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#3 Surg > 35 - Soft Tissue Masses > Flashcards

35 - Soft Tissue Masses Flashcards

1
Q

Goals of tumor management

A
  • Identify lesion
  • Rule out malignancy
  • Relieve pain
  • Prevent growth or spread (limit local destruction)
  • Cosmetic improvement
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2
Q

Tumor

A
  • General morphologic term for any abnormal mass
  • Does not define benign vs. malignant
  • “Soft Tissue” does not include epithelial tissue however there is such a great overlap in evaluation and management in this presentation epithelial factors and conditions will be included
  • Tumor just means a growth – to a patient, a tumor means cancer, so be careful
  • Both are just skin tags (acral cordon) – all others except bottom left
  • Bottom left is an amelanotic melanoma
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3
Q

Overview of soft tissue tumors

A
  • Over 80 distinct soft tissue tumor types
  • 100:1 ratio of benign to malignant STM
  • Most Common = Ganglion and fibroma (Benign) and Synovial sarcoma (Malignant)
  • Higher frequency of malignancy in the hind-foot
  • Early recognition common in the foot because of local prominence
  • There is clinical feature overlap between STM, dermatologic conditions and ulcerations
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4
Q

Classification system of soft tissue mass (STM)

A

Histologic type
o Cell type
o Germ layer

Biologic behavior
o Benign
o Malignant

Anatomic site
o Localized
o Widespread

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5
Q

Benign tumor staging

A
  • Stage 1 = latent, not growing
  • Stage 2 = active, enlarging but not invading, pushing tissues out of the way, entwining within them
  • Stage 3 = aggressive, invade other structures
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6
Q

Cellular changes

A
  • Hyperplasia (just more cells)
  • Metaplasia (one cell turns into different cell)
  • Dysplasia (disordered growth)
  • Neoplasia (new growth)
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7
Q

Factors influencing cell activity

A
  • Mechanical
  • Inflammatory
  • Infectious
  • Metabolic
  • Genetic
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8
Q

Morton’s neuroma

A
  • Example: 3rd interspace, deep transverse intermetatarsal ligament
  • Example: Ankle fracture where they partially nicked the nerve – scar tissue formation – NOT NEW GROWTH, just a neuroma
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9
Q

Benign neoplasm

A

o Named by adding “- oma” to the parenchymal cell type
o Both for cells of epithelial or mesenchymal origin
o Most are single cell origin

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10
Q

Malignant neoplasm

A

o “Carcinoma” if epithelial in origin

o “Sarcoma” if mesenchymal in origin

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11
Q

Diagnosis of a soft tissue mass

A
  • History
  • Clinical Characteristics
  • Imaging
  • Biopsy
  • CANNOT make a diagnosis by imaging – THE ONLY WAY TO DIAGNOSE IS BY BIOPSY***
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12
Q

Clinical features of a soft tissue mass to look for

A
  • Size
  • Shape
  • Texture
  • Location
  • Mobility
  • Color
  • Pain
  • Temperature
  • Pulse / Bruit
  • Parathesia
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13
Q

Diagnostic imaging modalities for soft tissue masses

A
  • X-ray
  • CT
  • Bone scan
  • MRI
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14
Q

Use of X-ray to assess soft tissue mass

A

o Calcification
o Bone Tumor simulating STM
o Bone invasion

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15
Q

Use of CT to assess soft tissue mass

A

o Location, Size, Bone invasion

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16
Q

Use of MRI to assess soft tissue mass

A

o Anatomic localization
o Relative tissue type
o Does not provide a definitive diagnosis

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17
Q

Biopsy

A
  • Most important method of identification for tumors
  • Provides vital information for prognosis and treatment
  • Excisional biopsy may provide “cure”
  • ***MOST IMPORTANT THING IS BIOPSY – need to know what you are looking for
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18
Q

Biopsy types

*THIS IS IMPORTANT

A
  • Closed biopsy
  • Incisional biopsy
  • Excisional biopsy
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19
Q

Closed biopsy

A

o Needle aspiration

o Core Biopsy

20
Q

Incisional biopsy

A

o Wedge
o Punch
o Shave

21
Q

Excisional biopsy

A

o Marginal
o Wide local
o Radical (TAKE OUT ENTIRE COMPARTMENT***)

22
Q

Lesions that should be biopsied

A
  • Fast growing
  • Inflamed or ulcerated
  • Large masses
  • Painful, pruritic and otherwise symptomatic
  • Ulcerations present for greater than 4 weeks
  • Non responsive to treatment
  • Pigmented Lesions
  • If there is no other reason for it to be ulcerated, ALWAYS BIOPSY IT
23
Q

Incision location

A
  • Direct access to the tumor
  • Do not cross compartments
  • Consider the local anatomy
  • Consider subsequent care
24
Q

Clinical considerations for biopsy

A
  • When determining incision location, consider access to mass, how to protect local anatomy, and plan for future excision if necessary
  • When dissecting tissue, determine normal or abnormal
  • Remove tissue so that we may achieve accuracy of pathology
  • Consider tissue planes and possible spread of tumor cells
25
Q

Tissue removal

A
  • Representative sample
  • Adequate amount
  • Avoid frankly necrotic tissue
  • Advancing edge?
  • If possible, excisional biopsy is best
26
Q

Compare incisional vs excisional biopsy

TEST QUESTION

A

Excisional biopsy preferred
o Diagnosis & Cure
o One procedure

Incisional best if
o Complicated anatomy
o Clinical suspicion of malignancy
o Large lesion (can’t do an excisional)

27
Q

Types of excision

TEST QUESTION

A
  • Intra-capsular Excision
  • Marginal Excision
  • Wide Local Excision
  • Radical Resection
28
Q

Intra-capsular Excision

A

o Excision within tumor capsule or margins
o De-bulking
o You’re not even taking the whole tumor, just “de-bulking it”

29
Q

Marginal Excision

A

o Excision of entire tumor and capsule with minimal normal tissue

30
Q

Wide Local Excision

A

o Excision of tumor and cuff of normal tissue

31
Q

Radical Resection

A

o Removal of entire anatomic compartment

32
Q

Incision location

A
  • Direct access to the tumor
  • Do not cross compartments
  • Consider the local anatomy
  • Consider subsequent care
33
Q

Neurofibromatosis

A
  • Neurofibromatosis – just wanted to do an intracapsular incision (de-bulk it) in order to prevent the nerve compression and relieve pain
34
Q

Mucocutaneous cyst

A
  • Related to ganglion cyst (mucoid cyst)
  • This is a mucocutaneous cyst, which is another type of mucoid cyst
  • Would have a thick gel fluid in it, just like in a ganglion cyst
35
Q

Example of plantar tumor

A
  • There is tumor everywhere
  • Need incision that allows you to get to everything
  • Widely invasive into the tissues – This is an intracapsular incision
  • Wide local incision – had to take a lot of tissue to get as much of it as you can so it doesn’t recur
36
Q

Example of tumor on hallux

A
  • Hard to get to both sides of the hallux
  • Need to design an incision that allows you to get to all sides of the hallux
  • This was putting pressure on the nerves underneath
  • INVADES tissue – no capsule, no separation of the vital structures
  • Had to take out a lot
  • Need to start from where you can see normal tissue
37
Q

Example of BAD approach

A
  • VERY BAD APPROACH – Need a wide marginal incision (this is very small)
  • You can’t see any anatomy
  • They will have multiple recurrences and an ugly scar already
  • Need to open it up to the extent of the lesion
38
Q

Dermafibroma

A
  • Skin is hard to close on the toes because there is not an excess of tissue – this approach saves 60% of tissue
39
Q

Pathology analysis of specimen

A
  • Formalin fixed
  • Frozen section
  • Culture media
  • Aerobic, anerobic, fungal, acid fast
40
Q

Fomalin fixed

A

o When you take it out, you need to send it to pathology – most tumors will go in formalin
o If you’re trying to get a culture, DO NOT put it in formalin (kills bacteria)
o If you are trying to test for gout, DO NOT put it in formalin (dissolves it)

41
Q

Frozen section

A

o Identify need for immediate further treatment

o They may be able to tell you if it is malignant or not

42
Q

Goals of biopsy

A
  • Determine histologic type and grade of tumor
  • Determine the anatomic extent of the tumor
  • Determine prognosis and establish further treatment
43
Q

Properties of benign tumors

*TEST QUESTION

A 
o	Well differentiated
o	Normochromatic
o	Rare mitoses
o	Cells retain normal function
o	Encapsulated
o	Push local structures aside
44
Q

Properties of malignant tumors

TEST QUESTION

A 
o	Anaplastic
o	Pleomorphic
o	Hyperchromatic
o	Mitoses common
o	Normal function lost
o	Invade local structures
45
Q

Staging of malignant tumors

A
  • Grade (G)
  • Anatomic site and extent (T)
  • Metastasis (M)
  • Used to predict prognosis, choose treatment, predict response to treatment and recurrence

Notes:
o Not going to belabor a lot of this, but these factors are used to predict prognosis
o We will always work with an oncologist or a surgeon that is experienced with melanoma and they usually do the staging, we will just do the local treatment of it
o You do need to understand what goes into the prognosis

46
Q

Lesions NOT to miss

A
  • Pigmented Lesions
  • High index of suspicion for malignancy
    o Large and/or fast growing
    o Associated with ulceration
    o Painful
  • Biopsy, Biopsy, Biopsy
  • If there is NO OTHER REASON for the patient to have an ulcer, you NEED TO BIOPSY it
47
Q

REVIEW

A
  • Biopsy is the only definitive way to diagnose a STM
  • Excisional biopsy is preferred if possible
  • Carefully consider approach to excision to avoid unnecessary damage or spread
  • Must have a low threshold for biopsy of suspicious lesions

#3 Surg (12 decks)

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