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  • Any soft tissue mass that is large or growing should be evaluated by biopsy using the techniques described later.
  • When the diagnosis of sarcoma is established, surgery remains the mainstay of therapy.

  • Medical comorbidities such as severe cardiopulmonary compromise may preclude safe surgery.

Expected Benefits

  • Limb preservation for soft tissue sarcomas of the extremity.

Potential Risks

  • Major neurovascular structures may need to be sacrificed to achieve oncologic goals, but management strategies designed to preserve these structures are preferable.
  • Risk of recurrent disease.

  • No special equipment is needed.
  • Occasionally, for deep lesions or lesions that have dramatically decreased in size with neoadjuvant therapy, intraoperative ultrasound may be useful to identify the lesion and to plan the incision.
  • A self-retaining retractor can assist with exposure.

  • Optimal management of soft tissue sarcomas requires a multidisciplinary approach at a high-volume center.
  • Input from medical and radiation oncologists experienced in managing this disease is critical.
  • Biopsy results should be evaluated by pathologists experienced with sarcoma.
  • MRI, ultrasound, and CT scanning are all routinely used to evaluate soft tissue sarcomas of the extremity.
  • Quite often, patients undergo extensive preoperative radiation therapy and chemotherapy before surgery.
  • Plastic surgical assistance for reconstruction can be necessary for wound closure.

  • The patient may be placed supine, prone, or in lateral position depending on the location of the lesion.
  • If a soft tissue flap reconstruction is planned, communication with the plastic surgery team is essential when positioning the patient.

  • Figure 29–1: Core needle biopsy.
    • For any soft tissue mass that is enlarging, symptomatic, or > 3–5 cm, biopsy should be performed.
    • Core needle biopsy is a reliable method to obtain sufficient material for accurate pathologic diagnosis.
    • Biopsy with ultrasound or CT guidance may be useful.
  • Figure 29–2: Incisional biopsy and placement of incision for resection.
    • For lesions > 5 cm, incisional biopsy may be appropriate.
    • Proper orientation of the incision is critical.
    • The incision must be in a plane parallel to the long axis of the limb and one that can be subsequently excised by a more definitive surgical procedure, if necessary.
    • Hemostasis is important to avoid development of hematomas that can expand along fascial planes and compromise a more definitive wide excision of the lesion at a later date.
    • Radical resection of soft tissue sarcomas involves careful operative planning.
    • Similar to incisional biopsy principles, the operative incision should be in a plane parallel to the long axis of the limb.
    • The skin incision should be oriented such that any previous biopsy sites are included en bloc with the specimen.
  • Figure 29–3: Skin flaps.
    • After the appropriate incision is made based on the above principles, skin flaps are raised to allow for an appropriate margin of excision.
  • Figure 29–4: Radical resection of tumor.
    • There is generally a pseudocapsule around the tumor; however, tumor infiltration may extend beyond the pseudocapsule.
    • ...

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