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