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Reply to the Letter to the Editor


The Mobile Segment in Sarcoma Resections

Randall, R. Lor MD, FACS

Clinical Orthopaedics and Related Research®: April 2018 - Volume 476 - Issue 4 - p 910
doi: 10.1007/s11999.0000000000000225

R. L. Randall, Professor, Huntsman Cancer Institute, Salt Lake City, UT, USA

R. L. Randall MD, FACS, Huntsman Cancer Institute 2000 Circle of Hope Dr. Salt Lake City, UT 84112 USA Email:

(RE: Randall RL. Pearls: The mobile segment in sarcoma resections. Clin Orthop Relat Res. 2017;475:2647-2648).

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

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The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Online date: February 26, 2018

To the Editor,

I would like to extend a warm thank you to Dr. He and colleagues for their thoughtful letter regarding my Pearls column [3]. Certainly, in concept, overzealous manipulation of the tumor might have some deleterious clinical effect. However, there is no evidence that by creating a mobile segment the physiologic pressure approaches or exceeds that created by ambulation and/or activities of daily living. In fact, one could argue that releasing the tumor in a strategic area decreases pressures applied by manual manipulation of the tumor that might occur otherwise with resection in situ, where it is still constrained.

In terms of the studies referenced, Nathan and colleagues [1] noted that increased pressure was associated with better chemotherapy-associated necrosis and longer survival. There proliferative assay was performed on cell lines and does not reflect the natural tumor microenvironment. Perry and colleagues [2] did speculate, based upon their in vitro data, that perioperative manipulation may increase local recurrence and metastatic spread but to my knowledge no clinical study has ever demonstrated this. And again, a mobile segment does not necessarily increase mechanical forces experienced by the tumor microenvironment.

Finally, the authors describe an approach described as “noncontact” and yet it remains unclear as to how such an approach might be any different clinically in terms of pressures exerted across the tumor during ultimate resection. I would also humbly caution against the propagation of the notion of iatrogenic metastatic spread by any surgical technique unless there is more-definitive investigation into this subject. Patients already have enough anxiety about their surgery, and as experts, we need not add to it by raising the largely unsupported idea that a potentially helpful surgical approach might increase the risk of local recurrence or metastasis, when there is no solid evidence that this is true.

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1. Nathan SS, DiResta GR, Casas-Ganem JE, Hoang BH, Sowers R, Yang R, Huvos AG, Gorlick R, Healey JH. Elevated physiologic tumor pressure promotes proliferation and chemosensitivity in human osteosarcoma. Clin Cancer Res. 2006;11:2389–2397.
2. Perry BC, Wang S, Basson MD. Extracellular pressure stimulates adhesion of sarcoma cells via activation of focal adhesion kinase and Akt. Am J Surg. 2010;200:610–614.
3. Randall RL. Pearls: The mobile segment in sarcoma resections. Clin Orthop Relat Res. 2017;475:2647–2648.
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