Management of Sarcomas October 25, 2014 Missoula, Montana Soft Tissue Sarcomas: A Multi-Disciplinary Strategy of Care Darin J. Davidson, MD, MHSc, FRCSC Department of Orthopaedics and Sports Medicine Assistant Professor, University of Washington School of Medicine Orthopedic Oncologist, Seattle Cancer Care Alliance
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Management of Sarcomas October 25, 2014 Missoula, Montana Soft Tissue Sarcomas: A Multi-Disciplinary Strategy of Care Darin J. Davidson, MD, MHSc, FRCSC.
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Management of Sarcomas
October 25, 2014Missoula, Montana
Soft Tissue Sarcomas:
A Multi-Disciplinary Strategy of Care
Darin J. Davidson, MD, MHSc, FRCSCDepartment of Orthopaedics and Sports Medicine
Assistant Professor, University of Washington School of MedicineOrthopedic Oncologist, Seattle Cancer Care Alliance
CASE STUDY
-- 62 year old male with right posterior arm soft tissue mass
-Close approximation to radial nerve
-Close approximation to humerus
• Image guided needle biopsy- synovial sarcoma
• Neoadjuvant chemotherapy
– Pazopanib trial
• Neoadjuvant radiation therapy
– Planned positive margin on radial nerve and humerus
• No increased risk of local recurrence
• Preserve function
Excision
Negative margin
Innervated latissimus flap to restore function
Sarcoma: Multi-disciplinary Team
• Treatment decisions not made independently by one specialty
• Essential to have multidisciplinary discussion– Surgeon(s)
– Radiation oncologist
– Medical oncologist
– Radiologist
– Pathologist
All have input into management of every case
One modality may optimize management of another
SCCA: Multi-disciplinary Sarcoma Program
Medical Oncology
Orthopaedic Oncology
Radiation Oncology
General Surgery
Jones, RobinConrad, Ernest ‘Chappie’
Kane, Gabrielle
Mann, Gary
Loggers, Elizabeth
Davidson, Darin Kim, EdwardPillarisetty, Venu
Pollack, SethLindberg, Antoinette
Pathology Radiology PediatricsPlastic Surgery
Hoch, Ben Ha, AliceHawkins, Doug
Neligan, Peter
How to contact us• Scheduling Contact: Leslie Fischer
• Sarcoma suggested by signal intensity heterogeneity
– Imaging characteristics are not typical of particular type of soft tissue sarcoma
– Fluid signal may be present in setting of necrosis or hemorrhage
High grade soft tissue sarcoma with areas of hemorrhage and necrosis
Management
• Local and systemic staging
–MRI of affected area
–Biopsy
–CT chest
• Mainstay of treatment is surgical resection
• Adjuvants
–Radiation therapy
–Chemotherapy
• Aggressive or malignant appearing bone or soft tissue lesions
• Soft tissue mass- >5cm, deep to fascia or overlying bone or neurovascular structures• Except definitive imaging of benign mass (eg.
lipoma)• Unclear diagnosis in symptomatic patient• Solitary bone lesion in a patient with a history of
carcinoma• Even if fractured!!• Just need to confirm not sarcoma
Indications for Biopsy
Biopsy Principles
• An asymptomatic (latent) or symptomatic bone lesion (active) that appears entirely benign on imaging does not need a biopsy
• A soft tissue lesion that appears entirely benign on MRI (lipoma, hemangioma) does not need a biopsy
• When in doubt, it is safer to do a biopsy
Biopsy Principles
• Extensile incision – longitudinal in extremities• Tract needs to be excised
• Avoid developing planes• Use involved compartment• Do not expose neurovascular structures• Meticulous hemostasis• Release tourniquet prior to wound closure• If using drain, bring out in line with incision• For bone lesions, ok to biopsy soft tissue mass• Frozen section
Importance of the Biopsy
• Whatever is exposed to the tumor is potentially contaminated and must be excised at definitive treatment
• When biopsy principles aren’t followed
– Increased risk of• Wrong diagnosis
• Altered treatment
• Altered outcome
• Complications
• Local recurrence of STS
Mankin et al, 1996
Noria et al, 1996
Surgical Resection
• Goal is complete resection of tumor with ‘adequate’ margin
–Definition of adequate margin controversial
–Use of preoperative radiation can affect extent of margin required
•Marginal excision of STS- LR >30%
•Marginal excision of STS after neoadjuvant XRT- LR <10%
•Consideration for preservation of vital (major nerves, vessels, bone) structures to preserve function
Gerrand et al, JBJS-B 2001
Radiation Therapy
• Neoadjuvant XRT ‘sterilizes’ reactive zone surrounding the tumor
–Allows for closer margin (still complete resection with negative margin)
• Preserve critical structures and improve function