ONCOLOGICAL CLINIC: SOFT PARTS SARCOMAS

Soft tissue sarcomas (SPB) are a large and heterogeneous group of rare tumors, which are characterized by frequently complex multidisciplinary treatment. Although in recent years there have been notable advances in the knowledge of the pathology and molecular biology of this disease, clinical treatment has evolved more discreetly and, in practice, mainly due to the rarity and complexity of this disease, the results are not always optimal.

• Alarm signs:
Tumors that affect soft tissue with any of the following signs should be considered potentially malignant:

Tumors greater than 5 cm.
Tumors that have experienced recent growth.
Deep (fixed) tumors.
Pain is not a symptom that per orients, but along with any of the above signs may reinforce the presumption of malignancy

• Diagnostic approach: Imaging studies, biopsy with radiological control.
Extremity sarcoma: Radiological explorations in the diagnosis and staging of soft tissue sarcomas of extremities. The method of choice in the diagnosis and local staging of an indeterminate or suspicious soft tissue mass of sarcoma is magnetic resonance imaging (MRI) with administration of intravenous contrast. In the event that MRI is contraindicated, a computed tomography (CT) with intravenous contrast should be used, preferably with additional reconstructions in sagittal and coronal planes. Valuations to include in the radiological report:

• Size
• Location (superficial or deep, compartmental or extracompartmental).
• Limits of the injury.
• Relationship with neurovascular structures.
• Extension of peritumoral edema.
• Contrast capture pattern.
• Suggestions of air to biopsy.

• Treatment of localized disease: Surgery of the primary tumor
Surgery: Conservative surgery of the limb will be performed. Only the possibility of amputation will be considered when it is not possible to achieve wide margins and / or functional reconstruction of the limb. The main stages of conservative surgery are tumor resection, reconstruction and soft tissue coverage. The first phase is the oncological part of the procedure, which must be independent of the following phases and must never be influenced by them. The resection is performed according to the appropriate oncological surgical margins for each tumor. The margins are defined as: intralesional, marginal, broad and radical. The ideal margin must be broad or radical. A wide margin is considered to be one that is larger than 1 cm or that includes an undamaged anatomical barrier (muscle fascia, periosteum, perineurium). The reconstruction of the soft tissues, after the resection, is fundamental. If it is difficult or impossible, conservative surgery should be reconsidered and questioned. The implantation bed of the different types of reconstruction has to be adequate with good vascularization and adequate muscular coverage.
The techniques of plastic surgery, such as the transposition of the twin muscles, the dorsal muscle width, the free or pediculated grafts of skin or muscle-cutaneous, collaborate in the coverage of the different types of reconstruction and in the tension-free closure of the wound, which contributes significantly to the decrease in morbidity.

Here is a clinical case of soft tissue sarcoma that we received at an oncology surgery service:

1. PERSONAL INFORMATION
   Name: Jairo Segundo Andrade Urdaneta
   CI: 11,999,181
   Age: 49 years old
   Date and place of birth: 09/18/1967

2. REASON FOR CONSULTATION
   1.-Volume increase in the inner side of the left thigh

3. CURRENT ILLNESS
   The patient is a 49-year-old male patient, natural and from the locality, with no relevant pathological history, who consulted for presenting an increase in volume on the inside of the left thigh for a month.
   The patient reports having been operated by the Traumatology service in the month of July of the current year, sample is taken for BIOPSIA

4. BIOPSY

MACROSCOPIC REPORT:
Nodular tumor of 14x8x6cms is received, smooth external surface with hemorrhage zones, soft yellowish brown cut with areas of hemorrhage and other cystic mucinous contents. In the same container 2 fragments of muscle tissue of 3x2x1,5cms, soft light brown
MICROSCOPIC REPORT:
Histologically, malignant neoplasm of mesenchymal origin is observed, consisting of bundles of fusiform cells with large atypical hyperchromatic nuclei and mitosis, myxoid area and other necrosis. Normal muscle tissue

1. DIAGNOSIS:
   TUMORATION OF ADJUSTABLE COMPARTMENT OF THIGH LEFT:

• FUSOCELLULAR ARCHIVE WITH MIXOID CHANGES OF INTERMEDIATE DEGREE OF MALIGNITY
  NOTE:
  1.- Tumor of 14cms
  2.- Grade II-III

1. Completely resected
   Immunihistochemical studies are suggested to establish histogenesis

2. IMMUNOHISTOCHEMISTRY
   SAMPLE:
   Left thigh tumor
   IMMUNOHISTOCHEMICAL DESCRIPTION:
   The Streptavidin-Biotin technique, the antigenic recovery method and adequate positive controls were used
   ANTIBODIES PERFORMED IMMUNOEXPRESSION
   Vimentina POSITIVE IN NEOPLASTIC CELLS
   CD34 POSITIVE IN BLOOD VESSELS
   Protein S100 NEGATIVE
   Actina smooth muscle POSITIVE IN WALLS OF BLOOD VESSELS

IMMUNOHISTOCHEMICAL DIAGNOSIS:
Left thigh tumor
MALIGNANT FIBROHYSTIOCITOMA

1. PHYSICAL EXAM
   Weight: 77kg
   Size: 1,80m
   FC: 57 lpm
   TA: 120/70 mmHg
   FR: 16 rpm
   Patient in regular clinical conditions, afebrile, hydrated, eupneic. Cardiopulmonary: audible vesicular murmur in both pulmonary fields without aggregates. Rhythmic heart sounds without murmurs. Abdomen soft, depressible not painful to superficial and deep palpation without visceromegalies. The tumor is palpated on the inside of the left thigh, approximately 4x3 cm in diameter. Neurological preserved.
   After continuous follow-up, and given the conditions, the oncology service decides to perform surgery by compartment

Thank God, satisfactory results were obtained and the patient was able to continue with his normal life.

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