Includes Index

It has been 30 years since the publication of the Atlas of Operations for Soft Tissue Tumors.
Additional information has been collected on the various procedures described in the first
atlas, and several new chapters have been added. The discussion, as it befits the title of the
book, is restricted in most chapters to the presentation of the surgical technique and the immediate effects on resection of tumor and postoperative complications.
Considering the extent of some of the operations illustrated in this book, a contemporary
surgeon might regard them as too “radical,” perhaps even an anachronism in the current era of
progressively less extensive surgery for locoregional control of various tumors in combination
with other modalities. Melanoma and breast are but just two examples where historically
“aggressive” surgeries for the treatment of primary localized or regionally metastatic tumors
have been replaced by less radical and less morbid approaches.
However, an operation with a large specimen and a long incision is not necessarily “radical”
from a biologic viewpoint. The surgical margin of these large specimens, as in resection of
retroperitoneal tumors or major amputations, is frequently in the range of a few millimeters
between the infiltrating edge of the tumor and the surface of the specimen. Although the narrow surgical margin may concern a rather small area of the specimen surface, it is an important
prognostic and etiological factor predictive of local recurrence. Such operations may be anatomically extensive but in reality are biologically conservative as the resections of retroperitoneal sarcomas clearly show with their high local recurrence rates. Many of the operations
described in this book are “extensive” but hardly are “radical” in the sense that the desire for a
wide surgical margin is always moderated by consideration of the effects of the extra margin
in the function or cosmetic appearance of the involved area or in surgical complications.
Radical resection carries the connotation of unnecessary removal of excessive uninvolved normal tissue without a concern for functional implications or without prior clear demonstration
of therapeutic benefit to this more aggressive approach. Again, this is not what procedures
demonstrated in this atlas entail. This principle is clearly manifest in the case of sarcomas of
the extremities where the goal of limb preservation with adequate function is optimally combined with the pursuit of an adequate surgical margin. This requires knowledge of the functional anatomy of the extremity as there is considerable functional reserve available for the
extremes of action whose removal does not affect routine activity.
In addition to the description of procedures according to anatomic or organ-based consideration, a thematic approach according to the surgical technique is also presented. This results in
some repetition of information and redundancy of style, but it is believed that looking at the
same thing from different points of view produces a deeper understanding and reveals the unity
in surgical technique that permeates several groups of procedures. Ligation and division of the
inferior epigastric vessels provides exposure in continuity of the iliac and femoral vessels and
surrounding space. This is an essential surgical step in a radical groin dissection (with incontinuity dissection of the inguinal and deep nodes), the abdominoinguinal incision, and the
internal hemipelvectomy. Preservation of these vessels also provides the main blood supply for
rectus abdominis flap mobilized to provide coverage for a defect in the contralateral lower
abdominal wall and groin. Mastering the technique of dissection in the bowel mesentery is a sine qua non in resecting tumors involving the bowel, in colon esophageal bypass, in
peritoneolysis used during construction of a Roux-en-Y loop, and in ileal loop bladder.
The description of extensive procedures described in this volume provides not only evidence of their feasibility but also information on how they can be done with a minimum of
complications. Such procedures are applied in patients with locally or regionally advanced
tumor with a favorable outlook. Patients more likely to respond to the surgical treatment are
those with a small number (1–3) of discrete tumor masses and a long duration of persistent
disease without rapid progression. It is possible that cancer therapy may go through a stage
where systemic treatment may be highly effective in destroying microscopic disease or small
metastatic nodules but unable to eradicate large metastatic masses calling in this case for their
surgical extirpation.
In the context of ever-increasing research discoveries in the medical treatment of cancers,
some surgeons may view this atlas or portions thereof to be of historical interest. I actually
believe that the surgeon’s role will not diminish, at least in the foreseeable future, and perhaps
may even become more important as part of a multidisciplinary team. A sound knowledge of
the gamut of surgical techniques in oncology enables the surgeon to be at the forefront of treatment for these patients and to offer the best opportunities for palliation or cure. I sincerely
hope that my experience, what I’ve learned—the successes and the failures—over the past 40
years can help young surgeons to continue improving the lives of cancer patients. I am confident that the future generations will continue to refine surgical techniques and better understand the applications of these techniques in the context of multimodality therapies.
I would like to express my gratitude to the late E. D. Holyoke, MD, and H. O. Douglass Jr.,
MD, for their unflagging support in the early steps of my career; and Nicholas Petrelli, MD, in
providing an example of unparalleled devotion to the mentorship of Fellows and his emphasis
on biologic research and participation in prospective randomized trials. From the younger
attendings who served in the Soft-tissue Melanoma Service, R. N. Nambisan, MD, R. Lopez,
MD, and M. Vezeridis, MD, distinguished themselves with their excellent clinical work.