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Approach to Soft Tissue Tumor in Upper Extremity
Nattakul Yamprasert Department of Orthopaedics,
Maharat Nakhon Ratchasima Hospital
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Overview• Definition
• Evaluation Protocol
• Investigation
• Biopsy
• Classification
• Definite Surgical Treatment
• Case Presentation
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What is Tumor?
“Any abnormal lump, bump or
mass is considered a tumor.”
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“The term ‘tumor’ does not
necessarily mean it is
malignant or it is a cancer.”
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“Solitary soft tissue mass is benign lesion”
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MYTH
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“Assuming that a solitary soft-tissue mass is a benign lesion and suitable for intralesional excision is also detrimental and could affect the patient's prognosis and complicate further surgical treatment if wrongly excised.”
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What is Sarcoma?“A type of cancer that begins in bone or
in the soft tissues of the body, including
cartilage, fat, muscle, blood vessels,
fibrous tissue, or other connective or
supportive tissue.”
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“For every 1 cm increase in the size of a
soft-tissue sarcoma at diagnosis there is a
3% to 5% decrease in the chance of cure.”
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Worrying Features (Suspected Malignancy)
• Size > 5 cm
• Increasing in size
• Deep to the deep fascia
• Painful
• Recurrent after excision
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Soft tissue lump,uncertain diagnosis
Worrying features No worrying features
Imaging study (ideally MRI)Refer for biopsy if imaging not helpful
Observation/Excisional biopsyAlways Pathology
Sarcoma center Benign
Sarcoma/Other malignancy
Refer tomultidisciplinary team
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Physical Examination
• Size
• Depth
• Mobility
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Inspection
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Inspection
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Palpation
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Imaging• X-ray
• CT Scan
• Bone scan
• MRI
• Sonography16
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X-Ray• Bone involvement
• Bone lysis
• Periosteal reaction
• Pressure effect
• Soft tissue swelling17
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Bone Scan• Multilple site of lesion
• 2 time-variable phases
• Detect abnormality does not observe in
initial phase
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CT Scan• Localizing small tumors in the bone
• Identify soft tissue extension/
calcification
• Provide anatomic location for staging
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MRI• Detail of soft tissue lesion
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MRI• Detail of soft tissue lesion
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Transillumination test22
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Transillumination Test for Tumor Diagnosis
Findings Likely Pathology
Bright Ganglion cyst filled with clear fluid
Equal Lipoma, Neurilemmoma
Indeterminate GCT, Inclusion cyst, Thick skin callus
Dark Ganglion cyst filled with blood, Aneurism, Calcification, Gouty tophi, Osteophyte
Source: http://www.eatonhand.com/img/img00087.htm23
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Biopsy• Needle Biopsy
• Open Biopsy
• Incisional Biopsy
• Marginal Biopsy
• Primary Wide Excision
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Needle Biopsy• Limited role in hand and
upper extremity
• Useful in subcutaneous lesion or confirmation of recurrent /metastatic lesion
• Fragmentation of tissue
• Difficult for grading
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Open Biopsy• Exsanguination is contraindicated! • Surgical technique for biopsy in extremity is
different from standard surgical dissections.
• Longitudinal incision is recommended.
• Avoid transverse / zigzag incision
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Incisional Biopsy• Direct approach
• Avoid extensive retraction
• Adequate visualization
• Hemostasis, avoid hematoma
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hTumor
Healthy tissue
Incision
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Marginal Resection• Removal through reactive
zone
• Reserve for small lesion ( diameter < 2 cm )
• Extensive contamination of operative field
• +/- soft tissue coverage in large lesion
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hTumor
Healthy tissue
Incision
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Primary Wide Excision• Tumor removal +
surrounding normal tissue
• Excellent oncologic procedure
• Use in case of high suspicious of malignancy, excessive contamination
• Consult musculoskeletal oncologist for decision
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hTumor
Healthy tissue
Incision
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Benign Soft Tissue Tumor
• Ganglion cyst
• Epidermal inclusion cyst
• Foreign body lesions
• Lipoma
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• Giant cell tumor of tendon sheath (Pigmented villonodula tenosynovitis)
• Neurilemoma
• Neurofibroma
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Soft Tissue Sarcoma• Epithelioid sarcoma
• Synovial sarcoma
• Liposarcoma
• Fibrosarcoma
• Maligant histiocytoma
• Malignant peripheral nerve sheath tumor
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Definitive Surgical Treatment
Benign tumor
• Marginal resection
• Intralesional curettage (in case of bone tumor)
• Frozen section for confirmation of tissue margin
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Histological Grading
• G0: Benign
• G1: Low Grade ( few cells, much stroma, little necrosis, mature cells, <5 mitoses/HPF)
• G2: High Grade (many cells, little stroma, much necrosis, immature cells, >10 mitoses/HPF)
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Staging of Benign Soft Tissue Tumor
Stage I:Latent
Stage II:Active
Stage III: Locally
Aggressive
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Enneking’s Surgical Stages
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Stage Grade Site
IA G1 Intracompartment (T1)
IB G1 Extracompartment(T2)
IIA G2 Intracompartment (T1)
IIB G2 Extracompartment (T2)
III Any G, Regional or distant metastasis
Any T, Regional or distant metastasis
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Definitive Surgical Treatment
Malignant tumor
• Functional reservation is secondary to disease eradication
• Response of tumor to radiation/chemotherapy
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AdequateResection
LocalRecurrence
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Case Presentation
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Case #1
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Final Diagnosis: Giant Cell Tumor of Tendon Sheath
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Case #2
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15-year-oldMass at thenar area and wristProgressive numbness of thumb, index and middle finger
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Final Diagnosis: Lipofibromatous Harmatoma
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Case #3
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79-year-old, M8-cm-mass at forearm for 1 yearNo pain
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Final Diagnosis: Candidiasis
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Case #4
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65-year-old, MReferred from Hospital X after failed excision of mass at wrist
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Transverse scar!
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Tissue excisionincluding transverse scar
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Paratenon was intact
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Defect closing by STSG
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Final Diagnosis: Candidiasis
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2 wks postop.
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6 wks postop.
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Case #5
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35-year-old, M Painful mass at left palm for 4 mo.
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Intraoperative Finding: Ill-defined intramuscular mass of lumbrical muscle with FDP, FDS tendon involvement
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Patho = Epithelioid Sarcoma Margin: not free
Definitive Surgery: “At least” Marginal resection The 3rd & 4th ray amputation
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6 months later…
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Definite Treatment: BE Amputation
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Take Home Message• Beware of solitary soft tissue mass in extremity
• Thorough physical examination is mandatory
• Biopsy incision different from standard surgical incision
• When in doubt, consult musculoskeletal oncologist
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