Principles of tumor management.

Primary musculoskeletal tumors are rare in the practice of orthopaedic surgery because they are unusual in the general population. The orthopaedist is often the first physician faced with the decision of how the patient should be evaluated and treated. The best opportunity for control of the tumor and maximal function is dependent on the initial management. History and physical examination are essential. Each patient must be appropriately staged to determine the anatomic extent of the tumor and its histologic type and grade. Plane x-ray examination, tomograms, isotope bone scans, angiograms, and CT are all useful tools in the staging of a musculoskeletal tumor but must be requested with specific questions asked of the radiologist if maximal benefit is to be obtained from them. Serum determination of calcium, phosphorus, alkaline phosphatase, protein electrophoresis, and sedimentation rate and urine determination of protein electrophoresis are the minimal laboratory evaluations suggested. Following careful staging of the patient and discussion with the pathologist regarding possible diagnoses and treatment, a thoughtful biopsy should be done. Consideration should be given to an immediate limb salvage procedure when appropriate, based on a frozen section diagnosis. This requires that the surgeon who performs the biopsy accept the responsibility for the definitive treatment of the patient.