Score Questions
A 54-year-old woman presents to the clinic with a mass on her upper back that she recently noticed. On inspection, a 2-cm soft tissue mass is palpable. The best way to obtain a tissue diagnosis is to use which of the following
A. Fine needle aspiration
B. Core needle biopsy
C. Excisional biopsy
D. Incisional biopsy
E. Shave biopsy
C.
Based on the size and location of the mass, diagnostic workup should begin with excisional biopsy. For larger masses or those located in anatomic areas that could be compromised by an excision, core biopsies are preferred over fine needle aspiration (FNA) because FNA only procures a scant amount of tissue for analysis. Incisional biopsies are performed when masses are generally larger than 3 to 5 cm, whereas excisional biopsies are performed for smaller masses. Both incisional and excisional biopsies are performed for masses that are located very deep in the tissue or when FNA or core biopsy is nondiagnostic. Shave biopsy is reserved for skin neoplasms
What size tumor should preop radiation by considered for STS?
>5cm
A 67-year-old man presents with fullness and is diagnosed with a retroperitoneal leiomyosarcoma of his abdomen with swelling of his lower legs. CT of the abdomen and pelvis with intravenous contrast shows the tumor invading the inferior vena cava (IVC). What is the treatment plan for this man
A. Definitive chemotherapy
B. Definitive chemotherapy and radiation
C. R0 resection with IVC reconstruction
D. Debulking of the tumor without IVC resection
E. Observation
C
The first-line therapy for leiomyosarcoma is surgical R0 (microscopically margin-negative) resection. For resection of tumors that invade the inferior vena cava (IVC) or are intimately associated with it, options include tumor resection with IVC ligation, patching of the IVC, and interposition graft of the IVC. Although adjuvant chemotherapy does play a major role in unresectable metastatic leiomyosarcomas, radiation does not. Debulking or R2 (residual macroscopic tumor) resection leads to high rates of recurrence and shows no benefit in survival.
What is the ABCDEs of skin lesions concerning for melanoma
Margins desired for sarcomas?
For sarcomas, 1- to 2-cm margins (if possible) are desired. However, narrower margins are acceptable if achieving them would result in major neurovascular compromise
A 56-year-old woman presents to your clinic 2 weeks after a laparoscopic wedge resection of a gastrointestinal stromal tumor in her stomach. Pathology demonstrates that the tumor is positive for c-KIT, with a mitotic count of 4 mm2 and a size of 3.5 cm. What is the next step in management
A. Imatinib
B. Observation
C. Chemotherapy
D. Radiation
E. Chemotherapy and radiation
For gastrointestinal stromal tumors (GISTs) that are greater than 3 cm, have mitosis greater than 5 mm2, and are metastatic, imatinib, an oral tyrosine kinase inhibitor of c-KIT, is correct. It has been recommended for prevention of recurrence in adjuvant therapy and reduction in size of the larger GIST tumors if given as neoadjuvant therapy. The specific KIT exon in which the GIST mutation resides affects the molecular and clinical phenotype. Observation after resection is not appropriate because the size of the tumor is greater than 3 cm and the higher recurrence rate. Chemotherapy and radiation are not the standard of care in GIST tumors.
What is the current recommendation for the treatment of asymptomatic, resectable desmoid tumors?
the current recommendation is to start with a "wait and see" approach—an initial period of surveillance with imaging every 3 months in order to demonstrate tumor stability/regression or progression. This should not be done for tumors that would result in functional limitations if the tumor increased in size
A 58-year-old woman with a history of a modified radical mastectomy with radiation for right-sided breast cancer presents to your clinic. She has had chronic lymphedema in her right arm since her surgery 10 years ago. She reports that over the past month the swelling has worsened and now encompasses her entire right upper arm. What etiology would you suspect to be the cause of her lymphedema?
A. Desmoid tumors
B. Angiosarcoma
C. Pleiomorphic sarcoma
D. Leiomyosarcoma
E. Fibrosarcoma
B
The development of angiosarcoma after mastectomy and radiation is known as Stewart-Treves syndrome. It typically occurs 10 years after the initial therapy. Desmoid tumors are associated with familial adenomatous polyposis syndrome and are soft tissue tumors that arise from prior surgery sites. Pleiomorphic sarcoma, leiomyosarcoma, and fibrosarcoma are associated with prior radiation exposure but not in this specific setting of postmastectomy and postaxillary radiation
A 37-year-old woman who is 6 weeks postpartum is referred to you for evaluation and treatment of a 3-cm biopsy-confirmed desmoid tumor on her right anterior abdominal wall. She is asymptomatic. Which of the following is an appropriate initial management strategy?
A. Watchful waiting
B. Definitive radiation
C. Application of topical imiquimod
D. Isolated limb perfusion
E. Isolated limb infusion
A
Desmoid tumors (aggressive fibromatosis) arise from aggressive proliferation of well-circumscribed fibroblasts. Although they rarely metastasize, they can be locally aggressive and cause severe morbidity. In patients with small tumors, who are asymptomatic and reliable for surveillance, watchful waiting has been found to be a good option. For patients undergoing watchful waiting, the tumors must be in a location where an increase in size would not necessitate a more aggressive surgery with possible functional deficits. Radiation is not appropriate. If the tumor increases in size or the patient becomes symptomatic during watchful waiting, then surgical resection is indicated. However, surgical resection is associated with a high rate of recurrence.
For patients with advanced or unresectable desmoids, the following systemic therapy options may be considered: nonsteroidal anti-inflammatory drugs, tyrosine kinase inhibitors, hormonal therapy, or chemotherapy. There is no role for topical imiquimod, isolated limb infusion, or isolated limb perfusion in the treatment of desmoid tumors.
Wound infection is often due to gram-positive bacteria, such as Staphylococcus and Streptococcus spp. If there is evidence of cellulitis, antibiotics are indicated. Abscess formation necessitates drainage by either aspirating the abscess, leaving a percutaneous drain, or reopening the incision.
A 65-year-old retired construction worker presents with a 5-mm painless, ulcerated lesion on his right upper chest. The lesion is itchy at times. Physical examination of the patient’s neck reveals no lymph node enlargement. Biopsy shows nodular variant BCC. What is the next step in management
A. Topical 5-fluorouracil
B. Radiation therapy
C. Excision with 3- to 5-mm margin
D. Observation
C
BCC is the most common form of skin cancer. Although BCCs rarely metastasize, they are characterized by slow but relentless and destructive local invasion that results in high morbidity without treatment. A biopsy for diagnosis is important before treatment of any skin cancer because it helps direct definitive excision. Fortunately, most nonmelanoma skin cancers are small, low-risk lesions that respond with 90% to 95% cure rates to standard treatment techniques, including curettage and electrodesiccation, radiation therapy, and surgical resection. Many skin cancers can be removed with elliptical excisions. 0.4-cm margins are recommended for low-risk BCC. For patients with unacceptable surgical risk, radiation should be used. For high risk lesions, Mohs surgery should be considered.
What type of imaging should truncal, retroperitoneal, and pelvic STS should be followed with
CT of the chest, abdomen, and pelvis with intravenous contrast.
A 61-year-old man is referred to you for evaluation of a painless, 7-cm mass in his right thigh a few centimeters above the knee. Physical examination demonstrates no neurovascular compromise. Core needle biopsy demonstrates a mix of atypical adipocytes and pleomorphic stroma with a high rate of mitoses. Preoperative imaging shows no evidence of distant disease. Which of the following is the best management approach
A. Definitive chemoradiation
B. Surgical excision with 1- to 2-cm margins
C. Surgical excision with 1- to 2-cm margins and sentinel lymph node biopsy
D. Neoadjuvant radiation followed by excision with 1- to 2-cm margins
E. Amputation at the proximal thigh
D
Surgery is the primary treatment modality for extremity soft tissue sarcoma. The main principles of treatment are resection to microscopically negative margins and preservation of extremity function. Dissection should be carried through grossly normal tissue. Neurovascular structures should be preserved unless they are grossly invaded by tumor. Preoperative radiation may be considered for tumors more than 5 cm to increase chances of complete tumor resection. Preoperative radiation, when compared to postoperative radiation, also has the advantages of lowering the total radiation dose and avoiding wound healing complications. Sentinel lymph node biopsy is not indicated as the majority of soft tissue sarcoma spreads through the hematogenous route. Amputation is rarely required and is reserved for cases in which functional outcome will be compromised by complete local resection of the tumor.
A 32-year-old woman presents with a mass on her right lower abdominal wall, which she noticed 3 weeks ago while taking a shower. She is asymptomatic. She had a normal delivery about 1 year ago and is not using contraceptive pills. On examination, the mass is 5-cm wide, mobile, firm, deep, and close to the anterior superior iliac spine. What is the best method of further evaluating the mass?
A. Excision of the mass
B. Incisional operative biopsy of the mass
C. MRI of the abdomen and pelvis
D. Image-guided core needle biopsy of the mass
E. Fine needle aspiration of the mass
D
This woman most likely has a desmoid tumor. Other possible diagnoses include benign soft tissue tumor, dermatofibrosarcoma protuberans, and sarcoma. A detailed history and physical examination is warranted to evaluate for familial adenomatous polyposis. Tissue biopsy is needed to confirm the diagnosis and treatment plan. Image-guided core needle biopsy is recommended, not fine needle biopsy. For asymptomatic desmoid tumors, the European Desmoid Working Group has recommended a period of watchful waiting. Surgical resection is recommended for symptomatic and growing tumors. Incisional or excisional biopsy is commonly used in extremity sarcoma. Appropriate imaging of primary site with computed tomography or magnetic resonance imaging is indicated to assess the resectability of the mass, which can be done after image-guided biopsy.
Along what axis and direction is incision made for STS resection?
The incision is made parallel to the long axis of the digit or limb and should include the previous biopsy tract
A 39-year-old man is taken to the operating room for resection of a presumed lipoma in the posterior compartment of his right leg. During the resection of the 6-cm mass, it is found to be fixed and areas of necrosis are noted. Although you can remove the gross mass, the margins are not definitively clear; however, you are unable to resect any further without significant functional deficits. Which of the following is most appropriate
A. Mark the periphery of the resection bed and critical structures with surgical clips.
B. Ensure that drains exit the skin as far away from the incision as possible.
C. Convert to a below-knee amputation.
D. Resect the neurovascular bundle in the compartment to achieve negative margins.
E. Place drains and close the incision.
A
Ideally, this man would have had a thorough preoperative assessment with magnetic resonance imaging and core needle biopsy prior to proceeding to surgery. Radiation therapy increases limb salvage rate and can be given preoperatively. Given the intraoperative description of the mass, it is likely to be a high-grade sarcoma (immobile, evidence of necrosis), and there is concern about the adequacy of the margins. The final pathology report will be informative. In this instance, it is prudent to mark the resection cavity with surgical clips to serve as a guide for postoperative radiation therapy.
Drains should exit the skin close to the edge of the incision so that it can be included in the radiation field or re-resected if necessary without much morbidity. Converting to a below-knee amputation or resecting major neurovascular bundle with subsequent severe functional deficit are incorrect in this case.
What type of imaging is needed to follow extremity STS following resection?
MRI with intravenous contrast. The image protocol phase should include, at a minimum, T1, T2 with fat suppression, and short-T1 inversion recovery (STIR) postcontrast
Most common location for STS?
Most commonly occurs in the extremities (60%), followed by the trunk (25%) and pelvis/retroperitoneum (15%)
Why is shave biopsies not recommended for lesions that appear to be melanoma?
1.Superficial shave biopsies are not recommended because they do not allow accurate determination of tumor thickness. All skin biopsies should be full thickness (either excisional or punch biopsy, as appropriate).
The standard of care and goal in the surgical management of soft tissue sarcomas is this type of surgery
Limb-sparing, function-preserving surgery
A 54-year old man is referred to your office for evaluation of a left thigh mass that was discovered after a minor trauma. He denies pain, weakness, or sensory changes in the leg. On physical examination you note a 6-cm firm mass that is immobile. There is no tenderness or bruising, and no other skin changes are associated with the mass. The remainder of your physical examination is without significant findings. Which of the following would be the next best step in management?
A. Repeat examination in 4 to 6 weeks to evaluate for resolution
B. Extremity plain film and MRI with and without contrast
C. Ultrasound of the mass and adjacent lymph node basins
D. Incisional operative biopsy of the mass
E. Operative excision of the mass
B
The patient presentation is concerning for a soft tissue sarcoma of the leg. The most common presenting symptom is a painless mass, and additional suggestive features include a firm, fixed mass that is more than 5 cm in size. Plain film of the extremity and magnetic resonance imaging with and without contrast are the preferred imaging modalities for evaluation of soft tissue sarcoma of the extremity. Given concern for malignancy, continued observation is not appropriate. Ultrasound is not the recommended imaging modality. Core needle biopsy is the preferred technique for tissue diagnosis. Incisional biopsy is also an acceptable modality; however, the incision should be oriented longitudinally along the extremity. Given high suspicion for soft tissue sarcoma, further evaluation is required prior to surgical excision. In additional to imaging of the mass, chest imaging would be required prior to treatment if soft tissue sarcoma is diagnosed.
Imaging interval for following STS tumors after resection?
The imaging interval should be every 3 to 6 months for 2 to 3 years, then every 6 months for 2 years, and then annually
What five histologic subtypes of STS are prone to lymph node spread
•S- Synovial cell
•C- Clear cell
•A- Angiosarcoma
•R- Rhabdomyosarcoma
•E- Epithelioid sarcoma
What are three benign soft tissue tumors?
Benign etiologies include hematoma (particularly in the setting of prior trauma), lipoma, neuroma, leiomyoma, and lymphangioma, cysts
This refers to the removal of all gross disease with a margin of normal tissue, including nervous and vascular structures with reconstruction as needed
Radical resection