Diagnosis And Surgical Management Of Soft Tissue Sarcoma
Background: All patients should be managed by a multidisciplinary team with expertise in STS. The differential diagnosis of STS of the extremities includes ruling out desmoids and other malignant and benign lesions previously discussed. An essential element of the workup is a history and physical examination (H&P). Laboratory tests have a limited role. Adequate and high-quality imaging studies are crucial to good clinical management of patients, because the presence of metastatic disease may change the management of the primary lesion and the overall approach to the patient‘s disease management. Imaging studies should also provide details about tumor size and contiguity to nearby visceral structures and neurovascular landmarks. The propensities to spread to various locations vary among the subtypes of sarcoma. Therefore, imaging should be individualized based on the subtype of sarcoma. MRI with or without CT is indicated for all lesions with a reasonable chance of being malignant. MRI is preferred for extremity sarcomas, whereas CT is preferred for retroperitoneal sarcomas. CT angiogram may be useful in patients for whom MRI is not feasible. Plain radiograph of the primary lesion is optional. Given the risk for hematogenous spread from a high-grade sarcoma to the lungs, imaging of the chest is essential for accurate staging. Amputation was once considered the standard treatment to achieve local control in patients with extremity sarcomas. In recent years, technical advances in reconstructive surgical procedures, implementation of multimodality therapy, and improved selection of patients for adjuvant therapy have minimized the functional deficits in patients who might otherwise require amputation. Because surgery is the standard primary treatment for most sarcomas, the panel has included a separate section on principles of sarcoma surgery. If a patient cannot be surgically treated according to these principles, preoperative RT or chemotherapy should be considered as alternate treatment options. The biopsy site should be excised en bloc with the definitive surgical specimen. Dissection should be through grossly normal tissue planes uncontaminated by the tumor. If it is close to or displaces major vessels or nerves, these do not need to be resected if the adventitia or perineurium is removed and the underlying neurovascular structures are not involved with gross tumor. Radical excision or entire anatomic compartment resection is not routinely necessary. Limb-sparing surgery is recommended for most patients with extremity STS to achieve local tumor control with minimal morbidity. Evaluation for post- operative rehabilitation is recommended for all patients with extremity sarcoma. If indicated, rehabilitation should be continued until maximum function is achieved.