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Surgery for Cancer of the Soft tissue

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Sarcomas an uncommon type of cancer, accounting for less than one percent of new cancers. These tumors can develop in a wide variety of locations in the body, including the muscles, tendons, fat tissue, nerves, or blood vessels. Surgery has long been the primary form of treatment for these cancers.

The cancer team must carefully assess the cell type and tumor grade of these soft-tissue growths. Most are benign, fat-cell tumors called lipomas. Some, though, are malignant sarcomas.  

The prognosis for patients diagnosed with sarcoma will depend on the location and size of the tumor, on whether the cancer has spread to other parts of the body, and various aspects of the cancer-cell type that are determined in the lab through examination of tumor tissue removed usually by needle biopsy. The pathologist examining the tumor sample can grade the aggressiveness of the tumor. High-grade tumors are those considered to have a greater capacity to spread. The cancer team will also use x-rays, usually MRI, and sometimes CT imaging to learn more about the extent of the sarcoma.

For patients who are deemed candidates for surgery, the surgeon will seek to resect a safe margin of tissue around the tumor to assure that all of the cancer has been removed. Even low-grade tumors can recur locally, so surgeons will try to achieve at least a couple of centimeters of healthy, excised tissue around the removed tumor to try to gain a higher likelihood that the site from which the tumor was removed is left cancer-free.

Many patients, and especially those with high-grade tumors, receive some combination of radiation or chemotherapy before surgery to shrink tumors or after surgery to kill any remaining cancer cells. This is more often the case for patients with high-grade sarcomas that have a greater likelihood of causing metastases.

The exact steps needed in operations performed to remove sarcomas are as varied and specific as the location and other characteristics of each individual’s tumor. The surgeries are all done via open incision, and they can sometimes require considerable healing and recovery time.

The major factor determining resectability is the extent of the invasion of vital structures rather than the size of the tumor. Tumors integrated with critical tissue, structures, or organs of the body may be not be removable. Even after surgery, repeat operations to address tumor regrowth are not uncommon.

Limb-sparing surgery for extremity sarcoma
The most common locations for sarcomas are the arms, legs, hands, or feet – accounting for about half of diagnosed cases of sarcomas. Today, surgery that spares limbs and avoids amputation is an option for most patients. Only in the uncommon case where the cancer encompasses essential structures of the limb is limb-sparing surgery not an option. In limb-sparing surgery, the surgeon resects the tumor, avoiding damage to the functional structures of the limbs as much as possible. Post-surgery, patients may participate in physical or occupational therapy to return them to optimal activity level and fullest possible use of the limb.

Chest wall and intra-abdominal sarcoma surgery
The chest, back, hips, shoulders, and abdomen are the next most likely place for sarcomas to occur, after the extremities. Chest-wall sarcomas, which arise most often from a rib, can sometimes involve the spine as well. Intra-abdominal sarcomas can occur at the site of abdominal or pelvic organs, or the pelvic wall. Surgery for a sarcoma inside the abdomen can be particularly challenging, due to the proximity of vital organs. The primary treatment for sarcoma in any of these areas is surgical resection, followed by reconstruction of the removed area.

Retroperitoneal sarcoma surgery
Retroperitoneal sarcoma is another type of rare intra-abdominal tumor, in this case arising behind the membrane that lines the abdomen and pelvis and that encloses the vital organs (the peritoneum). This cancer occurs with different cell types and grades, and these factors are important to a patient’s prognosis.

The only treatment proven to enhance survival with this cancer is open surgery to remove all or as much of the cancer tissue as possible. Because these cancers are usually discovered late, after the tumor is large and can be felt in the abdomen – and because these tumors are often positioned next to critical organs and other structures – removal of all of the cancer with no remaining tumor tissue left behind is often difficult. The surgeon will attempt to fully remove the tumor, with cancer-free margins, but this is not easy to confirm and in some cases is impossible to do. The surgery is also challenging and unique to each patient, depending on the position and extent of the cancer.

Furthermore, these cancers may necessitate removal of internal organs with which they are closely situated (for example, the kidney). The eventual return of these cancers to or near the original site is not uncommon. Follow-up surgery to examine the abdomen or pelvis for any additional or recurrent cancer is sometimes necessary, and additional cancer resections may result.

GI sarcoma surgery
These sarcomas arise in the connective tissue supporting the gastrointestinal (GI) tract. These cancers are often benign but have a risk of becoming malignant. They are usually located in or around the wall of the stomach but they can also develop in the bowel or esophagus. Surgery to remove these cancers works best if the tumors are still small.

Amputation
For a surgeon to be sure to remove all of a sarcoma, it is sometimes necessary to resect all or significant part of an arm or leg. Just a few decades ago, amputation was the standard form of treatment for extremity sarcomas. Today, amputation is an unusual circumstance, necessary in no more than five percent of patients with sarcoma of the limbs. For the most part, these are special situations in which a necessary nerve, artery, or muscle has cancer tissue around it that would need to be removed, but where such a removal would cause loss of function to the limb or result in chronic pain in the limb.

Today, though, most patients undergo limb-saving surgery and adjuvant treatment, which achieves survival rates equal to those for amputation, while sparing the patient any loss of arm or leg. Patients who undergo amputation may use a prosthesis to replace the removed limb.

Palliative surgery
Sometimes a sarcoma may be too advanced or widespread for complete removal, and curative surgery is not possible. However, some types of surgical treatment can still be beneficial in addressing the resulting symptoms.

If a sarcoma has invaded surrounding organs, or metastasized to other locations, and so cannot be fully removed, the surgeon may operate to debulk the primary tumor, removing as much cancer tissue as possible to decrease pain and mitigate functional problems.