William F. Enneking (Fig 1) was born in Madison, WI. His college education was interrupted by service as a seaman in the United States Navy (1943–1944). Returning to the University of Wisconsin, he obtained a bachelor’s degree and a medical degree. After interning at the University of Colorado in 1950, he spent the next 4 years as a resident in orthopaedic surgery at the University of Chicago. This program, under the direction Howard Hatcher, had a great tradition of excellence especially in the field of orthopaedic pathology. Among its graduates were Michael Bonfiglio, Mary Sherman, and Crawford Campbell. Enneking would be added to this distinguished list of orthopaedic surgeons especially skilled in pathology.Fig 1.: Dr. William F. Enneking (Photograph courtesy of Dr. Enneking).After spending 1 year as an instructor at the University of Chicago, Enneking went to the University of Mississippi as the chief of orthopaedic surgery. When the new medical school of the University of Florida was opened in 1969, Enneking moved to Gainesville, FL and began the orthopaedic service. During his tenure at the University of Florida he served as Professor of Orthopaedic Surgery and Pathology and Chairman of the Department of Orthopaedics. Since his retirement in 1980 he carries the title of Eugene L. Jewett Professor of Orthopaedic Surgery and Distinguished Service Professor, University of Florida. Enneking spent his career studying the pathologic features of bone tumors and their treatment. His contributions to this field have been substantial and have earned him many honors including 3 Kappa Delta awards. He has served as president of the Orthopaedic Research Society, the American Board of Surgery, and the American Orthopaedic Association. He has had an important role in the founding, growth, and development of the Musculoskeletal Tumor Society. His book, Musculoskeletal Tumor Surgery 1 is a landmark in the field. The classic article is an example of the bold application of basic knowledge of pathology and thorough consideration of surgical anatomy. The decision to do an amputation or a local resection of a sarcomatous lesion about the pelvis depends on many factors. It is apparent from many clinical studies that sarcomata arising from the skeleton and the enveloping mesenchymal soft parts vary widely in their aggressiveness and clinical course; but, as a class, sarcomata kill the patient if they remain untreated. Types of Sarcomata Sarcomata can be divided into 2 main groups. One group consists of the lesions that arise from the connective-tissue elements, that is, osteosarcoma, chondrosarcoma, fibrosarcoma, giant-cell sarcoma, rhabdomyosarcoma, synovioma, and liposarcoma. The other group includes the lesions that arise from the marrow elements of the skeleton, such as multiple myeloma, reticulum-cell sarcoma, Ewing’s sarcoma, Hodgkin’s sarcoma, lymphosarcoma, and undifferentiated round-cell sarcoma. These marrow lesions are sensitive to x-rays and to chemotherapy. Only in carefully selected instances should resection or amputation be performed. The connective-tissue lesions are less responsive to radiation therapy used palliatively or in an attempt to produce a cure. They have been almost totally unresponsive to chemotherapy administered by perfusion or by a more disseminated route. The only successful method of controlling this group of diseases has been surgical excision of the lesion prior to metastasis. In most instances surgical removal of the primary lesion is technically feasible. Therefore, the patient’s survival depends on whether metastasis has occurred prior to removal of the primary lesion. Although it is well recognized that sarcomata will recur locally after inadequate or incomplete excision, almost without exception the survival of the patient depends on whether secondary expressions of the lesions appear in other parts of the body. It might be germane at this point to consider some facts known about the metastases of malignant disease. With a few notable exceptions, sarcomata metastasize through the blood stream. Lymphatic metastasis is seen clinically so infrequently that, unless obvious abnormal lymph nodes are palpated in the patient, most clinicians do not perform radical local node dissections. Although occasional nodes contain metastatic sarcoma, notably synovioma, this condition is so unusual that it merits case reports in the literature from time to time. The physiopathology of the dissemination of sarcoma cells through the blood stream is still obscure. Little is known of the release of these neoplastic cells from the original tumor, their passage through the blood stream, their vitality, and their ability to reproduce themselves at a distance from their point of origin. The release of the cells is related to both cellular and extracellular factors. The chief cellular factor is the marked decrease in the ability of sarcoma cells to adhere to one another. The force required to separate 2 tumor cells may be as much as 6 times less than the force required to separate corresponding normal cells. Cellular adhesiveness is related to many factors, such as calcium concentration and electric charge, but the net result is that tumor cells display a markedly reduced power of adhesion. Once separated, the tumor cell is quite capable of moving of its own accord. Propelled by amoeboid movements, it can cover the distance to the blood vessels at a much higher speed than a normal cell. For example, the speed per hour of a fibrosarcoma cell is 10 times that of a normal fibroblast. The size of the tumor cell is no obstacle to its displacement and, because of its amoeboid properties, it is quite capable of crossing the finest capillary barrier. Certain extracellular factors, such as injury and local vascular thrombosis, favor the migration of tumor cells. The decisive role of microscopic injury and thrombosis in the dissemination of cells has been clearly demonstrated. Why a tumor cell should stop in one particular place after reaching the blood stream is not understood. A considerable amount of evidence shows that the tumor cells actually may be disseminated through the blood stream, but tumor cells are found in the blood relatively seldom. The major exception is in regions close to the tumor. The great majority, if not all, of the circulating tumor cells are rapidly destroyed in the blood stream before they reach a site where they may reproduce themselves and form a metastatic focus. Tumor cells that survive and form metastases appear to do so as a function of the histological and biological nature of the tumor, rather than because of the nature of the tissue in which these cells are deposited. Viable tumor cells pass through the blood to distant organs and may be cultured from human blood successfully, but a distinction must be drawn between the viability of the cell in the blood stream and its ability to produce a secondary tumor. Although a tumor may be capable of releasing viable cells into the blood, metastases may not appear until considerably later. It is well known that metastatic foci of sarcomata may appear in the lungs many years after removal of the primary lesion without evidence of primary recurrence. There is a suggestion that certain neoplastic materials from tumors may be carried through the blood stream by macrophages and that metastases may then arise by some means other than intact cellular elements. The studies of Collins and associates on the doubling theory of neoplastic cells are of interest in this regard. Their work was based on an observation that tumor cells reproduce themselves at regular intervals of time and that presumably metastasis develops from a single cell. The subsequent multiplication of cells follows a logarithmic curve. If one studies a pulmonary metastasis and determines the time required for it to double its size and then double it again, it is possible to plot retrogradely and logarithmically the time at which the first cell reached the lung. If this method is valid, frequently metastasis seems to have occurred long before the patient has any inkling of the presence of the primary lesion or is seen by his physician. In opposition to these ominous observations is the fact that sarcomata inadvertently mismanaged occasionally fail to follow the usual clinical course, and the patient appears to be cured at follow-up of many years’ duration. Sherman and Irani recently reported cases in which the patients survived 8 and 10 years despite amputation perilously close to large osteogenic sarcomata (after repeated surgical manipulations). In addition, a series of 133 spontaneous cures of various neoplasms was well documented recently by the American Cancer Society and accepted by a panel of experienced clinicians as spontaneous cures. Many interpretations can be made, but it appears that in some instances the patient or host presents resistance of some type, probably immunological, that results in the destruction of what would usually be accepted as a malignant tumor. In managing patients with sarcomata, one seems to be justified in attempting surgical removal in the absence of demonstrable metastasis, even in the presence of known sarcoma cells circulating in the blood stream, in an effort to produce a cure. The method of removing the sarcoma and the subsequent treatment of the patient should be based on what is known about metastasis. In discussing this group of patients, the only lesions included are those arising from the pelvis, the proximal end of the femur, or their enveloping soft parts under circumstances in which thigh amputation or hip disarticulation is not feasible. Hemipelvectomy for neoplasms about the pelvis is probably the procedure most commonly employed and, in terms of survival time, the results are documented best for this procedure. In most instances, it is done after an open biopsy with closure of the wound and a delay of 48 to 72 hours prior to amputation. It is believed generally that amputation for malignant skeletal neoplasms should be done proximal to the proximal joint of the involved bone in order to avoid amputating through tumor. Many of the sarcomatous processes that arise within the skeleton tend to grow more rapidly along lines of least resistance through the intertrabecular spaces and the medullary canal. Frequently, it is extremely difficult to determine by any method of examination the extent of these lesions within the bone. It is held generally that epiphyseal plates and articular cartilage form a fairly effective biological barrier against the extension of tumor. Therefore, if one amputates above or through the adjoining joint, he is likely to be safely proximal to the tumor. At one time it was believed that after the initial biopsy a delay of 6 months prior to hemipelvectomy produced a higher percentage of long-time survivals. It was thought that the tumor was stirred up by the biopsy and that local dissemination from the tumor might be produced if the amputation was done soon after the biopsy. However, it appears likely that the slight increase in survival time after a delay of 6 months is probably due to a natural selection of patients who are more resistant to their tumors. Now amputation is generally not delayed after biopsy. Preoperative irradiation in heavy doses after the biopsy and prior to amputation has been used in various centers. In studying these reports, it appears that there is no appreciable difference in the survival rate with or without irradiation. Local excision of sarcomata of the pelvis is practiced less frequently than hemipelvectomy and less is known about the survival rates with this method of treatment. If one takes into account the differences in the natural history of the various types of sarcoma, no reports in the literature permit comparison of the long-term survival rate of patients with similar tumors who have had local resection with the survival of similar patients who have had amputation. Local resection is done more frequently for soft-tissue tumors than for tumors arising from the skeleton. The literature includes no definitive study of the function of patients after local resection of neoplasms with the function of those after There is no to the of the 2 However, radical resection is with of function and resection appears to the patient the it seems to do a resection rather than of may be decisive in the selection of the most procedure. The of these from case to case and be in any particular order of or of were but in cases of local resection these other to be of no The the of the the ability of the to determine the local extent of the the ability to a on the of a the nature of the the of the patient, and the function of the procedure. one a hemipelvectomy or a local resection of a malignant lesion of the pelvis, certain will result in A on the involved prior to the procedure will the and if excision of a of the is surgical may produce of neoplastic cells into the blood stream, it is likely that a and with the definitive surgical procedure at the time the patient’s of the of the by with the who will be on to the histological is The should be to the patient, the and be of the clinical The for the biopsy should be in such a that it may be resection or In a study was at the Cancer to determine from wound the of wound by cells for of the and of the and In this study the of was per with the per found in similar studies at the University of The of these with local no difference in terms of between patients with and those without wound However, the were by local were in of cases in which was but in only 10 of in which was not of the biopsy site appears to be of to and, if the biopsy wound is not in the of the definitive local seems to be more When the lesion is a should be from the of the lesion and a should be This should be by the in terms of the clinical and other in order to that the tissue is of the lesion and to determine the nature of the lesion. biopsy should be until the is that he can determine whether the lesion a malignant and whether it can be as a lesion. of the lesion is not for When the has been to the of both the and the the wound should be as as possible and the should be with a and used the biopsy should be At the of the definitive procedure a of tissue about the biopsy wound should be and the should be in such a that the through which the biopsy was done remain to the lesion. The first in the definitive procedure should be of the most proximal the If a hemipelvectomy is to be this may be and divided at this If radical resection is to be the should be with in order to of tumor cells reaching the the surgical After the hemipelvectomy or local the wound should be with a large of This may be in a separate and the and the of the procedure by the to determine the presence or absence of tumor cells in the the should be divided by the or in the and the wound is the should effort to that he has the lesion In where it appears that the lesion has been should be obtained from the of the and from the corresponding of the If a tumor is the wound should be When local of has been local chemotherapy has been employed and clinically by many to kill the tumor cells. have been locally with such as and These studies have that the are with the tumor cells prior to of the they are but the are in in the wound after so many the of the that the results are In some degree of in The clinical of to a wound with tumor cells is as as surgery studies on the of a and the development of local wound are difficult to It is probably to at this time that no has been to wound The surgical as to whether to do a radical local resection or a hemipelvectomy are as the of the lesion was the single most important factor in the cases in which radical local of lesions were In order to a result after radical local one must the and the of the and and the In the lesion must be within the on the If the has been and the tumor has the local resection is probably the of the vessels and and of the and is perilously close to the extent of the lesion. The of the pelvis may be and a result may be If the is the only it may be the of local resection and a result still be If the lesion is the or the of these must be and the must be or must be done the must to this extent to attempt to the patient a result be from local The proximal of the lesion is not important between a local resection and for the result is not by this of the one is only in the proximal extent by the and the The extent of the lesion is of considerably more One to of some of the bone against which to the after a local If no of the bone can be the of a that may be involved by the as well as the biopsy must be is generally not a consideration in between the 2 After resection of large of the is usually to close the but if in the form of or may be to Local of it has been rather that of the wound by tumor cells the of the procedure the of Therefore, one is not justified in attempting local resection of inadvertently through the lesion is in order to the Therefore, if it appears that the of to a result would the so close to the tumor that is a hemipelvectomy should be of a local The should his decision on the evidence from the prior to the procedure. In the of or vascular are In the and of in many instances will the extent of the lesion. and examination should be done in In the of the particular should be to the of the soft-tissue as well as to the amount of bone should be in the of the may be of the or or may be by of the or its displacement as by may be in the extent of the lesion. may in displacement of major in the local extent of the and in the of neoplastic vessels which the extent of the lesion. and as to the of the lesion to the and the lesion to be close to these have been employed in an effort to the extent of neoplastic employed most commonly are calcium and but they have not been reports of the of have that this might be more one of the more difficult is the of the local extent of the lesion in soft-tissue sarcomata which no of the skeleton. without large lesions in the of the that, by to the bone excision of of the bone to the tumor The in these instances may be of on In almost there have been with to radical have been done on this in the but with the of to produce and more knowledge of these the of such is It may be that the recently increase in survival rates for is with of the definitive procedure at the time of biopsy. When one is as to the of the one is justified in the definitive procedure In the with the of the and close with the only 2 have been in cases of radical local In that of an undifferentiated metastatic with an primary the of undifferentiated sarcoma was In the other a fibrosarcoma was as a lesion because of inadequate obtained at biopsy. The nature of the lesion was on of the in the and a hemipelvectomy was done hours later. In no has a radical resection or hemipelvectomy been done for a has radical surgery been on of the The of has probably been the most important factor in whether to do a radical resection or a sarcomata, that is, the sarcomata that arise from marrow elements, such as multiple myeloma, reticulum-cell sarcoma, Ewing’s sarcoma, lymphosarcoma, and Hodgkin’s are more with is probably the most lesion in which radical resection is because of its do not tend to through the spaces or to the soft They tend to the of the local extent fairly both and at the time of surgery. Their on the is usually such that it is to determine what to be to the tumor. the clinical is such that the usually is quite apparent and, in the may occasionally be so obvious that resection should be done without the biopsy. sarcoma is less to local It to through the marrow spaces and to the soft Frequently, even with method of it is difficult to the local extent of an In cases of local resection of osteosarcoma, there was only one local at the site of In the soft-tissue sarcomata, by their themselves to local resection as well as to hemipelvectomy if their not function after local However, should be in attempting to soft-tissue sarcomata from the skeletal In the bone should be with the lesion in order to avoid of the wound with tumor cells. it through the is generally to local resection with the as after are frequently but in some instances local resection seems to be In patients who have a with a known or primary the of metastasis is a Many have that in certain instances the removal of a primary or metastatic skeletal lesion is by the and of distant However, this has been various tumors. in removal of the primary or skeletal metastasis is by a decrease in the of metastases and an increase in the size of the metastatic foci removal of the tumor the of new tumor and the factor the extent of metastasis in the is the presence of primary or skeletal In of this surgical resection of these lesions seems justified of the infrequently patients hemipelvectomy because of the This is of In many such instances, radical local resection the in the the may be by the patient that effort will be to the tumor safely and the of its function and, that if the extent of the tumor is such that the may not be the will the patient’s as to whether to with an attempt to the lesion. When has been with such patients, generally they are with a hemipelvectomy if that effort was to do a local In the of patients after local even they do not function so well as patients with has been that the of patients who have had This is of the result of a local resection in is a of the bone can be for of the These are to with no or in most instances, of a is required The of local resection hemipelvectomy from a point of are in and is required in the form of a or and the result of a hemipelvectomy is about the as that of a local patients have not had radical local have they been with after It is believed that an best on In radical local resection is to hemipelvectomy if the will not be and a result can be
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William F. Enneking (Fig 1) was born in Madison, WI. His college education was interrupted by service as a seaman in the United States Navy (1943–1944). Returning to the University of Wisconsin, he obtained a bachelor’s degree and a medical degree. After interning at the University of Colorado in 1950, he spent the next 4 years as a resident in orthopaedic surgery at the University of Chicago. This program, under the direction Howard Hatcher, had a great tradition of excellence especially in the field of orthopaedic pathology. Among its graduates were Michael Bonfiglio, Mary Sherman, and Crawford Campbell. Enneking would be added to this distinguished list of orthopaedic surgeons especially skilled in pathology.Fig 1.: Dr. William F. Enneking (Photograph courtesy of Dr. Enneking).After spending 1 year as an instructor at the University of Chicago, Enneking went to the University of Mississippi as the chief of orthopaedic surgery. When the new medical school of the University of Florida was opened in 1969, Enneking moved to Gainesville, FL and began the orthopaedic service. During his tenure at the University of Florida he served as Professor of Orthopaedic Surgery and Pathology and Chairman of the Department of Orthopaedics. Since his retirement in 1980 he carries the title of Eugene L. Jewett Professor of Orthopaedic Surgery and Distinguished Service Professor, University of Florida. Enneking spent his career studying the pathologic features of bone tumors and their treatment. His contributions to this field have been substantial and have earned him many honors including 3 Kappa Delta awards. He has served as president of the Orthopaedic Research Society, the American Board of Surgery, and the American Orthopaedic Association. He has had an important role in the founding, growth, and development of the Musculoskeletal Tumor Society. His book, Musculoskeletal Tumor Surgery 1 is a landmark in the field. The classic article is an example of the bold application of basic knowledge of pathology and thorough consideration of surgical anatomy. The decision to do an amputation or a local resection of a sarcomatous lesion about the pelvis depends on many factors. It is apparent from many clinical studies that sarcomata arising from the skeleton and the enveloping mesenchymal soft parts vary widely in their aggressiveness and clinical course; but, as a class, sarcomata kill the patient if they remain untreated. Types of Sarcomata Sarcomata can be divided into 2 main groups. One group consists of the lesions that arise from the connective-tissue elements, that is, osteosarcoma, chondrosarcoma, fibrosarcoma, giant-cell sarcoma, rhabdomyosarcoma, synovioma, and liposarcoma. The other group includes the lesions that arise from the marrow elements of the skeleton, such as multiple myeloma, reticulum-cell sarcoma, Ewing’s sarcoma, Hodgkin’s sarcoma, lymphosarcoma, and undifferentiated round-cell sarcoma. These marrow lesions are sensitive to x-rays and to chemotherapy. Only in carefully selected instances should resection or amputation be performed. The connective-tissue lesions are less responsive to radiation therapy used palliatively or in an attempt to produce a cure. They have been almost totally unresponsive to chemotherapy administered by perfusion or by a more disseminated route. The only successful method of controlling this group of diseases has been surgical excision of the lesion prior to metastasis. In most instances surgical removal of the primary lesion is technically feasible. Therefore, the patient’s survival depends on whether metastasis has occurred prior to removal of the primary lesion. Although it is well recognized that sarcomata will recur locally after inadequate or incomplete excision, almost without exception the survival of the patient depends on whether secondary expressions of the lesions appear in other parts of the body. It might be germane at this point to consider some facts known about the metastases of malignant disease. With a few notable exceptions, sarcomata metastasize through the blood stream. Lymphatic metastasis is seen clinically so infrequently that, unless obvious abnormal lymph nodes are palpated in the patient, most clinicians do not perform radical local node dissections. Although occasional nodes contain metastatic sarcoma, notably synovioma, this condition is so unusual that it merits case reports in the literature from time to time. The physiopathology of the dissemination of sarcoma cells through the blood stream is still obscure. Little is known of the release of these neoplastic cells from the original tumor, their passage through the blood stream, their vitality, and their ability to reproduce themselves at a distance from their point of origin. The release of the cells is related to both cellular and extracellular factors. The chief cellular factor is the marked decrease in the ability of sarcoma cells to adhere to one another. The force required to separate 2 tumor cells may be as much as 6 times less than the force required to separate corresponding normal cells. Cellular adhesiveness is related to many factors, such as calcium concentration and electric charge, but the net result is that tumor cells display a markedly reduced power of adhesion. Once separated, the tumor cell is quite capable of moving of its own accord. Propelled by amoeboid movements, it can cover the distance to the blood vessels at a much higher speed than a normal cell. For example, the speed per hour of a fibrosarcoma cell is 10 times that of a normal fibroblast. The size of the tumor cell is no obstacle to its displacement and, because of its amoeboid properties, it is quite capable of crossing the finest capillary barrier. Certain extracellular factors, such as injury and local vascular thrombosis, favor the migration of tumor cells. The decisive role of microscopic injury and thrombosis in the dissemination of cells has been clearly demonstrated. Why a tumor cell should stop in one particular place after reaching the blood stream is not understood. A considerable amount of evidence shows that the tumor cells actually may be disseminated through the blood stream, but tumor cells are found in the blood relatively seldom. The major exception is in regions close to the tumor. The great majority, if not all, of the circulating tumor cells are rapidly destroyed in the blood stream before they reach a site where they may reproduce themselves and form a metastatic focus. Tumor cells that survive and form metastases appear to do so as a function of the histological and biological nature of the tumor, rather than because of the nature of the tissue in which these cells are deposited. Viable tumor cells pass through the blood to distant organs and may be cultured from human blood successfully, but a distinction must be drawn between the viability of the cell in the blood stream and its ability to produce a secondary tumor. Although a tumor may be capable of releasing viable cells into the blood, metastases may not appear until considerably later. It is well known that metastatic foci of sarcomata may appear in the lungs many years after removal of the primary lesion without evidence of primary recurrence. There is a suggestion that certain neoplastic materials from tumors may be carried through the blood stream by macrophages and that metastases may then arise by some means other than intact cellular elements. The studies of Collins and associates on the doubling theory of neoplastic cells are of interest in this regard. Their work was based on an observation that tumor cells reproduce themselves at regular intervals of time and that presumably metastasis develops from a single cell. The subsequent multiplication of cells follows a logarithmic curve. If one studies a pulmonary metastasis and determines the time required for it to double its size and then double it again, it is possible to plot retrogradely and logarithmically the time at which the first cell reached the lung. If this method is valid, frequently metastasis seems to have occurred long before the patient has any inkling of the presence of the primary lesion or is seen by his physician. In opposition to these ominous observations is the fact that sarcomata inadvertently mismanaged occasionally fail to follow the usual clinical course, and the patient appears to be cured at follow-up of many years’ duration. Sherman and Irani recently reported cases in which the patients survived 8 and 10 years despite amputation perilously close to large osteogenic sarcomata (after repeated surgical manipulations). In addition, a series of 133 spontaneous cures of various neoplasms was well documented recently by the American Cancer Society and accepted by a panel of experienced clinicians as spontaneous cures. Many interpretations can be made, but it appears that in some instances the patient or host presents resistance of some type, probably immunological, that results in the destruction of what would usually be accepted as a malignant tumor. In managing patients with sarcomata, one seems to be justified in attempting surgical removal in the absence of demonstrable metastasis, even in the presence of known sarcoma cells circulating in the blood stream, in an effort to produce a cure. The method of removing the sarcoma and the subsequent treatment of the patient should be based on what is known about metastasis. In discussing this group of patients, the only lesions included are those arising from the pelvis, the proximal end of the femur, or their enveloping soft parts under circumstances in which thigh amputation or hip disarticulation is not feasible. Hemipelvectomy for neoplasms about the pelvis is probably the procedure most commonly employed and, in terms of survival time, the results are documented best for this procedure. In most instances, it is done after an open biopsy with closure of the wound and a delay of 48 to 72 hours prior to amputation. It is believed generally that amputation for malignant skeletal neoplasms should be done proximal to the proximal joint of the involved bone in order to avoid amputating through tumor. Many of the sarcomatous processes that arise within the skeleton tend to grow more rapidly along lines of least resistance through the intertrabecular spaces and the medullary canal. Frequently, it is extremely difficult to determine by any method of examination the extent of these lesions within the bone. It is held generally that epiphyseal plates and articular cartilage form a fairly effective biological barrier against the extension of tumor. Therefore, if one amputates above or through the adjoining joint, he is likely to be safely proximal to the tumor. At one time it was believed that after the initial biopsy a delay of 6 months prior to hemipelvectomy produced a higher percentage of long-time survivals. It was thought that the tumor was stirred up by the biopsy and that local dissemination from the tumor might be produced if the amputation was done soon after the biopsy. However, it appears likely that the slight increase in survival time after a delay of 6 months is probably due to a natural selection of patients who are more resistant to their tumors. Now amputation is generally not delayed after biopsy. Preoperative irradiation in heavy doses after the biopsy and prior to amputation has been used in various centers. In studying these reports, it appears that there is no appreciable difference in the survival rate with or without irradiation. Local excision of sarcomata of the pelvis is practiced less frequently than hemipelvectomy and less is known about the survival rates with this method of treatment. If one takes into account the differences in the natural history of the various types of sarcoma, no reports in the literature permit comparison of the long-term survival rate of patients with similar tumors who have had local resection with the survival of similar patients who have had amputation. Local resection is done more frequently for soft-tissue tumors than for tumors arising from the skeleton. The literature includes no definitive study of the function of patients after local resection of neoplasms with the function of those after There is no to the of the 2 However, radical resection is with of function and resection appears to the patient the it seems to do a resection rather than of may be decisive in the selection of the most procedure. The of these from case to case and be in any particular order of or of were but in cases of local resection these other to be of no The the of the the ability of the to determine the local extent of the the ability to a on the of a the nature of the the of the patient, and the function of the procedure. one a hemipelvectomy or a local resection of a malignant lesion of the pelvis, certain will result in A on the involved prior to the procedure will the and if excision of a of the is surgical may produce of neoplastic cells into the blood stream, it is likely that a and with the definitive surgical procedure at the time the patient’s of the of the by with the who will be on to the histological is The should be to the patient, the and be of the clinical The for the biopsy should be in such a that it may be resection or In a study was at the Cancer to determine from wound the of wound by cells for of the and of the and In this study the of was per with the per found in similar studies at the University of The of these with local no difference in terms of between patients with and those without wound However, the were by local were in of cases in which was but in only 10 of in which was not of the biopsy site appears to be of to and, if the biopsy wound is not in the of the definitive local seems to be more When the lesion is a should be from the of the lesion and a should be This should be by the in terms of the clinical and other in order to that the tissue is of the lesion and to determine the nature of the lesion. biopsy should be until the is that he can determine whether the lesion a malignant and whether it can be as a lesion. of the lesion is not for When the has been to the of both the and the the wound should be as as possible and the should be with a and used the biopsy should be At the of the definitive procedure a of tissue about the biopsy wound should be and the should be in such a that the through which the biopsy was done remain to the lesion. The first in the definitive procedure should be of the most proximal the If a hemipelvectomy is to be this may be and divided at this If radical resection is to be the should be with in order to of tumor cells reaching the the surgical After the hemipelvectomy or local the wound should be with a large of This may be in a separate and the and the of the procedure by the to determine the presence or absence of tumor cells in the the should be divided by the or in the and the wound is the should effort to that he has the lesion In where it appears that the lesion has been should be obtained from the of the and from the corresponding of the If a tumor is the wound should be When local of has been local chemotherapy has been employed and clinically by many to kill the tumor cells. have been locally with such as and These studies have that the are with the tumor cells prior to of the they are but the are in in the wound after so many the of the that the results are In some degree of in The clinical of to a wound with tumor cells is as as surgery studies on the of a and the development of local wound are difficult to It is probably to at this time that no has been to wound The surgical as to whether to do a radical local resection or a hemipelvectomy are as the of the lesion was the single most important factor in the cases in which radical local of lesions were In order to a result after radical local one must the and the of the and and the In the lesion must be within the on the If the has been and the tumor has the local resection is probably the of the vessels and and of the and is perilously close to the extent of the lesion. The of the pelvis may be and a result may be If the is the only it may be the of local resection and a result still be If the lesion is the or the of these must be and the must be or must be done the must to this extent to attempt to the patient a result be from local The proximal of the lesion is not important between a local resection and for the result is not by this of the one is only in the proximal extent by the and the The extent of the lesion is of considerably more One to of some of the bone against which to the after a local If no of the bone can be the of a that may be involved by the as well as the biopsy must be is generally not a consideration in between the 2 After resection of large of the is usually to close the but if in the form of or may be to Local of it has been rather that of the wound by tumor cells the of the procedure the of Therefore, one is not justified in attempting local resection of inadvertently through the lesion is in order to the Therefore, if it appears that the of to a result would the so close to the tumor that is a hemipelvectomy should be of a local The should his decision on the evidence from the prior to the procedure. In the of or vascular are In the and of in many instances will the extent of the lesion. and examination should be done in In the of the particular should be to the of the soft-tissue as well as to the amount of bone should be in the of the may be of the or or may be by of the or its displacement as by may be in the extent of the lesion. may in displacement of major in the local extent of the and in the of neoplastic vessels which the extent of the lesion. and as to the of the lesion to the and the lesion to be close to these have been employed in an effort to the extent of neoplastic employed most commonly are calcium and but they have not been reports of the of have that this might be more one of the more difficult is the of the local extent of the lesion in soft-tissue sarcomata which no of the skeleton. without large lesions in the of the that, by to the bone excision of of the bone to the tumor The in these instances may be of on In almost there have been with to radical have been done on this in the but with the of to produce and more knowledge of these the of such is It may be that the recently increase in survival rates for is with of the definitive procedure at the time of biopsy. When one is as to the of the one is justified in the definitive procedure In the with the of the and close with the only 2 have been in cases of radical local In that of an undifferentiated metastatic with an primary the of undifferentiated sarcoma was In the other a fibrosarcoma was as a lesion because of inadequate obtained at biopsy. The nature of the lesion was on of the in the and a hemipelvectomy was done hours later. In no has a radical resection or hemipelvectomy been done for a has radical surgery been on of the The of has probably been the most important factor in whether to do a radical resection or a sarcomata, that is, the sarcomata that arise from marrow elements, such as multiple myeloma, reticulum-cell sarcoma, Ewing’s sarcoma, lymphosarcoma, and Hodgkin’s are more with is probably the most lesion in which radical resection is because of its do not tend to through the spaces or to the soft They tend to the of the local extent fairly both and at the time of surgery. Their on the is usually such that it is to determine what to be to the tumor. the clinical is such that the usually is quite apparent and, in the may occasionally be so obvious that resection should be done without the biopsy. sarcoma is less to local It to through the marrow spaces and to the soft Frequently, even with method of it is difficult to the local extent of an In cases of local resection of osteosarcoma, there was only one local at the site of In the soft-tissue sarcomata, by their themselves to local resection as well as to hemipelvectomy if their not function after local However, should be in attempting to soft-tissue sarcomata from the skeletal In the bone should be with the lesion in order to avoid of the wound with tumor cells. it through the is generally to local resection with the as after are frequently but in some instances local resection seems to be In patients who have a with a known or primary the of metastasis is a Many have that in certain instances the removal of a primary or metastatic skeletal lesion is by the and of distant However, this has been various tumors. in removal of the primary or skeletal metastasis is by a decrease in the of metastases and an increase in the size of the metastatic foci removal of the tumor the of new tumor and the factor the extent of metastasis in the is the presence of primary or skeletal In of this surgical resection of these lesions seems justified of the infrequently patients hemipelvectomy because of the This is of In many such instances, radical local resection the in the the may be by the patient that effort will be to the tumor safely and the of its function and, that if the extent of the tumor is such that the may not be the will the patient’s as to whether to with an attempt to the lesion. When has been with such patients, generally they are with a hemipelvectomy if that effort was to do a local In the of patients after local even they do not function so well as patients with has been that the of patients who have had This is of the result of a local resection in is a of the bone can be for of the These are to with no or in most instances, of a is required The of local resection hemipelvectomy from a point of are in and is required in the form of a or and the result of a hemipelvectomy is about the as that of a local patients have not had radical local have they been with after It is believed that an best on In radical local resection is to hemipelvectomy if the will not be and a result can be
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