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

“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

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

X-Ray• Bone involvement

• Bone lysis

• Periosteal reaction

• Pressure effect

• Soft tissue swelling17

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

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

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

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

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

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

Definitive Surgical Treatment

Malignant tumor

• Functional reservation is secondary to disease eradication

• Response of tumor to radiation/chemotherapy

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AdequateResection

LocalRecurrence

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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