Surgical Principles

Abstract

Surgery in a patient with a musculoskeletal neoplasm is indicated either for diagnostic biopsy or for therapeutic resection. Occasionally the two procedures are combined and an excisional biopsy is done. Such a biopsy is appropriate when the preoperative evaluation suggests that the tumor is an aggressive benign (stage 2 or 3) or low-grade intracompartmental (IA) lesion. The margin of the excision should be wide, and the patient’s function not adversely affected by the resection. This usually is appropriate for small, well-circumscribed soft tissue lesions situated in the subcutaneous tissue or in a single muscle. A subcutaneous lesion should be removed with a 1–2 cm margin of normal tissue and not just “shelled out.” An intramuscular lesion should be excised by removing the entire muscle. Excisional biopsy is also suitable for small cortical or periosteal bone lesions which can be excised without a segmental resection of the bone being required. It is impossible to do a frozen section on many bone lesions, and it is often better widely to excise the lesion on the basis of the clinical and radiologic diagnosis than to perform an incisional biopsy and contaminate tissue unnecessarily. The indications for an excisional biopsy are limited, though, and the procedure must be planned as carefully as any other surgical resection.