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Letter to the Editor

Pearls

The Mobile Segment in Sarcoma Resections

He, Hong-bo PhD, MD; Hu, Yi-he PhD, MD; Wan, Jun PhD, MD

Clinical Orthopaedics and Related Research®: April 2018 - Volume 476 - Issue 4 - p 908–909
doi: 10.1007/s11999.0000000000000224
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H-bo He, Y-he Hu, J. Wan, Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan, China

Jun Wan PhD, MD, Department of Orthopedics Xiangya Hospital Central South University Xiangya Road 87# Changsha, Hunan 410008 China Email: amiba3000@163.com

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

The authors certify that neither they, nor any members of their immediate families, 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.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

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 22, 2018

To the Editor,

We read the recent Pearls column by R. Lor Randall MD [3] with great interest.

We agree with Dr. Randall that the mobile segment technique facilitates vessel dissection and tumor exposure, and the tension caused by distraction of the mobile segment makes the dissection of vessels and soft tissue around the sarcoma convenient. But we are concerned that this approach could place tension onto the sarcoma mass itself, putting pressure through indirect contact onto the sarcoma tissue. Some studies suggest that the more pressure on the tumor tissue, the greater possibility for recurrence and metastasis [1, 2]. Nathan and colleagues [1] found that the osteosarcoma interstitial fluid pressure could increase up to 50 mm Hg in vivo, which could promote the proliferation of the tumor. Perry and colleagues [2] designed a study to evaluate the extracellular pressure on adhesion in sarcoma cell lines. They found that along with increasing pressure, adhesion capability increased in all three sarcoma lines [2]. Both studies warn that manipulation or forces on the tumor could potentially trigger local recurrence or distant metastasis. Meanwhile, potential sarcoma emboli could be propelled into the circulation system by physical forces. We believe a noncontact approach is preferred for sarcoma resection. We would like to share our approach for resecting a sarcoma in a distal femur with lateral extraosseous mass.

First, we identify the biopsy site, which is anterior-laterally based. The incision comes lateral to that site and then curves back anteriorly as it runs distally, since our goal is to use a more anteriorly based approach for the sarcoma resection. Next, we expose the tumor by making an incision that begins proximally and laterally on the thigh to include the entire biopsy tract, crosses over the midline, and finishes distally and medially (Fig. 1). The next step is to dissect subcutaneously around the biopsy tract in order to excise it in continuity with the main tumor mass. It is important to take the two together to avoid risking contaminating the field with tumor cells. After exposing the biopsy and anterior portion of the tumor mass, we separate the rectus femoris muscle from the vastus medialis muscle (Fig. 2) and turn it over from the medial side of the biopsy tract to the lateral side (Fig. 3). After that, we perform a routine distal femoral tumor resection.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Fig. 3

Fig. 3

We believe this noncontact approach is a practical way to resect a sarcoma with lateral extraosseous mass in distal femur without adding the possibility of iatrogenic recurrence and metastasis.

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References

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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