Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2821_Библиотеки_им_академика_М_И_Перельмана

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According to the most recent World Health Organization definitions, soft tissue tumors should be described as benign, intermediate (locally aggressive), intermediate (rarely metastasizing),andmalignant.Thesetermshavebeenintroducedtoeliminateconfusionarising fromoutdateddescriptionssuchas“intermediatemalignancy.”Accordingtothisterminology, benigntumorsgrowlocally,donotinfiltrate,donotrecur,orrecurinanondestructivefashion. Schwannomaisanexampleofa benigntumor.Intermediate(locallyaggressive)tumorsmay grow inan infiltrative fashionand may recur locallyunless excised with a wide marginof normal tissue. Plantar fibromais anexample.Intermediate (rarelymetastasizing)tumors are locallyaggressive,growinaninfiltrativefashion,andarelikelytorecurlocally,andalsohave a demonstrated ability to metastasize to distant sites. An example of this type of tumor is angiomatoidfibroushistiocytoma.Malignanttumorssuchassynovialsarcoma(SS)andclear cell sarcoma (CCS)grow inan aggressive, infiltrative, andlocallydestructive manner,and carryahighriskofregionalanddistantmetastasis.

Local control of malignant tumors requires an uncompromised wide margin. Wide resectionsaremorelikelytocompromisetheskeletalstability,neurovascularstatus,andsoft tissueintegrityofthelimb.Surgeonsseektobalanceandoptimizetheoncologicandfunctional

The history and physical examination may be adequate to confirm the diagnosis of many commonsofttissuemassesinthefootandankle,suchasganglioncystandplantarfibroma.In thesecases,imagingofthelesionmaynotbeclinicallyindicated.Forsofttissuetumorsthat cannotbereadilydiagnosed,twoorthogonalhigh-qualityplainradiographsarerecommended astheinitialimagingstudy.Theradiographicfindingsmaypointtoapossiblediagnosis.For example, intramuscular hemangiomas (IMHs) may contain small rounded pebble-like calcificationscalledphleboliths,whereas30%ofSSscontainamorphouscalcifications.Soft tissuesarcomasandmetastaticcancersinthefootmayinvadeanearbybone,aworrisomesign associatedwith malignancy. Advanced imaging otherthanMRI,suchas CTscans,positron emissiontomography(PET)scans,andbonescans,isnotcommonlyusefulintheevaluationof

softtissuelesions.

cytopathologist are not available, needle biopsy may be inadequate or inconclusive. Open (incisional)biopsytechniquesarepreferredinthesecases.Openbiopsyisasafeandeffective techniquewhenproperlyplannedandexecuted.Moretissueallowsforbetterunderstandingof the cytoarchitecture of the lesion and reduces the risk of a nondiagnostic result. Essential materialforancillarystudiesandtissuebankingcanbeobtained.

Thesuccessofanincisionalbiopsydependsoncarefulprebiopsyplanning,properbiopsy execution,andadequatepostbiopsycareofthepatient(Table11-2).Allimagingstudiesmust becompletedpriortobiopsy.Thepathologistandthesurgeonshoulddiscussthecasepriorto thebiopsyortheymaydosointheoperatingroom.Atourniquetisappliedafterelevationbut without exsanguination. Tumor sampling is accomplished through adequate longitudinal incisionsthatapproachthelesionmostdirectly.Theincisionshouldbelongenoughtoallow visualizationoftheprocedure, confirmationof appropriate sampling,and hemostasis. Small “keyhole”biopsyincisionsarenotrecommended.Contaminationofuninvolvedstructuresand the neurovascularbundlesespeciallynearthemedialmalleolusshouldbecarefullyavoided. Thetourniquetshouldbereleasedafterthetumorissampled,andmeasuresshouldbetakento insurethatthewoundiscompletelydry.Unintentionalspreadofthetumormayoccurbecause of postbiopsy bleeding. A hematoma may track under subcutaneous tissues or through intramuscular spaces, causing a wide zone of contamination. During open biopsy, the pathologistshouldexamineafrozensectionofthebiopsymaterial toverifythatan adequate amountofviabletumorhasbeenobtained.Culturesshouldbeperformedunlessthepotential forinfectionhas been definitivelyruled out.A moderately compressive dressingshouldbe appliedandthepatientismadenonweight-bearingwiththeextremityelevatedfor3or4days. Thesurgeonwhoperformsthebiopsyshouldscheduleaface-to-faceencounterwiththepatient in7to10daystodiscusstheresultsoftheprocedureandthefuturetreatmentplan.Itisbestto avoiddeliveringbiopsyresultsoverthetelephoneorviaanintermediary.