Uploaded byNattakul Yamprasert
Approach to Soft Tissue Tumor in Upper Extremity
The document discusses the approach to diagnosing and treating soft tissue tumors in the upper extremity, emphasizing the importance of evaluation, imaging, and biopsy procedures. It highlights the distinction between benign and malignant tumors, the implications of size and growth patterns, and the necessity for accurate surgical interventions. Case presentations illustrate various tumor diagnoses, outcomes, and the need for multidisciplinary consultation in complex cases.
More Related Content
Similar to Approach to Soft Tissue Tumor in Upper Extremity
Approach to Soft Tissue Tumor in Upper Extremity
- 1. Approach to Soft TissueTumor in Upper Extremity Nattakul Yamprasert Department of Orthopaedics, Maharat Nakhon Ratchasima Hospital 1
- 2. Overview • Definition • EvaluationProtocol • Investigation • Biopsy • Classification • Definite Surgical Treatment • Case Presentation 2
- 3. What is Tumor? “Anyabnormal lump, bump or mass is considered a tumor.” 3
- 4. “The term ‘tumor’does not necessarily mean it is malignant or it is a cancer.” 4
- 5. “Solitary soft tissuemass is benign lesion” 5 MYTH
- 6. “Assuming that asolitary 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.” 6
- 7. What is Sarcoma? “Atype 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.” 7
- 8. “For every 1cm increase in the size of a soft-tissue sarcoma at diagnosis there is a 3% to 5% decrease in the chance of cure.” 8
- 9. Worrying Features (Suspected Malignancy) •Size > 5 cm • Increasing in size • Deep to the deep fascia • Painful • Recurrent after excision 9
- 10. 10 Soft tissue lump, uncertaindiagnosis Worrying features No worrying features Imaging study (ideally MRI) Refer for biopsy if imaging not helpful Observation/Excisional biopsy Always Pathology Sarcoma center Benign Sarcoma/Other malignancy Refer to multidisciplinary team
- 11. Physical Examination • Size •Depth • Mobility 11
- 12.
- 13.
- 14.
- 15.
- 16. Imaging • X-ray • CTScan • Bone scan • MRI • Sonography 16
- 17. X-Ray • Bone involvement •Bone lysis • Periosteal reaction • Pressure effect • Soft tissue swelling 17
- 18. Bone Scan • Multilplesite of lesion • 2 time-variable phases • Detect abnormality does not observe in initial phase 18
- 19. CT Scan • Localizingsmall tumors in the bone • Identify soft tissue extension/ calcification • Provide anatomic location for staging 19
- 20. MRI • Detail ofsoft tissue lesion 20
- 21. MRI • Detail ofsoft tissue lesion 21
- 22.
- 23. Transillumination Test for TumorDiagnosis Findings Likely Pathology Bright Ganglion cyst filled with clear fluid Equal Lipoma, Neurilemmoma Indetermina te GCT, Inclusion cyst, Thick skin callus Dark Ganglion cyst filled with blood, Aneurism, Calcification, Gouty tophi, Osteophyte Source: http://www.eatonhand.com/img/img00087.htm 23
- 24.
- 25. Biopsy • Needle Biopsy •Open Biopsy • Incisional Biopsy • Marginal Biopsy • Primary Wide Excision 25
- 26. Needle Biopsy • Limitedrole in hand and upper extremity • Useful in subcutaneous lesion or confirmation of recurrent /metastatic lesion • Fragmentation of tissue • Difficult for grading 26
- 27.
- 28. Open Biopsy • Exsanguinationis contraindicated! • Surgical technique for biopsy in extremity is different from standard surgical dissections. • Longitudinal incision is recommended. • Avoid transverse / zigzag incision 28
- 29. Incisional Biopsy • Directapproach • Avoid extensive retraction • Adequate visualization • Hemostasis, avoid hematoma 29 h Tumor Healthy tissue Incision
- 30. Marginal Resection • Removalthrough reactive zone • Reserve for small lesion ( diameter < 2 cm ) • Extensive contamination of operative field • +/- soft tissue coverage in large lesion 30 h Tumor Healthy tissue Incision
- 31. 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 31 h Tumor Healthy tissue Incision
- 32. Benign Soft TissueTumor • Ganglion cyst • Epidermal inclusion cyst • Foreign body lesions • Lipoma 32 • Giant cell tumor of tendon sheath (Pigmented villonodula tenosynovitis) • Neurilemoma • Neurofibroma
- 33. Soft Tissue Sarcoma •Epithelioid sarcoma • Synovial sarcoma • Liposarcoma • Fibrosarcoma • Maligant histiocytoma • Malignant peripheral nerve sheath tumor 33
- 34. Definitive Surgical Treatment Benigntumor • Marginal resection • Intralesional curettage (in case of bone tumor) • Frozen section for confirmation of tissue margin 34
- 35. 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) 35
- 36. Staging of BenignSoft Tissue Tumor Stage I: Latent Stage II: Active Stage III: Locally Aggressive 36
- 37. Enneking’s Surgical Stages 37 StageGrade 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
- 38. Definitive Surgical Treatment Malignanttumor • Functional reservation is secondary to disease eradication • Response of tumor to radiation/chemotherapy 38
- 39.
- 41.
- 42.
- 43.
- 44.
- 45. 45 Final Diagnosis: Giant CellTumor of Tendon Sheath
- 46.
- 47. 47 15-year-old Mass at thenararea and wrist Progressive numbness of thumb, index and middle finger
- 48.
- 49.
- 50.
- 51.
- 52.
- 53. 53 79-year-old, M 8-cm-mass atforearm for 1 year No pain
- 54.
- 55.
- 56.
- 57.
- 58.
- 59. 59 65-year-old, M Referred fromHospital X after failed excision of mass at wrist
- 60.
- 61.
- 62.
- 63.
- 64.
- 65.
- 66.
- 67.
- 68.
- 69.
- 70.
- 71.
- 72.
- 73. 73 35-year-old, M Painful massat left palm for 4 mo.
- 74.
- 75.
- 76. 76 Intraoperative Finding: Ill-defined intramuscular massof lumbrical muscle with FDP, FDS tendon involvement
- 77. 77 Patho = EpithelioidSarcoma Margin: not free Definitive Surgery: “At least” Marginal resection The 3rd & 4th ray amputation
- 78.
- 79.
- 80.
- 81. 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 81
- 82.