SOFT TISSUE SARCOMA SURGICAL MANAGEMENT

Definition of procedures and margins

  • Marginal excision – Equivalent to excisional biopsy as it shells out tumor and pseudo capsule
  • Wide excision – neoplasm removed from within the anatomical structures involved along with variable amount of “normal tissue”
  • Radical local resection – neoplasm and surrounding tissue removed by dissecting along planes separated by tumor and its tissue of origin by at least one uninvolved anatomical structure in both the longitudinal and the transverse plans.

The local behavior of these tumors often requires radical resection if surgery used alone.

Margins required per stage for ~90% local control as defined by Enneking

Stage Required Margin
IA Wide excision
IB Wide amputation
IIA Radical compartmental
IIB Radical amputation

AMPUTATION

Amputation should be considered for the following:

  • extensive soft tissue mass and/ or skin involvement
  • major arterial or nerve involvement
  • extensive bony involvement that requires whole bone resection
  • failure of preoperative therapy or recurrence following prior adjuvant radiation

Local Control Rate by Stage

Enneking Literature Review

Procedure IA IB IIA IIB
Intracapsular 10% 10% 0 0
Marginal 30% 30% 10% 10%
Wide 90% 90% 50% 30%
Radical 100% 100% 90% 80%

More radical procedures render a less functional limb and affect patient cosmetically and psychologically.

Results with Surgery Alone

Enneking Surgery Alone

# of pts Overall local Failure DM 5yr Survival (Adequate Surgery)
70 20% 33% 62%

Effect of Positive Margin

Local failure if negative margin ~2% vs. 100% if positive.
Current indications for amputation

  • Functional limb not achievable
  • Severely compromised normal tissue due to age
  • PVD

Surgical Sites (T)

  • Intracompartmental (T1) Extracompartmental (T2)
  • Intraosseous Soft-tissue extension
  • Intral-articular Soft-tissue extension
  • Superficial to deep fascia Deep fascial extension
  • Paraosseous Intraosseous or extrafascial
  • Intrafascial compartments
  • Ray of hand or foot
  • Posterior calf
  • Anterolateral leg
  • Anterior thigh
  • Medial thigh
  • Posterior thigh
  • Buttocks
  • Volar forearm
  • Dorsal forearm
  • Anterior arm
  • Posterior arm
  • Periscapular Extrafascial planes or spaces
  • Mid and hind foot
  • Popliteal space
  • Groin – femoral triangle
  • Intrapelvic
  • Midhand
  • Antecubital fossae
  • Axilla
  • Periclavicular
  • Paraspinal
  • Head and neck

Summary

  • Respectability is a major prognostic factor
  • 80-90% patients having gross total resection.
  • But wide margins are difficult to achieve.
  • 50% of patient with complete resection have local recurrences.
  • Local recurrence is the first site of recurrence in 75% of patients.
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