Correspondence (letter to the editor): Inadequate Initial Resection

It is useful and important for an article to try to shed a new light on a situation and thus provide interested physicians with new insights. However, the article cannot be accepted as a guide in all its aspects.

The authors recommend excision biopsy without further preoperative imaging for small tumors that according to clinical examination are definitely localized in the epifascial plane. Narrow marginal resection is sufficient, in their opinion. A sarcoma diagnosis that comes as a surprise is not rare, especially when the method the authors described in their article is used. Residual tumor cells in the resection margin are detected in up to 60% of patients. Since the resection status is an important prognostic factor for local tumor control and overall survival, even small tumors in the epifascial plane will have to be assumed to be malignant until the opposite has been confirmed and will have to be resected (1), if a sarcoma cannot be entirely excluded on imaging. In a center for musculoskeletal tumor surgery, radiological expertise is available, which helps in approaching a diagnosis by using high-resolution MRI scanning. The central issue is not the administration of contrast medium but how the examination is performed according to a standard protocol (suitable sequences; recommendations from the working group for musculoskeletal radiology in the German Society of Radiology).

From the radiotherapist’s perspective, narrow resection without preoperative imaging is not acceptable. If the tumor if confirmed as a high-grade sarcoma on histology, preoperative radiotherapy is indicated. If no diagnostic imaging procedures were undertaken before the surgery then a basis for defining the target volume is lacking. In order to achieve a high probability of local control, the radio-oncologist is rather likely to choose a more generous safety margin around the presumed tumor bed, in association with a high toxicity rate (which is unnecessary).

For specialist physicians in private practice, we wish to reiterate that any soft-tissue tumor should be considered as potentially malignant unless it has been confirmed to be benign, and that it is best to diagnose and treat such tumors in a tumor center.