Surgical management of soft tissue sarcoma: Histologic type and grade guide surgical planning and integration of multimodality therapy
© Markku Miettinen 2010.The primary treatment of sarcoma is surgical resection; however, as the understanding of this rare disease has improved, it is now clear that different sarcoma subtypes have varying growth patterns and metastatic potential. Although surgery continues to play the central role in the treatment of sarcomas, pathologic subtyping has allowed characterization of sarcomas that have an improved sensitivity to chemotherapy or radiation therapy. This has translated into a refinement of the surgical approach, and the addition of multidisciplinary treatment in an adjuvant or neo-adjuvant fashion. This review focuses on the surgical management of sarcoma, which is driven by the pathologic subtype. CLINICAL EVALUATION AND BIOPSY Soft tissue sarcomas (STSs) are often asymptomatic and are usually found incidentally. A survey on the clinical presentation demonstrated that most patients present with a mass, only one third of which cause pain symptoms.1 There can be an antecedent history of trauma, which is usually not related but often draws attention to a mass. There is often a hesitation to diagnose sarcoma; up to 20% of patients have been found to have a delay of 6 or more months between presentation to a physician and tissue diagnosis.1 The differential diagnosis of a mass includes a hematoma, benign lipoma, lymphoma, germ cell tumor, and sarcoma. A history of an enlarging or changing lesion should raise the suspicion of a malignancy. On physical examination it is important to differentiate between a soft, mobile lesion and one that is fixed or invading local structures.
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