J Korean Orthop Assoc.  2015 Aug;50(4):269-279. 10.4055/jkoa.2015.50.4.269.

Diagnoses and Approaches of Soft Tissue Tumors for Orthopaedic Non-Oncologists

• Kang HG

• KMID: 2035863
• DOI: http://doi.org/10.4055/jkoa.2015.50.4.269

Abstract

Soft tissue tumors are classified into benign and malignant on the basis of the patient's age, medical history, physical examination, pathological and radiologic examination. We have to caution against misdiagnosis of malignant tumor which can delay the treatment time. Lipoma, schwannoma, hemangioma, and ganglion cysts are common benign tumors, usually of small size and are often located in the superficial layer. Although it may be suspected as a benign tumor, performing contrast-enhanced magnetic resonance maging is preferably advantageous. Liposarcoma and undifferentiated pleomorphic sarcoma, the most common malignant soft tissue tumors, usually occur after middle age; rhabdomyosarcoma is usually presented in children and synovial sarcoma often occurs at a younger age. The magnetic resonance (MR) signal intensity of lipoma shows uniformity with subcutaneous fat, sarcoma should be suspected if it has a contrast-enhanced and non-fat-suppressed part. The MR signals of ganglion cysts show homogeneous and same signal intensity with joint fluid and urine, while the liquid containing sarcoma, like synovial sarcoma, is characterized by heterogeneous signal intensity and contrast enhancement. If surgery is performed, an incision should be made in the longitudinal direction of the limb and the excised tumor should be sent for pathology analysis. When the macroscopic finding of the tumor during surgery is different from the expected diagnosis, the operation should cease with biopsy only or the small superficial tumor can be excised widely if possible. The transfer should be considered unless you can be sure of a benign tumor in hands and feet of children. When diagnosed as malignant tumors, patients should be provided with sufficient information that can lead them to a musculoskeletal tumor specialist.

Keyword

soft tissue tumor; sarcoma; non-specialist doctor; right approach

MeSH Terms

Biopsy
Child
Diagnosis*
Diagnostic Errors
Extremities
Foot
Ganglion Cysts
Hand
Hemangioma
Humans
Joints
Lipoma
Liposarcoma
Middle Aged
Neurilemmoma
Pathology
Physical Examination
Rhabdomyosarcoma
Sarcoma
Sarcoma, Synovial
Specialization
Subcutaneous Fat

Figure

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  Figure 1 Age-related-incidence of common soft tissue sarcomas.

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  Figure 2 Synovial sarcoma can be confused with the popliteal cyst. T2 sagittal (A) and axial magnetic resonance images (B) show heterogeneous signal intensity with fluid-fluid level. (C) Synovial sarcoma has a contrast enhancement portion.

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  Figure 3 Lipogenic tumor should be compared with the subcutaneous fat layer of the magnetic resonance imaging signal. (A) Lipoma has totally the same signal as the subcutaneous fat layer in T1 (left), fat suppression (middle) and contrast enhancement (right). (B) A well-differentiated liposarcoma with deep location (left), nonfat suppression area (middle; arrow) and thick septum with enhancement area (right; arrow).

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  Figure 4 Undifferentiated pleomorphic sarcoma. Sarcoma is suspected, if the superficially located tumor shows a different signal than the subcutaneous fat layer (A) and has contrast enhancement (B).

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  Figure 5 Wide excisional biopsy. (A) A superficially located tumor of the arm shows a different signal compared with the subcutaneous fat layer. (B, C) The cephalic vein is compressed. (D) Superficial nerves and blood vessels in contact with sarcoma should be excised without dissection. (E) An excised sarcoma should be covered with normal tissues in all directions.

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  Figure 6 Benign soft tissue tumors in the hand show different magnetic resonance signals schwannoma (A), lipoma (B), and hemangioma (C).

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  Figure 7 Synovial sarcoma of the finger shows more contrast enhancement (A) than a giant cell tumor of the tendon sheath (B).

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  Figure 8 Remember, the colors of soft tissue tumors. Lioma (A), schwannoma (B), and hemangioma (C) is distinguished by the color of sarcoma (D).

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  Figure 9 (A) If intraoperatively, superficial tumor tissue differs from expected benign, wide excision can be performed before or after biopsy result. (B) The color of the sarcoma is quite different from that of subcutaneous fat tissue.

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  Figure 10 Algorithm for treatment of soft tissue tumors.

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