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SOFT TISSUE TUMORS SOFT TISSUE TUMORS
Early diagnosisEarly diagnosis
SOFT TISSUE TUMORS SOFT TISSUE TUMORS
Early diagnosisEarly diagnosis
Nicolas SANS
Hôpital Universitaire Purpan - Toulouse - FRANCE
This is not a muscular tear…
RHADOMYOSARCOMA
This is not a popliteal cyst…
LYMPHOMA
This is not an intramuscular hematoma …
ANY MUSCULAR LESION WHICH DOES NOT EVOLVE BETWEEN 2 CONTROLS HAS TO MAKE EVOKE A TUMOR
ANGIOSARCOMA
EPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGY
BENIGN TUMORS 300 /100 000
MALIGNANT TUMORS 3 /100 000
Kransdorf et Murphey, 1997
Soft Tissue Sarcomas
2000 new cases
per year in France
NATURAL HISTORYNATURAL HISTORYNATURAL HISTORYNATURAL HISTORY
Centrifugal
Longitudinal
Fibro-vascular reaction
NATURAL HISTORYNATURAL HISTORYNATURAL HISTORYNATURAL HISTORY
Centrifugal
Longitudinal
Fibro-vascular reaction
Capsule (B)
Pseudo capsule (M)
PHYSICAL SIGNSPHYSICAL SIGNSPHYSICAL SIGNSPHYSICAL SIGNS
deep mass, often little painful
duration of the symptoms ?
recent increase of volume ?
diameter > 5 cm
PROGNOSTIC FACTORSPROGNOSTIC FACTORSPROGNOSTIC FACTORSPROGNOSTIC FACTORS
• Age > 50 ansAge > 50 ans
• Male (Male (±)±)
• Location : head, neck, chestLocation : head, neck, chest
• Histological gradeHistological grade
• Histological type (±)Histological type (±)
• SURGICAL MARGINSSURGICAL MARGINS
• Age > 50 ansAge > 50 ans
• Male (Male (±)±)
• Location : head, neck, chestLocation : head, neck, chest
• Histological gradeHistological grade
• Histological type (±)Histological type (±)
• SURGICAL MARGINSSURGICAL MARGINS
The PROGNOSTIC depends on the The PROGNOSTIC depends on the initial surgical treatmentinitial surgical treatment
The PROGNOSTIC depends on the The PROGNOSTIC depends on the initial surgical treatmentinitial surgical treatment
R0R0
all tumour tissue was macroscopically all tumour tissue was macroscopically removed with microscopically clear marginsremoved with microscopically clear margins
recurrence 10% for 5 yearsrecurrence 10% for 5 years
R1R1
microscopic residual disease or with close microscopic residual disease or with close margins (less than 1 mm)margins (less than 1 mm)
recurrence 50% for 5 yearsrecurrence 50% for 5 years
R2R2
macroscopic residual diseasemacroscopic residual disease
recurrence 90% for 5 yearsrecurrence 90% for 5 years
R0R0
all tumour tissue was macroscopically all tumour tissue was macroscopically removed with microscopically clear marginsremoved with microscopically clear margins
recurrence 10% for 5 yearsrecurrence 10% for 5 years
R1R1
microscopic residual disease or with close microscopic residual disease or with close margins (less than 1 mm)margins (less than 1 mm)
recurrence 50% for 5 yearsrecurrence 50% for 5 years
R2R2
macroscopic residual diseasemacroscopic residual disease
recurrence 90% for 5 yearsrecurrence 90% for 5 years
Post operative Post operative
irradiation can’t irradiation can’t
improve an improve an
incorrect surgeryincorrect surgery
Muscular fascia
Enthesis
Cartilage
Cortical bone
Periost
Muscular fascia
Enthesis
Cartilage
Cortical bone
Periost
Anderson MW et al. AJR 1999
COMPARTMENTAL ANATOMY
UNI
PLURI
MEDICAL IMAGINGMEDICAL IMAGINGMEDICAL IMAGINGMEDICAL IMAGING
GOALS GOALS GOALS GOALS
1.1. To define the most To define the most sensitivesensitive technique in the technique in the
detection of the masses of soft tissuesdetection of the masses of soft tissues
2.2. To estimate the most To estimate the most specificspecific technique as for technique as for
the differentiation between a benign and the differentiation between a benign and
malignant tumormalignant tumor
3.3. To appreciate the To appreciate the operabilityoperability and participate in and participate in
the therapeutic planification the therapeutic planification
4.4. To approach the histological nature To approach the histological nature
INITIAL DIAGNOSISINITIAL DIAGNOSISINITIAL DIAGNOSISINITIAL DIAGNOSIS
In few cases images are In few cases images are
pathognomonicpathognomonic
Elastofibroma
Courtesy D Godefroy
Fibrolipoma of the median nerve
PLAIN RADIOGRAPHSPLAIN RADIOGRAPHSPLAIN RADIOGRAPHSPLAIN RADIOGRAPHS
Frequently Frequently
unrewardingunrewarding
PLAIN RADIOGRAPHSPLAIN RADIOGRAPHSPLAIN RADIOGRAPHSPLAIN RADIOGRAPHS
Sometimes evokes Sometimes evokes
the diagnosis the diagnosis
SONOGRAPHYSONOGRAPHYSONOGRAPHYSONOGRAPHY
cystic cystic vsvs solid lesions solid lesions
calficiationscalficiations
to eliminate an hematomato eliminate an hematoma
MRIMRIMRIMRI
Morphological Analysis - Signal analysisMorphological Analysis - Signal analysis
1. Multiplanar study (axial +++)
2. T1 weighted - T2 weighted
1. Pre and post Gadolinium injection
2. With and without fat saturation
3. Dynamic study
4. MRA
Superficial : « benign »
If size < 3 cm
Deep : « malignant »
If size > 5 cm
Depth & Size
Sarcoma
well defined margins
Poor defined margins
T
Hematoma
Desmoid tumor
Poor defined margins
Vascular and/or nervous contact
Surgical planification
Crossing a Fascia Extra compartmental
Crossing a Fascia
Fibromatosis Vascular tumorNervous tumor
NOT WITHOUT FAT SAT !!!
Synovialosarcoma
Gielen, JCAT 2003
NOT WITHOUT FAT !!!
T1 Fat Sat Gado
NOT WITHOUT FAT !!!
T1 Fat Sat Gado
SIGNAL ANALYSISSIGNAL ANALYSIS
Heterogeneous or hyperintense on T1Heterogeneous or hyperintense on T1
Synovialosarcoma
Se +++ Sp ---
Liposarcoma
Leiomyosarcoma
T1 T2
Homogeneous signal on T1 Heterogeneous on T2Homogeneous signal on T1 Heterogeneous on T2
Se = 72-80% Sp = 87-91%
Liposarcoma
Low signal intensity of the septa on T2Low signal intensity of the septa on T2
T2 T1 Fat Sat Gado
Fast and prolonged enhancementFast and prolonged enhancement
Necrosis > 50%Necrosis > 50%
MRIMRIMRIMRI
1.1. Lesion of more than 50 mm in diameterLesion of more than 50 mm in diameter
2.2. Deep localizationDeep localization
3.3. Irregular or lobulated marginsIrregular or lobulated margins
4.4. Irregular or tick septa Irregular or tick septa
5.5. Heterogeneous signal on T1 and T2Heterogeneous signal on T1 and T2
6.6. Low signal intensity of the septa on T2Low signal intensity of the septa on T2
7.7. Fast and prolonged enhancementFast and prolonged enhancement
8.8. Necrosis more than > 50%Necrosis more than > 50%
1.1. Lesion of more than 50 mm in diameterLesion of more than 50 mm in diameter
2.2. Deep localizationDeep localization
3.3. Irregular or lobulated marginsIrregular or lobulated margins
4.4. Irregular or tick septa Irregular or tick septa
5.5. Heterogeneous signal on T1 and T2Heterogeneous signal on T1 and T2
6.6. Low signal intensity of the septa on T2Low signal intensity of the septa on T2
7.7. Fast and prolonged enhancementFast and prolonged enhancement
8.8. Necrosis more than > 50%Necrosis more than > 50%
KRANSDORF, 2000; DESCHEPPER, 2000; VARMA, 1999;CEUGNART,2002
MORPHOLOGY
SIGNAL
PATHOLOGYPATHOLOGYPATHOLOGYPATHOLOGY
PATHOLOGYPATHOLOGYPATHOLOGYPATHOLOGY
1.1. To differentiate begnin or malignant tumorTo differentiate begnin or malignant tumor
2.2. To confirm that it is indeed a conjunctival tumor To confirm that it is indeed a conjunctival tumor
(vs lymphoma, metastasis…)(vs lymphoma, metastasis…)
3.3. Define the type of surgery which must be Define the type of surgery which must be
realized realized (enucleation for conjunctival tumor, extended (enucleation for conjunctival tumor, extended
resection for sarcoma)resection for sarcoma)
4.4. To discuss a neoadjuvant treatmentTo discuss a neoadjuvant treatment
GOALS
PATHOLOGYPATHOLOGYPATHOLOGYPATHOLOGY
1.1. MicrobiopsyMicrobiopsy
2.2. Biopsy excisionBiopsy excision
3.3. Surgical biopsySurgical biopsy
PATHOLOGYPATHOLOGYPATHOLOGYPATHOLOGY
Tissue sampleTissue sample
1.1. Formol fixationFormol fixation
2.2. Freezing - CryosectionFreezing - Cryosection
molecular studymolecular study
X
PATHOLOGYPATHOLOGYPATHOLOGYPATHOLOGY
Tissue sampleTissue sample
1.1. Formol fixationFormol fixation
2.2. Freezing - CryosectionFreezing - Cryosection
molecular studymolecular study
X
Pathologist !
PATHOLOGYPATHOLOGYPATHOLOGYPATHOLOGY
Tissue sampleTissue sample
1.1. Formol fixationFormol fixation
2.2. Freezing - CryosectionFreezing - Cryosection
molecular studymolecular study
X
Pathologist !
BIOPSYBIOPSYBIOPSYBIOPSY
1.1. Perform the biopsy before the Perform the biopsy before the
MRIMRI
2.2. Compromise or complicate the Compromise or complicate the
later treatment by an later treatment by an
unsuitable wayunsuitable way
What you should not make
BIOPSYBIOPSYBIOPSYBIOPSY
1.1. Perform the biopsy before the Perform the biopsy before the
MRIMRI
2.2. Compromise or complicate the Compromise or complicate the
later treatment by an later treatment by an
unsuitable wayunsuitable way
3.3. Obtain insufficient samplesObtain insufficient samples
What you should not make
STAGINGSTAGINGSTAGINGSTAGING
CONCLUSION (1)CONCLUSION (1)CONCLUSION (1)CONCLUSION (1)
The initial medical management of a soft tissue The initial medical management of a soft tissue
sarcoma is essential for the future of patientsarcoma is essential for the future of patient
Think of a sarcoma when :Think of a sarcoma when :
• Size more than 5 cmSize more than 5 cm
• DeepDeep
• Symptomatic lesionSymptomatic lesion
CONCLUSION (2)CONCLUSION (2)CONCLUSION (2)CONCLUSION (2)
1.1. MRI MRI
2.2. Discuss the therapeutic plan before any surgical Discuss the therapeutic plan before any surgical
procedureprocedure
3.3. BiopsyBiopsy
• Experimented pathologistExperimented pathologist
• FreezingFreezing
4.4. PHRC PHRC
MULTIDISCIPLINARY CONCERTATIONMULTIDISCIPLINARY CONCERTATION
Impact d’un Programme d’intervention de Santé Impact d’un Programme d’intervention de Santé
publique ciblé sur la prise en charge initiale des publique ciblé sur la prise en charge initiale des
SARcomes des tissus de l’adulteSARcomes des tissus de l’adulte
Impact d’un Programme d’intervention de Santé Impact d’un Programme d’intervention de Santé
publique ciblé sur la prise en charge initiale des publique ciblé sur la prise en charge initiale des
SARcomes des tissus de l’adulteSARcomes des tissus de l’adulte
AquitaineAquitaine
Languedoc-RoussillonLanguedoc-Roussillon
LimousinLimousin
Midi-PyrénéesMidi-Pyrénées
Pays de LoirePays de Loire
CONSTATSCONSTATSCONSTATSCONSTATS
NonNon conformitéconformité de la prise en de la prise en
charge initiale malgré la diffusion charge initiale malgré la diffusion
de recommandations nationalesde recommandations nationales
MéconnaissanceMéconnaissance clinique et clinique et
radiologiqueradiologique
MultiplicitéMultiplicité des intervenants ; sites des intervenants ; sites
spécialisés ?spécialisés ?
PAYS SCANDINAVES (1989) :
prise en charge spécialisée dans
80% des cas
OBJECTIFSOBJECTIFSOBJECTIFSOBJECTIFS
Mise en place d’Mise en place d’actions collectivesactions collectives pour améliorer la prise en pour améliorer la prise en
charge des STM de l’adulte (diagnostic + bilan initial)charge des STM de l’adulte (diagnostic + bilan initial)
Mesurer Mesurer l’impact l’impact en terme de :en terme de :
• proportion de prise en charge globale adéquateproportion de prise en charge globale adéquate
• surviesurvie
Estimer Estimer l’incidence régionalel’incidence régionale des sarcomes en collaboration des sarcomes en collaboration
avec les registres départementaux des cancers des régions avec les registres départementaux des cancers des régions
étudiéesétudiées