Soft tissue sarcomas of adults

1. Soft tissue sarcomas of adults

2. Soft Tissue Sarcoma Epidemiology • Incidence: 2/100.000 per year • Frequency: 0,8-1% of all malignant tumours • Aetiology: widely unknown

3. Soft Tissue SarcomaPredisposing Factors • Exposure to chemicals • Phenoxyacetic acid • Chlorophenole • Thorotrast (radioactive) • Vinylchloride • Arsenic • Chron. Lymphatic edema • Stewart-Treves Syndrome • Ionising radiation • Genetic predisposition • Neurofibromatosis • Li-Fraumeni Syndrome • fam. Retinoblastoma • fam. Polyposis coli • Radiation • Increase MFH • Viruses • HIV and kaposi sarcoma

4. Soft Tissue SarcomaHistologic Classification

5. Soft Tissue SarcomaLocalisation

8. Soft Tissue SarcomaStages (UICC) Stage G T LN M OAS (5a) IA G1 T1 N0 M0 79 IB G1 T2 N0 M0 IIA G2 T1 N0 M0 65 IIB G2 T2 N0 M0 IIIA G3-4 T1 N0 M0 45 IIIB G3-4 T2 N0 M0 IVA all G all T N1 M0 10 IVB all G all T all N M1

9. Clinical presentation • Asymptomatic mass • Pain and disability • Pressure manifestations • Arterial • Venous • Nerves • Metastases • Local • Blood • Lymphatic

19. Diagnostic work up • Tissue diagnosis • FNABC • True cut needle • Open biopsy • Incisional • Excisional • Imaging • Tumor CT or MRI • Bone plain or MRI • Lung plain or CT

20. Management of local disease(Surgery) • Tumor resection • Radical or compartmental excision • Wide local excision • Enucleation • Intracapsular • Lymphadenectomy only in epitheliod, angiosarcoma & synovial sarcoma • Amputations • Reconstructions

21. Management of local disease(Radiotherapy) • Should pre operative if • Rapid growth • High grade • Large size • Should post operative in most tumors except • G1 • Small G2

22. Management of local disease(chemotherapy) • Could be used with radio as pre oprative neoadjuvant • Its use post operative is controversial • Best results with recurrence either loocal or distant

23. Soft Tissue SarcomaTherapeutic strategy for adults Local Stage Metastatic Stage non rad. surgery Radical surgery Surgery Surgery +/- adj. CT/RT CT +/- Salv. Op. neoadj. CT/RT + Surgery Exp. therapy

24. Soft Tissue SarcomaCHEMOTHERAPY PROTOCOLIFADIC, q 14 DAYS • DOXORUBICIN 25 mg/m² Day 1, 2 • IFOSFAMIDE 1500 mg/m² Days 1-4 • DTIC 200 mg/m² Days 1-4 • G-CSF 5 µg/ kg Days 5-13

25. Surgery of the wound and infections

26. Wound healing processrestoration/regeneration • Collagen formation • finroblasts- protocollagen • hydroxylation • Epithelial coverage • Contraction in the tissues • Blood vessels • migration and division • Angiogenesis • Vasculogenesis, in situ.

27. Wound Healing: Stages • Hemostasis • platelets, endothelial cells, fibrin & fibronectin • Inflammation • neutrophils, macrophages, lymphocytes, growth factors and proteases and cytokines • Proliferation - fibroblasts, epithelial & endothelial • growth factors. • Remodeling - collagenase

28. Wound healing phases • Lag (24-48 h) • acute inflammatory response • Prolifaretive (4-5 weeks) • migration of fibroblasts, capillaries • wound strength: 1st month 50% 2nd month 75% 6th month 95% • Maturation: cross linking, remodelling, contraction

29. Clinical management • First intention healing • primary closure, epithelisation 48-72 h • 2nd intention- contaminated wounds • granulation tissue • 10 000 organism/mm3 • 3rd intention- delayed primary closure • 3-4 days observation, closure

31. Abnormal wound healing • Large, dead space that accumulates fluid, • excessive fat that obscures the fascia, BMI>52 • poor blood supply, • attenuated and weakened fascia, • excessive wound tension • chronic lung disease, chronic cough, and vomiting • malnutrition, old age, diabetes (neutrophil dysfunction, and microvascular disease) decreasing phagocytosis, chemotaxis, killing bacteria, adherence, impaired lymphocyte function, glycosylation of C3, which impairs phagocytosis, and an increased risk of bacterial and fungal infections. • cigarette smoking, chronic steroids, and prior surgery

32. Special wound healing problems • Gastrointestinal • stricture, anastomotic leak • Keloid, hypertrohpic scar • Marjolin ulcer-sqamous cell carcinoma • chronic wound • pressure ulcer • diabetec ulcer • venous stasis

33. Keloid and hypertrophic scar

34. Keloid and hypertrophic scar

35. Treatment of chronic wounds • Removal of non-viable tissue including: necrotic tissue, slough, foreign debris including residual material from dressings. • Removal of nonviable tissue is referred to as debridement. • Removal of foreign debris is referred to as cleansing. • 4 Types of Debridement Autolytic, Biochemical, Mechanical, Sharp

36. Wound etiologies • Arterial • Venous • Diabetic • Trauma • Surgical • Auto-immune • Pressure • Mixed

37. Chronic wound treatment • Debridement • Cleansing • Maintaining a moist environment • Preventing Further Injury

38. Debridement • Removal of ALL devitalized tissue • Not the Physical Therapy “Pick and Whittle” • Healthy bleeding tissue introduces beneficial platelets and Growth factors • Allows for thorough investigation of the wound • Remove potentially infected tissue • Obtain appropriate deep cultures

39. Debridement • Mechanical • Surgical – “Audible Bleeding ?” • Enzymatic • Autolytic = Hydrogels, hydrocolloids, saline

40. Is there adequate blood flow to the ulcer?Arterial based wounds • Feel the pulse • Segmental pressures • Doppler examination • Waveforms • Can you examine the microvascular circulation?

41. Is there adequate blood flow from the ulcer?Venous Stasis Ulcers • Skin discoloration • Hemosiderin deposition • Stasis dermatitis • Lipodermatosclerosis • Loss of hair on the legs • Shiny skin on the tibias

42. Diabetesmultifactorial • Increased risk of infection • Neuropathy (loss of protective sensation) • Vascular effects • Macrovascular ( trifurcation disease below the knee ) • Microvascular (affects medial layer to prevent vasodilatation) • Humeral (decreased NO)

43. Infections • Invasion by pathogenic microorganism • Nosocomial • Autoinfection • Virulence • Carriers • Opportunistic bacteria

44. Soft Tissue Infections • cellulitis, intact blood supply • Lymphangitis • Erysipelas- cellulitis+lymphangitis • subcutaneous abscess • Impetigo-multiple intraepithelial abscesses • Furuncle-sweet glands • Carbuncle- subcutaneous tissue • perirectal abscess-fistula at anal crypt • distal phalanx of the finger (felon)

45. Erysipelas It is acute, non suppurative, spreading inflammation of the skin dt invasion of its lymohatics • Rose pink • Hot • Tense • Tender • Smooth • Blanching on pressure • Marked edema dt lymphatic obstruction

46. Erysipelas • Course • Resolution • Erysipelas migrans • Lymph edema • Gangrene and sloughing • Death • Treatment • Isolation • Rest and elevation • Icthyol or lead subacetate • penicillin

47. It is a staphylococcal infection originating in a hair follicle but involve the sc tissue and adjacent hair follicle Painful induraed swelling, red, hot & dusky Grow in all directions, central become soft & boggy then break with multiple discharging sinuses

48. Carbuncle

49. Gas Gangrene • It is an acute fatal rapidly spreading infection caused by a mixture of gas forming organisms of clostridia group • Predisposing • Bad general conditions • Local ischemia • In-adequte surgical wound care • Clostridial soft tissue include cellulitis and myonecrosis. • Clostridium perfringens • Cl nevyi • Cl septicum • Cl sordelli

50. Gas Gangrene Powerful exotoxin • Skin and SC tissue • oedematous celluitis with gas that destroy local microcirculation • release RBCs and hemolysis • Early sacchrolytic----- hemolysis--- brick red • Late proteolytic--- H2 + Fe---- iron sulphide--- black color • Muscles toxins lead to necrosis • Toxins generally