Principles of Surgical Resection & Margins

Principles of Surgical Resection & Margins

Prepared by Dr. Ali Erkan YENIGUL

Tumour resection aims to achieve oncologic control while preserving function; margin status is critical for local recurrence risk.

Historical Background

• Pre-1940s → Amputation was standard treatment.
• 1940s sonrası → Tumour resection 
• 1970s → Chemotherapy + Radiotherapy + Limb-sparing surgery standard of care.

Basic Principles

• Wide surgical margin = most important factor for local control.
• All imaging must be completed before surgery.
• Surgical planning should be based on imaging close to surgery date.

Enneking’s Margin Classification

Intralesional Curettage / piecemeal debulking / Macroscopic disease remains

Marginal Shelling out via pseudocapsule- reactive zone / May leave satellite or skip lesions 

Wide En bloc with cuff of normal tissue / Adequate, but skip lesions possible

Radical En bloc removal of whole compartment / No residual local disease

 Natural Barriers

• Bone: Cortical bone, articular cartilage
• Joint: Articular cartilage, capsule
• Soft tissue: Fascial septa, tendon origins/insertions
• Barrier effect: Fascia, tendon sheath, vascular sheath, cartilage act as protective margins

 Critical Points in Limb-Sparing Surgery

• Poor biopsy incision
• Major vascular involvement
• Motor nerve sacrifice
• Preoperative infection
• Expected poor motor function after resection
  ➡️ These complicate but do not always contraindicate limb-sparing surgery.

Advanced Techniques

• Microsurgical reconstruction
• Tendon transfers, nerve/vessel grafts
• Flap coverage after large resections

Role of Adjunctive Therapies

• Neoadjuvant chemotherapy/radiotherapy → may shrink tumour, improve margin status.
• Wide margins still required even after neoadjuvant treatment.

Practical Margin Rules

• Bone tumours: ≥ 3 cm bone marrow margin on T1 MRI.
• Soft tissue tumours: Aim for ≥ 2 cm margin.

References

1. Enneking WF. Musculoskeletal Tumor Surgery. New York: Churchill Livingstone; 1983.
2. Simon MA, Springfield DS. Surgery for Bone and Soft-Tissue Tumors. Philadelphia: Lippincott-Raven; 1998.
3. Healey JH, Lane JM. Operative Techniques in Orthopaedic Surgical Oncology. Philadelphia: Lippincott Williams & Wilkins; 1996. (For the figures and the margin classification)
4. Mankin HJ, Hornicek FJ. Diagnosis, classification, and management of soft tissue sarcomas. Cancer Control. 2005;12(1):5–21.
5. O’Donnell RJ, Springfield DS, Motwani HK, et al. Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. J Bone Joint Surg Am. 1994;76(12):1827–33.