Presented at AW Sjahranie General Hospital under supervision of dr. Elvis K. SpB

1. Soft Tissue Sarcoma
DR. ISA BASUKI
DEPARTMENT OF SURGERY,
AW SJAHRANIE GENERAL HOSPITAL

2. Introduction
• Soft tissue sarcomas are cancerous (malignant) tumors that
originate in the soft tissues of your body
• Rare  1% adult, 15% paediatric neoplasms
• Can occur at any site:
– Extermities 43%
– Visceral 19%
– Retroperitoneal 15%
– Trunk/thoracic 10%
– Other 13%
• Characterized by their genetic alterations, morphology under
light microscopy and grade

3. Cytogenetic changes
• Divided into 2 catagories:
– One group has specific changes and relatively simple karyotypes eg. fusion
gene or point mutation
– Other group has non-spesific changes and complex karyotypes
• Genetic syndromes associated with STS include
– neurofibromatosis,
– retinoblastoma,
– Li-Fraumenii syndrome,
– Gardener’s syndrome (familial adenomatous poliposis)

4. Other aetiological factors
• Radiation exposure (osteosarcoma, angiosarcoma)
• Chronic lymphoedema
• Trauma
• Chemical exposure eg. arsenic, polyvinyl chloride (hepatic
angiosarcoma)
• Infections eg. Herpes Human Virus-8: causes Kaposi’s Sarcoma
in immunocompromized patients

5. Classification
• Soft tissue and bone
• viscera (gastrointestinal,
genitourinary, and gynecologic
organs)
• nonvisceral soft tissues (muscle,
tendon, adipose, pleura, and
connective tissue)
• By differentiation (usually with
IHC staining)
• adipocytic tumors
• fibroblastic/myofibroblastic tumors
• fibrohistiocytic tumors
• smooth muscle tumors
• pericytic (perivascular) tumors
• primitive neuroectodermal tumors
(PNETs)
• skeletal muscle tumors
• vascular tumors
• osseous tumors
• tumors of uncertain differentiation

6. Presentation (extremity STS)
• Mostly asymptomatic mass
• Pain in 33% due to destruction of surrounding tissues
• Rarely paraneoplastic symptoms eg. fever

7. Diagnosis
• Open or large gauge core biopsies
• In which masses should biopsies be done:
 symptomatic
 Enlarging
 > 5 cm
 persists longer than 4 weeks
• Incision biopsies should not interfere with subsequent surgery,
therefore:
 over most superficial part of mass
 no raising of flaps
 meticulous haemostasis to prevent haematomas
• FNA limited value, mostly to diagnose recurrence

8. Imaging
• MRI
– For extremity masses
– Gives good delineation between muscle, tumor and blood vessels
• CT for abdominal and retroperitoneal
• PET
– May help determine high vs. low grade
– May be helpful in recurrences

9. Biopsy
• Most present as painless mass leading to delayed diagnosis as
lipoma or hematoma
• Core needle biopsy guided by palpation or by image guidance if
not palpable
– Few cases of tumor seeding with closed biopsy so some recommend
tattooing site for later excision with specimen
• Excisional biopsy for superficial small lesions if needle biopsy
non-diagnostic
• Incision biopsy
– Longitudinal incision without tissue flaps with meticulous hemostasis to
prevent tumor seeding in hematomas
– Send biopsy fresh and orientated

10. Staging
• AJCC/UICC Staging System for Soft Tissue Sarcomas
– T1: <5cm
• T1a: superficial to muscular fascia
• T1b: Deep to muscular fascia
– T2: >5cm
• T2a: superficial to muscular fascia
• T2b: Deep to muscular fascia
– N1: Regional nodal involvement
– Grading
• G1: Well-differentiated
• G2: Moderately differentiated
• G3: Poorly differentiated
• G4: Undifferentiated

11. Cont’d
Stage IA G1,2 T1a,b N0 M0
Stage IB G2,2 T2a,b N0 M0
Stage IIA G3,4 T1a,b N0 M0
Stage IIB G3,4 T2a N0 M0
Stage III G3,4 T2b N0 M0
Stage IV Any G Any T N1 M1
Staging system predicts survival and risk of metastasis, but not local recurrence
**Does not take into account extremity vs. visceral

12. Relative risk for recurrence and
survival
• Age >50 years 1.6
• Local recurrence at presentation 2.0
• Microscopically positive margin 1.8
• Size 5.0–10.0 cm 1.9
• Size > 10.0 cm 1.5
• High-grade 4.3
• Deep location 2.5
• Local recurrence 1.5

13. Management
Surgery
• Surgery is the principal therapeutic modality
• Controversy:
– extent of surgery required
– optimum combination of radio- and chemotherapy
• Objective: complete removal of tumour with negative margins
with maximum preservation of function
• Neurovascular structures can generally be preserved with
meticulous dissection
• Bone also mostly preserved as invasion of bone is rare and
periosteum provides a good fascial plane

14. Cont’d
• Amputations:
– rarely required
– reserved for patients with unresectable tumours, no metastasis and good
propensity for rehabilitation
• Limb-sparing vs amputation
– Comparison study with post-op radiation in limb sparing showed no
difference in survival
• Amputation still may be indicated for neurovascular or bone
involvement

15. Resection
• Arbitrary 2 cm margin if no plan for post-op radiotherapy
• Negative margins may be adequate for post-op radiation therapy
– Presence of positive margins increases local recurrence by 10-15%
• No need for lymph node dissection as only 2-3% have nodal
metastasis

16. Management
Radiotherapy
• Controversial
• Adjuvant radiotherapy proven to improve local recurrence and
overall survival outcomes in high grade and > 5 cm lesions
• Still no consensus on neoadjuvent radiotherapy and differs
between centers
• More studies are needed in this area
• Both brachytherapy and external beam radiation are used

17. Adjuvant radiotherapy
• Small, low grade tumors resected with 2 cm margins may not
require radiation
• Improves local control but not survival
• Whether improved local control leads to improved survival is
controversial

18. Management
Chemotherapy
• Opposite of radiotherapy
• Neoadjuvant chemotherapy proven to improve outcome
• Advantages:
– subsequent surgery easier due to shrinkage of the tumour
– may treat micrometastasis
– leaves vasculature intact for improved drug delivery
– enables assessm
– ent of therapeutic response or resistance to therapy
• Can improve local control, but not survival
• Combination with radiation or neoadjuvant therapy are controversial
• Hypothermic isolated limb perfusion may be used for palliation

19. Cont’d
• Adjuvant chemotherapy still largely investigational and
controversial
• Statistically significant improvement in overall survival has not
been proven
• 3 most commonly used drugs are doxorubicin, ifosfamide and
gemcitabine
• Doxorubicin and ibosfamide have response rates of 20%
• Their use depends on the histological subtype of STS
• High grade lesions respond better to therapy than low grade
lesions

20. Recurrent and metastatic disease
• Lung most common site of mets, but visceral often go to liver
• 50% recurrence of extremity STS in the lung
• Local recurrence: mass or nodules in surgical scar
• Isolated local recurrence: resection
• If this is the only recurrence site, resectable and patient fit for
surgery: resection
• All unresectable or extrapulmonary metastasis treated with
chemotherapy

21. Cont’d
• Resection of pulmonary mets can give 5 year survival of 32% if all mets
can be removed
– > 3 mets is poor prognosticator
• Poor prognosis
• Relation between local lymphnode metastasis and survival
controversial
• Studies: improvement in survival if local lymphadenectomy if no
distant metastasis
• However, only true if done with initial curative surgery and not if done
after
• Median survival from development of metastatic disease is 8-12
months

22. Treatment of Recurrence
• 20-30% of STS patients will recur
• More common in retroperitoneal and head & neck high grade
tumors because hard to get clear margins
– 38% for retroperitoneal
– 42% for head and neck
– 5-25% for extremity
• After re-resection recurrence is 32% for extremity and much
higher for visceral

23. Prognosis
• Factors that negatively impact prognosis:
– Age > 50 yrs
– Size > 8 cm
– Vascular invasion
– Local infiltration (vs. pushing)
– Tumour necrosis
– Deep location
– High grade tumours
– Recurrent disease
– Certain histological subtypes eg. non-liposarcoma histology

24. Visceral and Retroperitoneal sts
• 34% of all STS
• Most common RPSTS are liposarcoma (40%), leiomyosarcoma
(25%), malignant peripheral nerve sheath tumour and
fibrosarcoma
• Most common visceral STS are gastrointestinal stromal tumour
(GIST), leiomyosarcoma and desmoid tumour

25. Presentation
• Asymptomatic mass
• Pain
• Gastrointestinal bleeding
• Incomplete obstruction
• Neurological symptoms due to invasion of neurovascular
structures

26. Imaging
• CT-abdomen
• CT scan can show cystic/solid/necrotic components and relation
to surroundings
• Also allows evaluation of the liver, the most common site of
metastasis

28. Staging
• No official staging system
• The same grading system applies as for extremity STS

29. Differential diagnosis
• Important to exclude:
– lymphoma,
– germ cell tumours (young patients)
– adrenal gland tumours

30. Diagnosis
• Laparotomy with open biopsy
• CT guided biopsy has a limited role only
• Only if:
– unresectable tumour
– doubtful diagnosis
– neoadjuvent chemotherapy considered

31. Treatment
• Surgery the mainstay of treatment
• En bloc resection is standard treatment
– bowel prep
– assess bilateral kidney function
– 50-80% need organ resection
– 78% of primary lesions can be completely resected
• Completeness of resection and grading of the tumour are the
most important prognostic factors
• “Enucleation” along the pseudocapsule is associated with high
recurrence
• Chemotherapy principles are the same as for extremity STS

32. Cont’d
• Radiotherapy controversial
• High morbidity and mortality due to radiosensitivity of
surrounding organs
• Full-dose external beam radiation not possible due
• Intensity-modulated radiation showing promising results
• Targeted dose escalation to the area most at risk for recurrence

34. Prognosis for retroperitoneal sarcomas
• 5 year survival after complete resection of 54-65%
– Drops to 10-36% if incompletely resected
• Recurrence occurs in 46-59% of completely resected tumors

35. Gastrointestinal stromal tumour
(GIST)
• STS arising from the gastrointestinal tract (GIT)
• Most common visceral STS
• 90% mutations in c-kit proto-oncogene
• 5-7% mutations in PDGFR-α
• 5% no mutations on either of above
• C-kit and PDGFR-α both tyrosine kinase transmembrane
receptors
• Normally expressed by hematopoietic cells, germs cells,
interstitial cells of Cajal

36. Cont’d
• Mostly discovered incidentally
• Occur most in stomach (50%) and proximal small bowel (25%)
• Can occur throughout the GIT including omentum, mesentery,
peritoneum
• 50% metastatic at presentation, mostly to liver and peritoneum
• Surgery is primary method treatment
• Complete resection of even small tumours (< 5cm) has high
recurrence

37. Cont’d
• Recurrence correlates with tumour size and mitotic index
• < 5cm with < 5 mitosis/50 high power fields = low risk
• > 10 cm with > 10 mitosis/50 high power fields = high risk
• Standard chemotherapy rarely effective
• High response rates to Imatinib – tyrosine kinase inhibitor
• Neoadjuvant therapy may enhance resectability and adjuvant
therapy has shown increased disease free but not overall
survival

38. Cont’d
• Some patients poor response to Imatinib
• Response depends on type of mutation and location of mutation
on KIT
• Treatment of resistant patients include:
– increasing dose of Imatinib
– metastatectomy of liver/peritoneal metastasis or radiofrequency ablation
(reasonable results)
– Sunitinib – inhibitor of multiple receptor kinases including tyrosine
kinase, VEGFR-1, 2 and 3, PDGFR-α and β, KIT, FLT₃
• A number of new drugs are being developed

39. GastroIntestinal Stromal Tumour (GIST)

40. GastroIntestinal Stromal Tumour (GIST)

41. Other common STS
• 3 most common subgroups STS previously considered to be:
– malignant fibrous histiocytoma (MFH),
– liposarcoma
– leiomyosarcoma (LMS).
• MFH now considered to be pleomorphic STS without
differensiation
• This is because many tumours previously thought to be MFH,
share biochemical markers similar to other subtypes of STS
• Liposarcoma and LMS now considered 2 most common
subgroups

42. Malignant Fibrous Histiocytoma (MFH)

43. Most common sts
• Liposarcoma
• LMS
• Synovial Sarcoma
• Angiosarcoma
• Kaposi’s Sarcoma
• GIST
• Dermatofibrosarcoma Protruberans (DFSP)
• Aggressive Fibromatosis/Desmoid Tumour
• Alveolar Soft Part Sarcoma
• Rhabdomyosarcoma

44. Liposarcoma
• 20% of STS
• Types:
– well-differentiated (retroperitoneum, low-grade)
– myxoid (extremities, low-grade)
– round cell (extremities)
– dedifferentiated (retroperitoneum, high grade)
– pleomorphic (extremities, high grade)
• Aetiology unknown, variety of cytogenetic abnormalities

45. Leiomyosarcoma (lms)
• Occur throughout the body
• Also in the uterus, but different gene expression pattern from
non-uterine LMS
• Variety of cytogenetic changes
• Cutaneous lesions low risk for mets compared to subcutaneous
and deep lesions
• Gemcitabine promising for treatment of mets

46. Synovial Sarcoma
• Unrelated to the synovium
• Histologic resemblance of synovial cells
• 2 types: monophasic, biphasic
• Fusion of genes between chromosome 18 and X chromosome –
t(X,18)
• Sensitive to Ifosfamide regimes

48. Angiosarcoma
• Strong environmental factor aetiology
• Irradiation, lymphoedema, chemical
• Scalp, face, post-irradiation areas
• Vinyl chloride (plastic) – angiosarcoma of the liver
• Surgery and paclitaxel treatment

49. Kaposi’s Sarcoma
• HHV-8 important in pathogenesis
• Immunocompromized patients, AIDS
• Pink, purple, red, brown patches or nodules
• Mostly skin, oral mucosa
• Non-HIV: mostly lower extremities
• HIV: more wide spread, any organ, may lead to haemorrhage or
organ dysfunction

50. Cont’d
• Indolent to aggressive course
• Local lesions: injection with vinblastine, toplical alitretinoin,
liquid nitrogen cryotherapy
• More extensive involvement of lower extremities: radiation, but
leads to lymphoedema
• Systemic disease: doxorubicin

51. Dermatofibrosarcoma Protuberans
(DFSP)
• Occurs near body surface
• Metastasis unusual
• Surgery primary treatment, recognizing outer margins may be
difficult
• Translocation of chromosomes 17 and 22
• This results in production of PDGFB. Therefore metastasis may
respond to Imatinib

52. Aggresssive Fibromatosis (AF) /
Desmoid tumour
• Monoclonal of myofibroblastlike cells with variable collagen
disposition
• Locally invasive, rarely metastasize but can be multifocal
• Histological similarities with proliferative phase of wound
healing, therefore trauma can cause AF
• Pregnancy, oral contraceptive also causes of AF
• Occurs 1000-fold more in patients with familial adenomatous
polyposis (FAP)

53. Aggresssive Fibromatosis (AF) /
Desmoid tumour
• Gardner syndrome: intestinal polyposis, oeteomas, fibromas,
sebaceous and epidermal cysts
• Genetics: CTNNB1 pathway and WTC (APC)
• No consensus on optimal treatment
• High recurrence after surgery, can even be caused by surgery
• Variety of non-surgical treatments: methotrexate, vinblastine,
NSAID’s, tamoxifen, radiation, Imatinib

54. Alveolar Soft-part Sarcoma
• Slow-growing tumour, late metastasis
• t(X,17), ASPSCR-TFE-3 fusion
• Low response to chemotherapy
• Responds well to surgery, can even resect metastasis due to slow
growth

55. Rhabdomyosarcoma (RMS)
• Most common paediatric STS
• Historically <20% survived with surgery alone due to rapid metastasis
• Today more than 70% cure with multimodal treatment (surgery,
chemo- and radiotherapy)
• Arises from primitive precursor cells for striated muscle
• Types: embryonal (58%), alveolar (31%), botryoid, pleomorphic,
anaplastic
• Variety of cytogenetic changes
• Presentation: mass with overlying erythema
• Most common sites: head and neck (35-40%), genitourinary tract
(25%), extremities (20%)

56. Rhabdomyosarcoma (RMS)
• Staging according to tumour size, location, confinement to an
anatomic site of origin (stage I and II), nodal spread (stage III),
distant metastasis (stage IV)
• 5 year survival: 90% stage I
80% stage II
70% stage III
30% stage IV
• Most common sites metastasis are lungs and bone
• Staging workup: high-resolution imaging of primary, CT-chest
and bone scan

57. Rhabdomyosarcoma (RMS)
• Complete resection best chance of local control
• Not always possible due to location (eg. orbital)
• Radiotherapy for residual disease and stage III
• Chemotherapy standard treatment for RMS and is plays the
largest part in cure
• Vincristine, dactinomycin, cyclophosphamide
• Metastasis has poorer prognosis, but remissions and cure are
possible with chemotherapy and radiotherapy of primary and
metastatic sites

58. Conclusion
• STS are heterogeneous tumours
• They are uncommon and expertise are often lacking at all levels
involved (pathologist, surgeon, oncologist etc.)
• Studies have shown significant improvement in survival and
functional outcomes if treated at high volume centres

59. References
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3. Atalay C, Altinok M, Seref B.The impact of lymphnode metastasis on survival in
extremity soft tissue sarcomas. World J Surg 2007;31:1433-1437.
4. Engellau J, Samuelsson V, Anderson H, Bjerkehagen B, Rissler P, Sundby-Hall K et al.
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60. THANK YOU