Soft-tissue Sarcomas

Abstract

This article discusses the epidemiology, diagnosis, and management of primary soft-tissue sarcomas (STS). These musculoskeletal tumors are a rare and heterogeneous group of malignancies, which are best managed by multidisciplinary teams in specialist sarcoma referral centers. Historically, the standard for local control of these tumors has been amputation. Evolutions in multimodality treatment have seen a shift toward preservation of the limb. Advances in limb-sparing surgery have seen the quality of life in sarcoma patients to improve drastically; however, unplanned surgical excision of STS remains a major treatment dilemma in the control of local disease.

Keywords: Limb-sparing surgery; Sarcoma; biopsy; limb prosthesis; musculoskeletal oncology; orthopedic tumors; sarcoma; soft-tissue sarcoma; tumors; unplanned excision of sarcoma.

Figure 1

(a) Magnetic resonance imaging and (b) Computed tomography of a left gluteal synovial sarcoma. This patient successfully underwent wide resection and plastic reconstruction with a latissimus dorsi flap

Figure 2

Computed tomography guided core-needle biopsy of a left thigh, in Ewing's sarcoma

Figure 3

Inappropriate excisions. (a) Tibial neurovascular structure bruising is seen, a small lump believed to be a hematoma was excised, then found to be a synovial sarcoma. (b) Fungating right lower-leg tumor. This patient had undergone an unplanned excision of a small mass by a general surgeon, which turned out to be a sarcoma. Subsequently, the sarcoma locally recurred, rapidly grew, and began to fungate. (c) Forearm undifferentiated pleomorphic sarcoma, underwent unplanned excision prior to referral. Local recurrence resulted in the patient requiring above-elbow amputation

Figure 4

Golf ball sized 4.2 cm. Consider any lump bigger than this to be a sarcoma until proven otherwise

Figure 5

Axial MRI showing surgical margins of a right-sided thigh undifferentiated pleomorphic sarcoma. Red circle (innermost) represents an intralesional margin. Yellow circle (2^nd from center) represents a marginal excision. Green circle (outermost line) represents a wide excision

Figure 6

The intraoperative photograph showing the marginal excision of a high-grade liposarcoma

Figure 7

Peroperative clinical photographs (a) The cavity remaining following the wide-margin excision of a tumor of the thigh, where soft tissue and a section of femur, which the tumor had engulfed, were also excised. (b) The excised undifferentiated pleomorphic sarcoma from a patient's thigh. Note the surrounding soft tissue and femur to achieve the wide margin

Figure 8

Clinical photograph showing a medial forearm reconstruction, with a skin and muscle flap, following the wide excision of a synovial sarcoma