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Silent but deadly how to spot a sarcoma

• Craig Gerrand
• Consultant Orthopaedic Surgeon
• Freeman Hospital, Newcastle

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Introduction

• What is a sarcoma, and why does it matter?
• Who gets sarcomas?
• What is the best treatment for a sarcoma?
• How can I tell a sarcoma from a ganglion?

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What is a lipoma?

• Benign tumour of mature adipose tissue

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What is a ganglion?

• A simple fluid filled cyst usually arising from a
  joint or tendon.

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What is a sarcoma?
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Bone and soft tissue sarcomas

• Are rare malignant tumours arising from
  connective tissues
• Heterogenous in type and location
• Most are mesenchymal in origin

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How rare is rare?

• Soft tissue masses are common (many hundreds in a
  GP lifetime)
• Malignant soft tissue sarcomas are uncommon (1 or
  2 in a GP lifetime)
• England and Wales
• 400 primary bone tumours per annum
• 1500 soft tissue sarcomas per annum

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How malignant 1?

• Survival of all patients with bone sarcomas

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How malignant 3?

• Survival of all patients with soft tissue sarcomas

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Primary bone tumoursMorphological classification

• Over 30 variants

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Soft tissue sarcoma Morphological classification

• Over 100 variants

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Aetiology

• Most are sporadic
• Predisposing factors
• inherited predisposition
• immunosuppression
• irradiation
• specific chemicals
• Genetic changes within cells lead to tumours

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Age distribution of primary bone tumours
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Age distribution of soft tissue sarcomas
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Soft Tissue SarcomaDistribution

• 55 extremities
• 35 retroperitoneum and viscera
• 10 head and neck

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What is the best treatment for sarcomas?
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Best treatment

• Early detection and referral
• Multidisciplinary team management

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Why refer early?

• Delays in diagnosis are common
• Risk of metastasis relates to size of tumour

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Where do delays occur?

• Patient (7 months)
• GP (7 months)
• Hospital

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Biopsy of sarcomas

• Sarcomas are implantable
• Therefore
• Careful planning is mandatory

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The Whoops! procedure

• Excision without regard to principles of tumour
  surgery and usually without imaging
• ie tumour shelled out without considering the
  possibility of malignancy
• Further treatment complicated

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Principles of biopsy

• Image first
• Careful planning with regard to definitive
  surgery
• If in doubt, discuss!
• Excise the biopsy track during definitive surgery
• Extensile incisions
• Avoid neurovascular structures
• Good haemostasis
• Drain through or close to the wound

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Treatment of sarcomas

• Multidisciplinary team
• Combined approach with radiotherapy, surgery and
  chemotherapy
• Specialist centre

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Patient perspective

• Rare tumour
• Often incorrectly reassured
• May have to travel for treatment

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Low grade fatty tumours

• Low risk of local recurrence
• Low risk of metastatic disease
• Treatment by planned marginal excision

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Indications for amputation

• Adequate margins not possible with limb salvage
• Major complications of radiotherapy would follow
• A below knee amputation may be more serviceable
  than a salvaged distal extremity
• Some cases of local recurrence may not be
  treatable by standard surgery and radiotherapy

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The future

• Changes in administrative structure (NICE, NSCAG,
  NCRI)
• Better identification of risk groups
• Better chemotherapy
• Better radiotherapy
• Tissue engineering
• Gene therapy
• New imaging modalities

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Who to refer 1?

• Soft tissue masses
• Size gt5cm
• Painful
• Increasing in size
• Deep to fascia
• Recurring after previous excision

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Who to refer 2?

• Undiagnosed bone pain needs an x-ray!
• Bone abnormalities on X-ray
• Bone destruction
• New bone formation
• Associated soft tissue swelling
• Periosteal elevation

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North of England Bone and Soft Tissue Tumour
Service

• Orthopaedics
• Shona Murray
• Craig Gerrand
• Mike Gibson
• Plastic Surgery
• Rick Milner
• General Surgery
• Derek Manus
• Paul Hainsworth
• Thoracic surgery
• Sion Barnard

• Clinical Oncology
• Helen Lucraft
• Charles Kelly
• Medical Oncology
• Mark Verrill
• Ruth Plummer
• Paediatric Oncology
• Juliet Hale
• Quentin Campbell Hewson
• Alan Craft

• Radiology
• Geoff Hide
• Chris Baudoin
• Pathology
• Petra Dildey
• Macmillan nurse
• Joy Dowd

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Thank you