In an adult with good performance status and no contraindicating comorbidities, is salvage (limb‑sparing) surgery feasible for an intermediate‑grade fibrosarcoma of the proximal femoral shaft involving the hip joint synovial capsule?

Salvage Limb-Sparing Surgery for Intermediate-Grade Fibrosarcoma of Proximal Femur with Hip Joint Involvement

Yes, salvage limb-sparing surgery is feasible and should be pursued for an intermediate-grade fibrosarcoma of the proximal femoral shaft involving the hip joint synovial capsule in an adult with good performance status. 1

Primary Surgical Approach

The goal is functional limb preservation through wide en-bloc resection with endoprosthetic reconstruction, not amputation. 1

• Limb salvage is the standard approach for extremity sarcomas when oncologically sound resection can be achieved while maintaining limb function 1, 2
• The NCCN explicitly states that amputation should only be considered when gross total resection would render the limb nonfunctional or based on patient preference after expert evaluation 1, 3
• Most patients with proximal femoral sarcomas should be considered candidates for limb salvage 1

Surgical Technique for Hip Joint Involvement

When the synovial capsule is involved, extra-articular resection of both the proximal femur and acetabulum is required, followed by custom endoprosthetic reconstruction. 4

• The dissection must proceed through grossly normal tissue planes uncontaminated by tumor 1, 2
• En-bloc extra-articular resection should include the acetabulum and proximal femur when intra-articular extension is present 4
• Reconstruction using a coned hemi-pelvic implant with fluted stem and modular femoral component allows adequate tumor clearance with stable reconstruction 4
• If major vessels are displaced but not invaded, the adventitia should be removed without resecting the underlying neurovascular structures 1, 2

Margin Requirements

Achieve R0 resection (no microscopic residual disease) as the primary surgical goal, though close margins are acceptable at resistant anatomic barriers. 1, 2

• Wide excision with negative margins is mandatory; R1 or R2 margins significantly increase local recurrence and reduce overall survival 1
• Minimal margins (even <1 cm) are acceptable at resistant anatomic planes such as muscular fascia, periosteum, and perineurium if these structures are uninvolved 1, 2
• Radical compartmental resection is NOT routinely necessary 1, 2
• Surgical clips should mark areas of close margins to guide potential adjuvant radiation 1

Multimodal Treatment Strategy

Adjuvant radiation therapy (50-60 Gy postoperatively) is standard for intermediate-grade, deep tumors >5 cm and should be planned regardless of final margin status. 1, 5

• For intermediate-high grade, deep tumors >5 cm, wide excision combined with radiation therapy is the standard treatment 1
• Preoperative radiation (50 Gy) is an alternative option that may facilitate resection 1
• Adjuvant chemotherapy is NOT standard for fibrosarcoma but may be considered as an individualized option for high-risk features (G2-3, deep, >5 cm) 1

Reconstructive Considerations

Endoprosthetic replacement provides satisfactory long-term functional outcomes with acceptable complication rates. 6, 7

• Proximal femoral endoprosthetic survival rates are 87% at 5 years and 80% at 10 years 6
• Functional outcomes are generally good, with median Enneking scores of 22 points (range 12-28) 6
• Mechanical failures are the most common long-term complication (41% overall complication rate), but most do not require amputation 6
• If extensive soft tissue loss is anticipated or vascular reconstruction is needed, plastic surgery involvement should be integrated from the outset 5

Critical Prerequisites

Surgery must be performed by a surgeon with specific expertise in sarcoma management within a multidisciplinary team at a reference center. 1, 2

• Mandatory evaluation by a sarcoma expert surgeon is required before any definitive surgical decision 1, 3, 2
• All management decisions must be made by a formally constituted sarcoma multidisciplinary team including surgical oncology, medical oncology, radiation oncology, pathology, and radiology 1, 5, 2
• Treatment at reference centers with access to the full spectrum of care is the accepted standard 1

When Amputation Becomes Necessary

Amputation should only be performed if limb-sparing resection would leave the limb without useful function or if the patient explicitly prefers it after complete discussion. 1, 3

• Before considering amputation, patients must be evaluated by a surgeon with expertise in soft tissue sarcomas 1, 3
• Amputation is indicated when gross total resection would render the limb nonfunctional (e.g., extensive compromise of major neurovascular structures that cannot be preserved) 1, 3
• Hip joint involvement alone does not mandate amputation if extra-articular resection with endoprosthetic reconstruction is technically feasible 4

Common Pitfalls to Avoid

• Never perform definitive resection without histopathological confirmation by a specialist sarcoma pathologist 2
• Never accept positive margins without attempting re-resection when functionally feasible, as this significantly impacts survival 1, 2
• Never perform internal fixation if pathological fracture is present, as this disseminates tumor and increases local recurrence risk; use external splintage instead 1
• Never proceed with surgery outside a multidisciplinary sarcoma team at a reference center 1, 2