CORR Insights®: Do Surgical Margins Affect Local Recurrence and Survival in Extremity, Nonmetastatic, High-grade Osteosarcoma?

W hile there is certainly no consensus as to how wide a margin of resection should be [1], surgeons agree that oncologic outcome must take priority over functional results when performing surgery for patients with osteosarcoma. The debate begins with the understanding that the patient’s survival can be affected by the hands of the surgeon, despite the enormous benefits of chemotherapy and the confusing effects of local recurrence on survival. In a study of patients with locally recurrent osteosarcoma published almost a decade ago by Nathan et al. [5], it is noted that six of 13 patients with positive margins and 14 of 389 with negative margins developed local recurrence. The strongest correlation with poor survival was local recurrence within the first year after primary resection [5]. It would seem from this study alone that positive margins and local recurrence should be avoided at all cost. However, a study by Rougraff and colleagues [6] found that despite having no local recurrences after hip disarticulation for osteosarcoma of the femur, there was no difference in duration of survival or of disease-free survival when compared to patients undergoing limb-salvage surgery or above knee amputations in spite of higher local recurrence rates in these groups. One of the reasons for this, the authors speculate, is that the small percentage difference in local control, confounded by nearly 50% of the patients dying, represents such a small discrepancy that it did not affect the overall survival statistics. The literature can be confusing when considering margins, local recurrence, and survival. Readers should consider how words like ‘‘only’’ or ‘‘small’’ may influence decisions about margins. A study by Kong and colleagues [3], with the title, ‘‘Local Recurrence Has Only a Small Effect on Survival in High-risk Extremity Osteosarcoma’’ might allow us as surgeons to let down our guard a bit, relax, or push the envelope when the margin is ‘‘close.’’ In the current study, Bertrand and his colleagues showed that after controlling for relevant confounding variables, the presence of a positive This CORR Insights is a commentary on the article ‘‘Do Surgical Margins Affect Local Recurrence and Survival in Extremity, Nonmetastatic, High-grade Osteosarcoma?’’ by Bertrand and colleagues available at: DOI: 10.1007/s11999-015-4359-x. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999-0154359-x. K. S. Beebe MD (&) Musculoskeletal Oncology and Limb Salvage, Rutgers-New Jersey Medical School, 140 Bergen St., Newark, NJ 07101-1709, USA e-mail: kathleen.beebe@rutgers.edu CORR Insights Published online: 20 June 2015 The Association of Bone and Joint Surgeons1 2015