Surgical margins and handling of soft-tissue sarcoma in extremities: a clinical practice guideline

Questions 1. In limb salvage surgery for extremity soft- tissue sarcoma (STS), what is an adequate surgical margin? 2. What is the appropriate number of samples to take from the margins of a surgical resection specimen? 3. What is the appropriate handling of surgical resection specimens? Background Surgery is the primary treatment for extremity STS. The combination of radiotherapy with surgery allows for limb salvage by using radiation to biologically "sterilize" microscopic extensions of tumour and to spare neurovascular and osseous structures. Adjuvant chemotherapy in STS-except for rhabdomyosarcoma and Ewing sarcoma-continues to be controversial. Methods The MEDLINE and EMBASE databases (1975 to June 2011) and the Cochrane Library were searched for pertinent studies. The Web sites of the main guideline organizations and the American Society of Clinical Oncology conference proceedings (2007-2010) were also searched. Results and Conclusions Thirty-three papers, including four guidelines, one protocol, and one abstract, were eligible for inclusion. The data suggest that patients with clear margins have a better prognosis, but no prospective studies have indicated how wide margins should be. In limb-salvage surgery for extremity STS, the procedure should be planned to achieve a clear margin. However, to preserve functionality, surgery may result in a very close (<1 cm) or even microscopically positive margin. In this circumstance, the use of preoperative or postoperative radiation should be considered. No studies described the optimal number of tissue sections required to assess adequacy of excision nor the appropriate handling of surgical resection specimens. The Sarcoma Disease Site Group made its recommendations based on expert opinion and consensus.