporeal Radiation Therapy (ECRT).
LSS for soft tissue sarcoma involves removing the tumor with healthy tissue all around. This is possible since the sarcomas usually push the important neurovascular structures rather than invading them. LSS for soft-tissue sarcomas usually requires radiation in addition to surgery. Radiation can be given before surgery (Pre Op RT) or after surgery (Post Op RT), each having its own advantages and disadvantages. Nowadays, radiation therapy can also be administered by a technique called Brachytherapy in which catheters are placed in a tumor bed after tumor excision, and radiation is given through these catheters. Brachytherapy not only has the advantage of the lesser dose being given to surrounding normal tissues and hence lesser side effects but also this process is finished in 7 days compared to 5 weeks for pre-op RT and 6-7 weeks for post-op RT.
Limb salvage surgery has its own challenges. Sometimes, the sarcoma tends to involve the major blood vessel in which blood vessel needs to be removed along with tumor and is reconstructed. A previous unplanned biopsy or inappropriate surgery can increase the complexity of LSS, it may lead to a change in the reconstruction plan along with the need for microvascular surgery in form of flaps for wound cover and so on thereby increasing the costs and complications and may even compromise final functional outcome.
