Connective Tissue Oncology Society

11th Annual MeetingBoca Raton, November 19-21 2005

A European project for surgical margins assessment in STS of the extremities and

superficial trunk

Gronchi A, Grimer R, Hoogendoorn PCW, Van Coevorden F, Bauer H, Kindblom LG, Bonvalot S, Coindre JM, Hohenberger P, Wardelman E, Ruka W, Rutkowski P, Collini P, Dei Tos AP

Background

• R0 = clear margin = Wide ?

• R1 = tumour at margin = Marginal or intralesional ?

• R2 = residual macroscopic disease = Intralesional

Do we all speak the same language ?

• Intralesional

• Marginal

• Wide

• Radical

Do we all speak the same language ?

Kawaguchi et al 2004, Clin Orthop 419

Japanese orthopaedic surgeons…

Quantify the concept of “barrier”

• Joint cartilage = 5cm

• Thick barrier = 3cm– Young periosteum– Tendon– Thick fascia (ie fascia lata, presacral fascia)

• Thin barrier = 2cm– Adult periosteum– Vascular adventitia– Perineural sheath– Normal muscular fascia

• Adherent tumour = – 1cm

• 5 cm. margin = Curative

• >2 cm margin = Adequately wide

• <1 cm margin = Inadequately wide

• “reacting zone” = Marginal

• Tumour at the margin = Intralesional

Kawaguchi et al 2004, Clin Orthop 419

Japanese orthopedic surgeons…

This is a time for a redefinition of our “activity”…

You have heard medical oncoloGIST claiming…

We should DESIST using RECIST at least in GIST

CTOS Barcelona

2003

You have also heard surgical oncologist and orthopaedic

oncologist talking…

… about surgical marginsConsensus Meeting

Trieste 2005

What is “safe” in STS

surgery?

• An intact fascial layer ?

• 5 cm of muscle longitudinally ?

• 1cm of muscle radially ?

• Periosteum ?

• Adventitia over vessels ?

One example

7 mm.

How would you have done it ?

• Much better…

• Same…

• Other

What would you call it ?• Wide ?

• Inadequately wide ?

• Close ?

• Marginal ?

Do we know what is “safe”?

AIM OF THE PROJECT

To have one form for a

prospective data base

Details of closer margins

•Width

•Quality (fascia, muscle, periosteum….)

Details of histology

• Subtype

• Grade

• Vascular invasion (Y/N)

• Nature of margin (pushing or infiltrative)

Details of adjuvant/neoadjuvant

treatments•CT

•RT

•Other

Margins depend on….

• The type of tumour

• The grade

• The location

• Response to neoadjuvant therapies (CT different from RT ?)

• The surgeon

• The patient

OUR EXAMPLE

Participating groups

•EORTC - STBSG

ISG BSG FSG SSG

NWWDT PSG GEIS

+ YOU ?

End Point

•Local recurrence free survival

• Metastasis free survival

• Disease specific survival

… and eventually know

How close we should dare go to this !

… alessandro.gronchi@istitutotumori.mi.it