retroperitoneal and head & neck soft tissue sarcoma: advances and challenges … ·...

Retroperitoneal and Head & Neck Soft

Tissue Sarcoma: Advances and

Challenges in Surgical Techniques

K C Soo

National Cancer Centre Singapore

Duke-NUS Graduate Medical School

2 March 2013

2

Sarcomas – difficult to treat because

• Paucity of randomised studies

• Anatomical location and route of spread make

for difficult surgery

Rare disease

• ASR* STS Male – 5.12 / 100,000 Female – 4.58 / 100,000

Colorectal Male – 53 / 100,000 Female – 47 / 100,000

i.e. 1% of adult and 15% of paediatric malignancies

• Diverse histological subtypes

• Heterogeneous biological behaviour

*Cancer Rates and Risks, NIH Monograph, 4th Edition

Challenges in Management of Retroperitoneal and Head & Neck STS

• Difficulty of preoperative biopsy - tissue diagnosis before treatment

• 60 year old male from

Indonesian

• Percutaneous biopsy

– low grade sarcoma

or paraganglioma

• Treated definitively

with chemotherapy!

• Came to NCC for

second opinion

• Biopsy and frozen

section at NCC -

?Lymphoma

• Final histology -

paraganglioma

• Re-laparotomy and

resection of tumour

• Final histology –

hemangiopericytoma

• Presented at Joint

Tumour Board – no

role for adjuvant

chemo or radiation

therapy

Challenges in Management of Retroperitoneal and Head & Neck STS

• Difficulty of preoperative biopsy

• Anatomical proximity and compression

− 40y Chinese female

− Initially presented with vague abdominal pain

− CT Abdomen and Pelvis performed showed a large 17 x 9 x 10cm

retroperitoneal mass centered around the duodenal C loop with the

pancreatic head, inseparable from it, compressing the inferior vena

cava with the superior mesenteric artery drapping over the mass.

• She underwent 6 cycles of chemotherapy, last cycle given on 5/9/12

• Had radiation preoperative to downsize the tumour further

SMA Origin

Pancreas

IVC Tumor

Left Renal

Vein

Tumor

Underwent elective Resection of Retroperitoneal

Tumour and subtotal pancreatectomy

Tumor

Pancreatic Stump

SMA SMV

• Difficulty of preoperative biopsy

• Anatomical proximity and compression

• Late presentation

Tumour causing parapharyngeal displacement and

dumb bell extension through masticor space onto cheek

Tumour pushing branches of facial nerve anteriorly

Mandibulotomy to access parapharyngeal space to remove

tumour en bloc

• Difficulty of preoperative biopsy

• Anatomical proximity and compression

• Late presentation

• Clear surgical margins

− 70 / Chinese / Male

− Presented to NUH with a left groin mass and scrotal swelling for 1 year

duration in Feb 2011

− Underwent left groin exploration and excision of spermatic cord and left

testis on 2/11/2012

− Histology returned as well differentiated liposarcoma sclerosing type

involving left spermatic cord resection margin and focally involves the

circumferential radial margin, testis normal

− Underwent wider re-excision of tumour on 22/11/12, histology margins

positive again

− Was offered repeat surgery in NUH, choose to come to NCC for second

opinion

Enhancing mass / collection medially over pubic tubercle

En bloc resection including inguinal ligament and its

incision into pubic tuberacle Femoral artery

and vein

Pubic

tuberacle

Inferiorly based rectus abdominis myocutaneous flap

to reconstruct inguinal ligament and close the soft

tissue defect

Histology

• Left groin soft tissue – no

evidence of well differentiated

sarcoma

• Tissue over pubic symphysis –

negative for malignancy

• Difficulty of preoperative biopsy

• Anatomical proximity and compression

• Late presentation

• Clear surgical margins

• Radiation induced sarcomas – significant proportion of

H&N STS − 60y Chinese male

− Nasopharyngeal carcinoma T2N0M0 – 1995

− radiotherapy + bradytherapy 1996

− presented as supraclavicular lump 2011 s/p left modified radical neck dissection on

11/4/2012

− (IJV, SCM taken, accessory nerve preserved)

− Histology:

> high grade myxofibrosacroma

> involvement of resection margins

> Infiltrating into pre-vertebral muscle

> left MRND - 0/9 nodes

> Submental - 0/1 nodes

− Presented with recurrence in Dec 12

Extensive involvement of tissues around carotids extending

retropharyngeal and superiorly to occiput. Vagus nerve

also involved.

Histology: Malignant spindle cell tumour consistent

with high grade myxofibrosarcoma, margins

negative

• Difficulty of preoperative biopsy

• Anatomical proximity and compression

• Late presentation

• Clear surgical margins

• Radiation induced sarcomas – significant proportion of H&N STS

• Major vascular involvement

• 70 year old female

from Vietnam with

right hypochrondial

pain

Mass in the region of head

of pancreas involving the

IVC

duodenum

pancreas tumour

IVC

IVC

Lumen

Caval leiyomyosarcoma

• Difficulty of preoperative biopsy

• Anatomical proximity and compression

• Late presentation

• Clear surgical margins

• Radiation induced sarcomas – significant proportion of H&N STS

• Major vascular involvement

• Treatment in multidisciplinary centre vs surgeons /

medical oncologists who have occasional encounters with

STS − 35/Chinese/Male

− Retroperitoneal mass seen in the region of the second and third part of

the duodenum encasing the right renal artery and compressing the IVC

− Treated for 1 year with chemotherapy

− Consulted Peter MacCallum Cancer Centre who referred patient to

NCCS

Left

Renal

Vein

Dilated Lumbar Veins

IVC compressed by Tumor

Aorta

• Preservation of left kidney

by transecting left renal

vein medial to lumbar

vessel

• Ureteric stents to measure

right and left renal

function

• Right nephrectomy and

IVC resection

• Consideration for right

renal auto-transplantation

Surgical Considerations

Soft tissue sarcomas should be treated at a tumour centre : a

comparison of quality of surgery in 375 patients

Acta Orthop Scand 1994, 65 : 47

Local recurrence rate was 2.45x higher in patients

who were not referred, 1.3x higher in the patients

who were referred after surgery than in patients

who were referred to a multidisciplinary tumour

centre before any manipulation of the tumour.

Thank you

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