Soft Tissue

Tumours

I GEDE EKA WIRATNAYA

SMF/ SUB BAG ORTHOPAEDI &

TRAUMATOLOGI FK UNUD/RSUP SANGLAH
DENPASAR
 Neoplasm origin from soft tissue
component

Soft Tissue Tumours

INCIDENCE
Benign soft tissue tumours common
Malignant rare

Pathological Classification
Benign
Malignant
Reactive tumour like lesions
Benign
Enneking's Stage
1. Latent/inactive
2. Active/growing & symptomatic
3. Aggressive

Malignant
Enneking's Classification

STAGING
STAGING
 Size
> 5 cm malignant
Superficial or deep
Thigh & buttocks sarcoma
Consistency
firm & not very painful
Cystic or solid
Solid lesion could represent either a
benign or malignant

DIAGNOSTIC CLUES
 Length of symptoms
A mass that has rapidly increased in size
over 2/12 is more sarcoma
Plain X-ray findings
Every soft tissue mass intervention
should have a plain radiograph
MR scan findings
MRI gives the most information of any
radiographic study

DIAGNOSTIC CLUES
 History: painless swelling (bone tumours:
pain -> swelling)
Examination +/- transillumination
Plain radiography
Subcutaneous lesion
< 5 cm (lipoma, cyst, inflammatory)
Observe
Excisional biopsy
Biopsy if not lipoma
DIAGNOSTIC STEPS
Deep lesion
< 5 cm (lipoma, schwannoma)
> 5 cm, or not cystic, or painful
MR scan incisional/trucut needle
biopsy/fine needle aspiration

If possibility of malignancy exists

Isotope bone scan for other lesions
FBC, ESR
Chest X-ray
CT scan of chest, for metastases

DIAGNOSTIC STEPS
Local control
Surgical resection or amputation
Radiation therapy
Combination of both

Lung metastases systemic control with

chemotherapy

Use of adjuvant chemotherapy for nonmetastatic soft

tissue sarcomas controversial because it has not been
shown to be very effective in improving survival & is
a/w significant morbidity & cost

Local recurrence common

TREATMENT
PROGNOSTIC FACTORS
Stage (Enneking's stage)
Histologic grade
High-grade lesions have worse prognosis
Size of lesion
Small lesions (<5 cm) are rarely malignant
Depth of lesion
Superficial (subcutaneous) soft tissue
sarcomas have better prognosis than deep
(below muscle fascia) lesions
Age
Surgical margins
Lung metastases
Malignant fibrous tumours
Fibrosarcoma

Age group 30-80

Enlarging painless mass
Usually 10 cm in size before symptoms
Plain X-ray: usually normal unless encroaching on
bone -> erosion/destruction
MRI: deep-seated inhomogenous mass

Histology slightly different Herring bone

appearance

Treatment
Wide local excision
If >5 cm, add radiotherapy, preop +/- postop +/-
periop
Malignant fibrous histiocytoma
(Pleomorphic sarcoma)
Malignant cells are of histiocytic derivation
Most common soft-tissue sarcoma in adults
Age group 30-80
Histology type & prognosis
Pleomorphic (commonest) - 55% 5-yr mortality :
Giant cell - 55%
Myxoid - 23%
Inflammatory -33%

Clinical
Enlarging painless mass (painful mass in osseous tumour)
Usually 10 cm in size before symptoms
Early osseous invasion & metastases to regional lymph
nodes common
Paraneoplastic syndromes
Eosinophilia
Hypoglycemia
Fever
Abnormal LFT

Radiological
Plain X-ray Usually normal
If encroaching on bone ->
erosion/destruction

MRI
Inhomogenous mass, mixed density signal,
Areas of internal hemorrhage, Areas of
myxoid density (signal), Occasionally lobular
growth
Pathology

storiform (cartwheel) pattern

Treatment

Wide local excision stage I

Amputation reserved for multiple recurrences
Stage II tumors require excision with wide
margins or amputation
If >5 cm, add radiotherapy, preop +/- postop
+/- periop
Lipomas
Subcutaneous/intramuscular or intermuscular
tumours of mature fat
Most are not painful
Plain X-rays may show a radiolucent region in soft
tissues
MR or CT scan show a well demarcated lesion with
exactly same signal as fat

Treatment
If no symptoms leave alone
If mass growing or causing symptoms excise
Recurrence uncommon
Subgroups: spindle cell lipoma & pleomorphic lipoma

Benign fatty tumours

 Liposarcomas
Malignant tumours with differentiation towards
fatty tissue
signet ring type cells (lipoblasts) in common

Range from low grade to high grade

Can be difficult to differentiate between a benign
lipoma & a low grade liposarcoma

Treatment
Low grade liposarcomas treated with wide local
excision +/- radiotherapy
High grade liposarcomas treated with wide local
excision + radiotherapy
Malignant fatty tumours
Neurilemmoma (benign schwannoma)
Benign nerve sheath tumour
Young to middle aged patients
Usually asymptomatic apart from mass
MR: eccentric mass arising from a peripheral
nerve

Histologically contains Antoni A or Antoni B cells

Antoni A - compact spindle cells, twisted
nuclei, indistinct cytoplasm, clear vacuoles
Antoni B - less cellular

Treat by excision leaving nerve intact

Benign peripheral nerve tumours

Neurofibroma
Solitary or multiple (see neurofibromatosis)
Most are superficial, grow slowly & painless
When they involve a major nerve they can
expand nerve in a fusiform fashion

Histologically, interlacing bundles of elongated

cells with wavy dark staining nuclei

Treatment- excision with a marginal line

In neurofibromatosis, malignant change occurs in
5-30% of patients
Malignant tumours of muscle
tissue
Rhabdomyosarcoma
Most common sarcoma in young patients
Highly malignant, Grows rapidly

Histology
Spindle cells in parallel bundles,
multinucleated giant cells & racquet shaped
cells
Cross striations within tumour cells
(rhabdomyoblasts)

Sensitive to multiagent chemotherapy

Treat with preop chemo, followed by wide
surgical excision & radiotherapy
Benign vascular tumours
Haemangioma
Seen in children & adults
Regresses with age
Can be cutaneous, subcutaneous,
intramuscular

Plain X-ray can show small pleboliths

MR scan shows a heterogenous lesion with
many small blood vessels

Treat nonoperatively if possible

Wide surgical resection if symptomatic
Local recurrence rate high
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