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“Sarcoma” is a group of cancers that arise from the bone, cartilage, fat or blood vessels and may occur in any part of the human anatomy. Traditional treatment of sarcoma and soft tissue tumors requires extremity amputation and results in loss of function and aesthetic. Affected individuals may experience difficulty with returning to their occupations and with social reintegration. The treatment of sarcomas has evolved rapidly since the advent of microsurgical techniques and extremity amputation is now uncommon. The standard of care now involves a multidisciplinary approach that is able to achieve tumor clearance with extremity preservation, functional and aesthetic reconstruction, rehabilitation and good long-term survival.
Sacromas often present as an enlarging mass in the trunk or more frequently, the extremities. They may be painless in the early stages. These masses may be associated with pressure symptoms and later present with nerve symptoms, including sensory loss or muscle paralysis. Bone sarcomas may present with bone pain, especially at night, and eventually lead to weakening of the bone and fractures.
Sarcomas originate from the bone, cartilage, fat or blood vessels. There are many subtypes of sarcomas and there is a wide variance of behavior of these lesions, ranging from benign to aggressive malignant tumors.
Benign or intermediate lesions may be slow-growing and asymptomatic, and enlarge slowly over many years without invasion of other tissues. Malignant lesions often grow quickly and cause rapid progression of symptoms. They spread through the bloodstream and may affect the liver and lungs, and less often, the lymph nodes.
Sarcoma treatment aims to achieve tumor clearance with extremity preservation, functional and aesthetic reconstruction, rehabilitation and good long-term survival. This requires a multi-specialty approach and involves medical specialists who have skillsets specific to management of these cases. The following specialists are often required in their management for optimal outcomes:
Wide excision of sarcomas often leaves defects in the skin, subcutaneous fat, muscle and/or other critical structures such as the blood vessels, nerves, cartilage and/or bone. Reconstructive surgery is often required to restore the missing tissue and permit functional recovery, cover critical structures, minimize contour depression and expedite wound healing to facilitate progress to further radiation therapy or chemotherapy where required. Reconstructive surgery also brings fresh tissue to the excision site and prevents wound healing complications that may occur in some cases where radiation therapy is administered prior to surgery. Reconstruction is often performed at the same surgical sitting as the tumor excision surgery.
Bony defect reconstruction may be performed using custom-made prostheses, bone grafts or bone flaps, and muscle and tendon reconstruction may be achieved using muscle flaps or tendon grafts. Finally, skin may be replaced using regional or distant flaps, with the application of microsurgical expertise in the latter. Microsurgery is a niche surgical technique that involves connecting the blood vessels of the flap to vessels in the vicinity of the defect using ultra-fine sutures that are thinner than a strand of hair. Successful outcomes are possible in the vast majority of cases and require careful preoperative planning, precise technical execution and an experienced practitioner.
Most individuals will require a short hospital stay following the surgery. Weightbearing is dependent on the stability of the bone and joints and postoperative physical therapy and rehabilitation.
Smokers are advised to for cessation of smoking for at least 3 weeks postoperatively to minimize the possibility of complications relating to delayed wound healing. Skin grafts and flaps placed over mobile areas such as joints will require a short period of immobilization until they are fully healed.
The lower extremity has locomotive, psychological and aesthetic functions. Extremity preservation is of significant importance to many individuals, especially in young persons. Successful reconstruction is a keystone in its salvage. Dr Yeo is experienced in the field extremity preservation. He completed a fellowship in Advanced Microsurgical Reconstruction under Professor Hung-Chi Chen, one of the international pioneers and leaders in this field. He has since performed many successful cases of extremity salvage in Singapore since completion of his fellowship.