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Surgery for soft tissue sarcoma
Surgery is the primary treatment for soft tissue sarcoma. The type of surgery you have depends mainly on the type, size and location of the tumour. When planning surgery, your healthcare team will also consider other factors, such as the level of physical function after surgery and how much tissue to remove to lessen the chance that the cancer will come back in the same area (called local recurrence).
Surgery may be done for different reasons. You may have surgery to:
- completely remove the tumour, especially if it is in an arm or leg
- treat a soft tissue sarcoma that comes back, or recurs, after treatment
- remove a metastatic tumour
- reduce pain or ease symptoms of advanced soft tissue sarcoma (palliative treatment)
Surgery is used to remove stage 1, 2 and 3, and sometimes stage 4, soft tissue sarcomas. The goal of surgery is to remove the entire tumour along with a margin of healthy tissue around it. This tissue is then examined under a microscope to look for cancer cells. A negative surgical margin means that no cancer cells were found at the edge of the removed tissue. A positive surgical margin means that cancer cells were found in the removed tissue.
Sometimes surgery is the only treatment needed for smaller, low-grade soft tissue sarcomas. It may also be the only treatment needed for superficial tumours, which are those that develop near the surface of the body and are not in deeper tissues such as muscle. If there is a positive surgical margin, then surgery to remove more tissue, or re-resection, is usually done. This surgery is often followed by radiation therapy. If re-resection is not possible, radiation therapy may be given after the first surgery.
In some cases, soft tissue sarcomas develop in areas where it may be difficult to do surgery. For example, tumours in the trunk or abdomen may be close to vital organs that can’t be removed or might be damaged by surgery. If surgery to remove a sarcoma is too difficult or life threatening because of the where the tumour is in the body, you may have radiation therapy, with or without chemotherapy, instead of surgery.
The retroperitoneum is the area at the back of the abdomen. Soft tissue sarcomas in the retroperitoneum can grow to be quite large before they are found. On average, they are 15–20 cm, or 6–8 in, at diagnosis. In 50%–70% of cases, these tumours have grown into nearby structures and the surgeon may need to remove organs, including part of the colon, kidney, small intestine, bladder and major blood vessels, to remove all of the tumour.
A surgeon who specializes in treating soft tissue sarcoma will be part of your multidisciplinary healthcare team. Your surgeon will assess you very carefully before surgery and will follow the standard procedure for surgery.
Before removing tumours in the arm or leg, the surgeon will assess the condition of the skin, especially if you have received radiation therapy. Skin that has received radiation therapy may not heal properly after surgery. The surgeon will determine if special procedures like skin grafts need to be done to cover areas after surgery.
A biopsy is an important part of the evaluation before surgery. Often a biopsy needs to be done by a surgeon who specializes in soft tissue sarcomas. The surgeon will plan the biopsy and surgery together because the area from where the biopsy sample is taken is often removed during surgery to remove the tumour. Biopsy and surgery are planned to ensure as little damage to normal tissue as possible and to ensure the best functional outcome possible.
Different types of surgery may be done, depending on the type, location and size of the tumour.
The following types of surgical procedures are used to treat soft tissue sarcoma.
Wide local excision is used to remove the tumour and some normal tissue around it. Depending on the location and stage of the soft tissue sarcoma, a wide margin of normal tissue around the tumour is removed. The surgeon will decide how much tissue should be removed based on the type of soft tissue sarcoma, the type or location of tissue and if radiation was used. It may be hard to remove a wide margin of normal tissue around tumours in some areas, such as the head and neck, because there is a risk of damaging important structures. Any tissue from or near the biopsy site is also removed along with the tumour.
Depending on the amount of tissue removed, the surgeon may replace it with a skin graft or tissue flap. Skin grafts and tissue flaps take skin or tissue from one part of the body and place it over the wound. A skin grafts or tissue flap is often done at the same time as surgery to remove the cancer.
Limb-sparing, or limb-salvage, surgery may be used to treat a soft tissue sarcoma that develops in an arm or leg. Most people with a soft tissue sarcoma in a limb can be successfully treated with limb-sparing surgery. Limb-sparing surgery is usually an option unless the cancer has spread to important nerves or blood vessels, but this is uncommon.
Limb-sparing surgery is a complex procedure that removes the cancer, but not the arm or leg. The surgeon removes the entire tumour while trying to save nearby tendons, nerves and blood vessels to keep as much function as possible in the arm or leg. The surgeon keeps enough soft tissue, skin and muscle to rebuild, or reconstruct, a functional limb. Reconstructive surgery helps restore the structure and function of an arm or leg.
Depending on the amount of tissue removed, the surgeon may replace it with a skin graft or tissue flap taken from another part of the body. Many people need a tissue flap to rebuild the wound made when the tumour is removed. A tissue flap includes skin and some tissue underneath it, including fat and muscle.
Most soft tissue sarcomas do not spread directly into the bone, so bone rarely needs to be removed. If the bone must be removed, the surgeon may replace it with a bone graft or an internal prosthesis. An internal prosthesis, or endoprosthesis, may be made of metal and other materials. The surgeon implants into the healthy part of the bone. If a bone graft or an endoprosthesis is placed into the bone during limb-sparing surgery, more surgery may be needed in the future because these can become loose or break over time.
Surgery for a soft tissue sarcoma that develops in an arm or leg may involve removing the cancer and all or part of the limb. This is called amputation. Years ago, about half of all soft tissue sarcomas in a limb were treated by amputation. Today, amputations are done less than 5% of the time.
Amputation may be the only option if the tumour is large and has spread into important nerves, blood vessels or muscles. Removing these vital structures would leave a limb that doesn’t work well or would cause long-term problems. In these cases, a limb amputation may be the best option. An amputation may also be needed if the sarcoma has come back in the same limb after limb-sparing surgery.
The surgeon looks at imaging tests, such as MRI scans, to help decide how much of an arm or leg needs to be amputated. Muscle, soft tissue and skin are used to form a cuff around the amputated bone, which is called the stump. Right after amputation surgery, the stump is covered with a tight-fitting bandage to help shape it. Once the tissues of the stump are healed enough, you will be fitted for an artificial limb, or prosthesis.
Modern prostheses have improved the lives of many people who need to have a limb amputated. Most major centres have clinics devoted to caring for amputees. People who need to have their legs amputated below the knee can have near normal function. People with amputation above the knee can also return to activities surprisingly well.
In some cases, cancer has spread, or metastasized, to other organs and the original tumour and all the metastases cannot be removed by surgery. If removing the limb won’t completely remove the tumours, amputation is not done unless it can relieve pain or other symptoms caused by the primary tumour.
Skin grafts and tissue flaps
You may need skin and soft tissue reconstruction to fix tissue that is removed during surgery. The surgeon will take a skin graft or tissue flap from one part of the body to replace tissue where surgery was done. The area from where the graft or flap is taken is called the donor site. Reconstruction is often done at the same time as the surgery to remove the soft tissue sarcoma.
A skin graft uses a piece of skin taken from another part of the body. The graft is placed over the surgical wound and stitched in place.
If larger areas need to be covered, then a tissue flap may be used. Different types of tissue flaps may be used depending on where the tissue is needed and how large it is.
- A free flap uses skin taken from another part of the body, along with some of the tissue underneath and its blood vessels.
- A local or rotational flap uses tissue next to the wound to make the repair.
- A pedicle flap uses tissue from a donor site farther away, but close enough to keep the flap connected to its original blood supply.
Some muscle may also be included in the tissue flap to provide good coverage and function, especially with limb-sparing surgery.
In certain cases of advanced soft tissue sarcoma, surgery may be used to treat cancer that has spread to the lung, or lung metastasis. Surgery to remove a lung metastasis is called lung metastasectomy.
Surgery to remove a lung metastasis may be an option if:
- the primary cancer is controlled
- there are only a few (usually 3 or less) metastases
- there is a good chance that surgery will remove all of the tumour in the lung and you will still have enough lung function
- you are healthy enough to have surgery
The type of the surgery used depends on the size and location of the lung metastasis and the surgeon’s preference.
Find out more about treatment of lung metastases.
Surgery for soft tissue sarcoma can be very complex. The type of surgery you have and your recovery after surgery depend on the type of tumour and where it is in the body. Talk to your healthcare team at the soft tissue sarcoma clinic. They have expertise in treating these types of tumours and can let you know what to expect after surgery.
When you wake up after surgery, you may have several tubes in your body. After surgery, fluid and blood can build up in the area where the tumour was removed. The surgeon will often place tubes during surgery to drain this fluid and blood. Drainage tubes help lower the risk of infection. Infection is a common problem with limb-sparing surgery, especially when radiation therapy is given before surgery. The healthcare team removes the drainage tubes when there is little or no fluid draining from them.
Some people need major surgery to treat soft tissue sarcoma. You may need to stay in bed for the first few days after surgery. Getting up for the first time after surgery may seem difficult. If you had a tumour removed from an arm or leg, the limb will need to heal before you can use it very much. Your doctor will tell you when and how you can use your arm or leg after surgery.
If you need to have an amputation, you will need an artificial limb, or prosthesis. You will see a prosthetist before and after your surgery. This specialist will explain the types of prostheses you can have and fit you for a prosthesis.
Find out more about surgery and rehabilitation after treatment for soft tissue sarcoma. To make the decisions that are right for you, ask your healthcare team questions about surgery.