SOFT%20TISSUE%20TUMORS%20%20Early%20diagnosis

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SOFT TISSUE TUMORS Early diagnosis
Nicolas SANS Hôpital Universitaire Purpan -
Toulouse - FRANCE
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This is not a muscular tear
RHADOMYOSARCOMA
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This is not a popliteal cyst
LYMPHOMA
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This is not an intramuscular hematoma
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ANGIOSARCOMA
ANY MUSCULAR LESION WHICH DOES NOT EVOLVE BETWEEN
2 CONTROLS HAS TO MAKE EVOKE A TUMOR
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EPIDEMIOLOGY

• BENIGN TUMORS 300 /100 000
• MALIGNANT TUMORS 3 /100 000

Kransdorf et Murphey, 1997
Soft Tissue Sarcomas 2000 new cases per year in
France
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CAT

• The rarity and the anatomo-clinical
  heterogeneousness returns the difficult treatment
  
• The vital and functional future is strongly
  dependent on the initial treatment of the tumor
• A multidisciplinary approach is necessary and,
  it, from the diagnostic time to the post
  therapeutic time

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NATURAL HISTORY
Centrifugal Longitudinal Fibro-vascular
reaction
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NATURAL HISTORY
Centrifugal Longitudinal Fibro-vascular
reaction Capsule (B) Pseudo capsule (M)
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PHYSICAL SIGNS

• deep mass, often little painful
• duration of the symptoms ?
• recent increase of volume ?
• diameter gt 5 cm

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PROGNOSTIC FACTORS

• Age gt 50 ans
• Male ()
• Location head, neck, chest
• Histological grade
• Histological type ()
• SURGICAL MARGINS

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The PROGNOSTIC depends on the initial surgical
treatment

• R0
• all tumour tissue was macroscopically removed
  with microscopically clear margins
• recurrence 10 for 5 years
• R1
• microscopic residual disease or with close
  margins (less than 1 mm)
• recurrence 50 for 5 years
• R2
• macroscopic residual disease
• recurrence 90 for 5 years

Post operative irradiation cant improve an
incorrect surgery
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COMPARTMENTAL ANATOMY
Muscular fascia Enthesis Cartilage Cortical
bone Periost
UNI PLURI
Anderson MW et al. AJR 1999
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MEDICAL IMAGING
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GOALS

1. To define the most sensitive technique in the
   detection of the masses of soft tissues
2. To estimate the most specific technique as for
   the differentiation between a benign and
   malignant tumor
3. To appreciate the operability and participate in
   the therapeutic planification
4. To approach the histological nature

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INITIAL DIAGNOSIS
In few cases images are pathognomonic
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Elastofibroma
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Fibrolipoma of the median nerve
Courtesy D Godefroy
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PLAIN RADIOGRAPHS

• Frequently unrewarding

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PLAIN RADIOGRAPHS

• Sometimes evokes the diagnosis

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SONOGRAPHY

• cystic vs solid lesions
• calficiations
• to eliminate an hematoma

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CT
Lipoma
Ossificans myositis
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MRI

• Morphological Analysis - Signal analysis

1. Multiplanar study (axial )
2. T1 weighted - T2 weighted
3. Pre and post Gadolinium injection
4. With and without fat saturation
5. Dynamic study
6. MRA

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Depth Size
Superficial  benign  If size lt 3 cm
Deep  malignant  If size gt 5 cm
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well defined margins
Sarcoma
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• Poor defined margins

T
Hematoma
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Poor defined margins
Desmoid tumor
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Vascular and/or nervous contact
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Surgical planification
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Crossing a Fascia
Extra compartmental
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Crossing a Fascia
Fibromatosis Vascular tumor Nervous tumor
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NOT WITHOUT FAT SAT !!!
Synovialosarcoma
Gielen, JCAT 2003
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NOT WITHOUT FAT !!!
T1 Fat Sat Gado
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NOT WITHOUT FAT !!!
T1 Fat Sat Gado
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• IN FAVOR OF MALIGNANCY
• Heterogeneous T1
• T1 homogeneous ? T2 heterogeneous
• Low signal intensity of the septa on T2
• Necrosis represents more than 50 of the lesion

Hermann et al. BJR 1992 6514-20
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SIGNAL ANALYSIS
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Heterogeneous or hyperintense on T1
Synovialosarcoma
Liposarcoma
Se Sp ---
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Homogeneous signal on T1
Heterogeneous on T2
T1
T2
Se 72-80 Sp 87-91
Leiomyosarcoma
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Low signal intensity of the septa on T2
Liposarcoma
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Fast and prolonged enhancement
T2
T1 Fat Sat Gado
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Necrosis gt 50
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MRI

1. Lesion of more than 50 mm in diameter
2. Deep localization
3. Irregular or lobulated margins
4. Irregular or tick septa
5. Heterogeneous signal on T1 and T2
6. Low signal intensity of the septa on T2
7. Fast and prolonged enhancement
8. Necrosis more than gt 50

MORPHOLOGY
SIGNAL
KRANSDORF, 2000 DESCHEPPER, 2000 VARMA,
1999CEUGNART,2002
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PATHOLOGY
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PATHOLOGY
GOALS

1. To differentiate begnin or malignant tumor
2. To confirm that it is indeed a conjunctival tumor
   (vs lymphoma, metastasis)
3. Define the type of surgery which must be realized
   (enucleation for conjunctival tumor, extended
   resection for sarcoma)
4. To discuss a neoadjuvant treatment

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PATHOLOGY

1. Microbiopsy
2. Biopsy excision
3. Surgical biopsy

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PATHOLOGY

• Tissue sample
• Formol fixation
• Freezing - Cryosection
• molecular study

X
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PATHOLOGY

• Tissue sample
• Formol fixation
• Freezing - Cryosection
• molecular study

X
Pathologist !
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PATHOLOGY

• Tissue sample
• Formol fixation
• Freezing - Cryosection
• molecular study

X
Pathologist !
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BIOPSY
What you should not make

1. Perform the biopsy before the MRI
2. Compromise or complicate the later treatment by
   an unsuitable way

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BIOPSY
What you should not make

1. Perform the biopsy before the MRI
2. Compromise or complicate the later treatment by
   an unsuitable way
3. Obtain insufficient samples

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STAGING
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CONCLUSION (1)

• The initial medical management of a soft tissue
  sarcoma is essential for the future of patient
• Think of a sarcoma when
• Size more than 5 cm
• Deep
• Symptomatic lesion

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CONCLUSION (2)
MULTIDISCIPLINARY CONCERTATION

• MRI
• Discuss the therapeutic plan before any surgical
  procedure
• Biopsy
• Experimented pathologist
• Freezing
• PHRC

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Impact dun Programme dintervention de Santé
publique ciblé sur la prise en charge initiale
des SARcomes des tissus de ladulte

• Aquitaine
• Languedoc-Roussillon
• Limousin
• Midi-Pyrénées
• Pays de Loire

IPSSar
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CONSTATS

• Non conformité de la prise en charge initiale
  malgré la diffusion de recommandations nationales
• Méconnaissance clinique et radiologique
• Multiplicité des intervenants sites
  spécialisés ?

PAYS SCANDINAVES (1989) prise en charge
spécialisée dans 80 des cas
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OBJECTIFS

• Mise en place dactions collectives pour
  améliorer la prise en charge des STM de ladulte
  (diagnostic bilan initial)
• Mesurer limpact en terme de
• proportion de prise en charge globale adéquate
• survie
• Estimer lincidence régionale des sarcomes en
  collaboration avec les registres départementaux
  des cancers des régions étudiées