Surgery is the most common treatment option for most types of sarcoma. This consists of resection and reconstruction.

The objective of surgical resection is to achieve adequate oncologic margins. Decisions about the optimal surgical procedure are made with reference to the tumour type, extent and response to neoadjuvant therapy if appropriate (refer to sections 4.2.2 and 4.2.3).

The objective of reconstruction is to promote wound healing, optimise function and improve the appearance of the affected area.

When surgery involves the limb, the preference is for limb salvage surgery, though occasionally ablative surgery (amputation) may be required.

Most patients are considered as candidates for limb salvage surgery. When considering the feasibility of limb preservation, the following should be taken into account:

• the outcome of surgery in regard to local recurrence
• distant metastasis and survival outcome (this should be comparable to that of ablative surgery)
• risk of complications
• possible re-operations and secondary amputation
• the functional outcome (this should be equivalent to or better than amputation).

All surgical options (including amputation) should be discussed with and acceptable to the patient.

It is important that the rehabilitation team has specific skills with limb salvage surgery and amputee rehabilitation. Upper limb amputees should receive rehabilitation as soon as possible after surgery.

Appropriate vascular and plastic surgical reconstructive options should be available.

Training, experience and treatment centre characteristics

The training and experience required of the surgeon is as follows:

• surgeon (FRACS or equivalent) with adequate training and experience and institutional cross- credentialling and agreed scope of practice within this area (ACSQHC 2004)
• adequate training including subspecialty training at a national or international centre of excellence with continued practice as part of a recognised multidisciplinary team
• plastic surgeon with an interest and expertise in sarcoma reconstructive surgery.

Hospital or treatment unit characteristics for providing safe and quality care include:

• appropriate nursing and theatre resources to manage complex surgery
• theatre with prosthetics capability
• 24-hour medical staff availability
• 24-hour operating room access
• specialist pathology expertise / molecular pathology
• full anatomic imaging modalities
• specialist interventional diagnostic radiology and nuclear medicine expertise.

Surgical volumes

High-volume centres generally have better clinical outcomes (Bhangu et al. 2004; Gutierrez et al. 2007; Sampo et al. 2012; Stiller et al. 2006) and are associated with improved rates of functional limb preservation, lower rates of local recurrence, good rates of overall survival and improved quality of life

(Cancer Council Australia Sarcoma Guidelines Working Party 2014). Centres that do not have sufficient caseloads should establish processes to routinely refer surgical cases to a high-volume centre.