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SOFT TISSUE TUMORS Early diagnosis

SOFT TISSUE TUMORS Early diagnosis. Nicolas SANS Hôpital Universitaire Purpan - Toulouse - FRANCE. This is not a muscular tear…. RHADOMYOSARCOMA. This is not a popliteal cyst…. LYMPHOMA. This is not an intramuscular hematoma …. ANGIOSARCOMA.

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SOFT TISSUE TUMORS Early diagnosis

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  1. SOFT TISSUE TUMORS Early diagnosis Nicolas SANS Hôpital Universitaire Purpan - Toulouse - FRANCE

  2. This is not a muscular tear… RHADOMYOSARCOMA

  3. This is not a popliteal cyst… LYMPHOMA

  4. This is not an intramuscular hematoma …

  5. ANGIOSARCOMA ANY MUSCULAR LESION WHICH DOES NOT EVOLVE BETWEEN 2 CONTROLS HAS TO MAKE EVOKE A TUMOR

  6. 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

  7. NATURAL HISTORY Centrifugal Longitudinal Fibro-vascular reaction

  8. NATURAL HISTORY Centrifugal Longitudinal Fibro-vascular reaction Capsule (B) Pseudo capsule (M)

  9. PHYSICAL SIGNS • deep mass, often little painful • duration of the symptoms ? • recent increase of volume ? • diameter > 5 cm

  10. PROGNOSTIC FACTORS • Age > 50 ans • Male (±) • Location : head, neck, chest • Histological grade • Histological type (±) • SURGICAL MARGINS

  11. 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 can’t improve an incorrect surgery

  12. COMPARTMENTAL ANATOMY Muscular fascia Enthesis Cartilage Cortical bone Periost UNI PLURI Anderson MW et al. AJR 1999

  13. MEDICAL IMAGING

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

  15. INITIAL DIAGNOSIS In few cases images are pathognomonic

  16. Elastofibroma

  17. Fibrolipoma of the median nerve Courtesy D Godefroy

  18. PLAIN RADIOGRAPHS • Frequently unrewarding

  19. PLAIN RADIOGRAPHS • Sometimes evokes the diagnosis

  20. SONOGRAPHY • cystic vs solid lesions • calficiations • to eliminate an hematoma

  21. MRI Morphological Analysis - Signal analysis • Multiplanar study (axial +++) • T1 weighted - T2 weighted • Pre and post Gadolinium injection • With and without fat saturation • Dynamic study • MRA

  22. Depth & Size Superficial : « benign » If size < 3 cm Deep : « malignant » If size > 5 cm

  23. well defined margins Sarcoma

  24. Poor defined margins T Hematoma

  25. Poor defined margins Desmoid tumor

  26. Vascular and/or nervous contact

  27. Surgical planification

  28. Crossing a Fascia Extra compartmental

  29. Crossing a Fascia Fibromatosis Vascular tumor Nervous tumor

  30. NOT WITHOUT FAT SAT !!! Synovialosarcoma Gielen, JCAT 2003

  31. NOT WITHOUT FAT !!! T1 Fat Sat Gado

  32. NOT WITHOUT FAT !!! T1 Fat Sat Gado

  33. SIGNAL ANALYSIS

  34. Heterogeneous or hyperintense on T1 Synovialosarcoma Liposarcoma Se +++ Sp ---

  35. Homogeneous signal on T1 Heterogeneous on T2 T1 T2 Se = 72-80% Sp = 87-91% Leiomyosarcoma

  36. Low signal intensity of the septa on T2 Liposarcoma

  37. Fast and prolonged enhancement T2 T1 Fat Sat Gado

  38. Necrosis > 50%

  39. MRI • Lesion of more than 50 mm in diameter • Deep localization • Irregular or lobulated margins • Irregular or tick septa • Heterogeneous signal on T1 and T2 • Low signal intensity of the septa on T2 • Fast and prolonged enhancement • Necrosis more than > 50% MORPHOLOGY SIGNAL KRANSDORF, 2000; DESCHEPPER, 2000; VARMA, 1999;CEUGNART,2002

  40. PATHOLOGY

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

  42. PATHOLOGY • Microbiopsy • Biopsy excision • Surgical biopsy

  43. PATHOLOGY Tissue sample • Formol fixation • Freezing - Cryosection molecular study X

  44. PATHOLOGY Tissue sample • Formol fixation • Freezing - Cryosection molecular study X Pathologist !

  45. PATHOLOGY Tissue sample • Formol fixation • Freezing - Cryosection molecular study X Pathologist !

  46. BIOPSY What you should not make • Perform the biopsy before the MRI • Compromise or complicate the later treatment by an unsuitable way

  47. BIOPSY What you should not make • Perform the biopsy before the MRI • Compromise or complicate the later treatment by an unsuitable way • Obtain insufficient samples

  48. STAGING

  49. 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

  50. CONCLUSION (2) MULTIDISCIPLINARY CONCERTATION • MRI • Discuss the therapeutic plan before any surgical procedure • Biopsy • Experimented pathologist • Freezing • PHRC

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