NEW METHOD OF EVALUATING THE SURGICAL MARGIN AND SAFETY MARGIN FOR MUSCULOSKELETAL SARCOMA, ANALYZED ON THE BASIS OF 457 SURGICAL CASES

The evaluation of surgical margin is useful in determining the curativ e success of surgical treatment of musculoskeletal sarcoma and the deg ree to which later surgery will be reduced by the preoperative therapy . However, until recently no reliable evaluation method has been devel oped for these purposes. In this paper we propose a new method for eva luating the surgical margin as drafted in 1989 by the Bone and Soft Ti ssue Tumour Committee of the Japanese Orthopaedic Association (JOA). I n this method, surgical margin was classified into four types based on the distance between the surgical margin and the reactive zone of the tumour. These classifications of surgical margin (in order of surgica l extent) are curative wide margin (curative margin), wide margin, mar ginal margin, and intralesional margin. The surgical margin is said to be curative if the margin is more than 5 cm outside the reactive zone . It is referred to as wide if the margin is less than 5 cm. Similarly , a margin that is in the reactive zone is considered as marginal, and a margin passing through a tumour as intralesional. Moreover, wide ma rgin is classified as adequate (at least 2 cm outside the reactive zon e) or inadequate (1 cm). In our evaluation, a ''thin'' barrier is cons idered to be a 2-cm thickness of normal tissue, a ''thick'' barrier as a 3-cm thickness, and joint cartilage is said to be equivalent to a 5 -cm thickness. In addition, a surgical margin that is outside a barrie r, with normal tissue between the barrier and the reactive zone of the tumour, is considered to be curative. This method was applied in 457 cases (involving 499 surgeries) at the Cancer Institute Hospital to de termine clinical significance in the treatment of musculoskeletal sarc oma (1979-1994). From the results of this study we were able to conclu de that this evaluation method can be highly useful in clinical practi ce for establishing optimum surgery. Moreover, we found that the safet y margin for high-grade musculoskeletal sarcoma is a curative margin p roviding an adequate wide margin of 3 cm or more when preoperative the rapy is not performed or is not effective, while the safety margin for high-grade sarcoma that responds to preoperative chemo- or radiothera py seems to be an adequate wide margin of 2 cm. Here, radiotherapy is more effective compared to chemotherapy for reducing surgical margin. An inadequate wide margin, however, combined with radiotherapy, is not enough to ensure local curative success following surgery for musculo skeletal sarcoma. Therefore, we have determined that these procedures should be used only when establishing a safety margin is difficult, ev en if ablasion or various reconstructive modalities are applied. On th e other hand, for low-grade sarcoma, an inadequate wide margin can be considered as safe.