Soft Tissue Sarcoma Specialist Surgeon Singapore 

Limb Salvage and Neurovascular Management in Complex Sarcoma Resection

We approach the vast spectrum of soft tissue sarcomas—from the common liposarcoma to the rarest histological subtypes—not merely as biological entities, but as invasive threats to the functional architecture of the limb. Under the surgical direction of Dr. Saminathan Suresh Nathan, we navigate the high-stakes "no-man's land" of these tumors. Our focus is on the trade-off between radical oncological clearance and the preservation of critical nerves and vessels. By utilizing thirty years of surgical discernment, we specialize in the definitive local control required to prevent the devastating recurrence rates associated with inadequate primary excisions. In the upper limb, single nerve sacrifices are compensable with tendon transfers. In the lower limb sciatic nerve sacrifice is compensable with ankle-foot orthoses. Antecubital and popliteal fossa tumors portend major neurovascular involvement and should be considered for amputation. The foot is especially tricky. Foot sparing surgery must ensure a sensate foot. Tibial nerve sacrifices necessitate amputation as below knee prostheses are more functional than insensate feet. 

Vessel bypasses are at considerable risk with chemotherapy or radiation therapy. The lack of soft tissue coverage may necessitate amputation. 

When soft tissue tumors abut bone, special problems arise. Bony resection entails considerable morbidity. Periosteal resection increases risk of pathological fracture and requires multimodality therapy (radiation, chemotherapy, surgery). 

Low grade sarcomas look like normal tissue under the microscope. This poor delineation of margins results in high risk of local recurrence. Dedifferentiation of tumors into a worse grade does happen with relatively benign looking tumors. 

Lymph node metastasis are uncommon and nodal dissection not routinely recommended. We employ the technique of sentinel node biopsy in nodal-metastasis prone tumors namely synovial sarcomas (in only 10%), rhabdomyosarcoma and melanomas.

Margins are the most important surgical consideration in soft tissue sarcomas. Positive margins are associated with 80% local recurrence. Marginal resections result in 20% local recurrence. Wide resections give about 10 % local recurrence. Radical resections have a 5% local recurrence rate. There is no difference in survival between limb-salvage and amputation. There is, however, a slightly higher incidence of local failure with limb-salvage.

Unplanned excisions represent a “no-man’s land” in terms of evidence-based medicine and are covered elsewhere in this website. They usually require re-excision as the are associated with 15% positive margins.

Surgical Considerations

• The Critical 2mm Margin: We prioritize achieving a verified wide oncological cuff; while marginal resections carry a significant recurrence risk, radical clearance remains the primary driver of long-term survival.

• Neurovascular Decision-Making: We specialize in the difficult calculus of limb salvage—evaluating when a nerve sacrifice is functional and compensable versus when it compromises the mechanical integrity of the foot or hand.

• Management of Unplanned Excisions: Providing definitive re-excision protocols for patients whose primary surgery elsewhere resulted in contaminated tissue planes, ensuring oncological safety is restored.

Figure 1 (video). The case is a soft tissue sarcoma of the thigh. This presented as a tumor in the sciatic nerve which was resected intraneurally using a microscope. The patient did not have any neurological deficit and a well-centralised spot of sarcoma was fount surrounded by benign tissue.