Background – Limb salvage surgeries for soft tissue sarcomas (STS) leads to significant amount of morbidity and fear psychosis among the affected individual. We looked into the potential complications and its implications.

Patients & Methods – Retrospective review of 96 patients over a period of 5 years from 1999 to 2004 with a minimum follow up of 8 months. Complete data of every patient was reviewed with particular emphasis on post op complications.

Results – 72 patients had STS in their lower limbs while the rest had in the upper limbs. 53 tumours were either at the level of knee or above the knee while 19 were found below the knee. The anterior compartment of the thigh was the most common site (13) with Vastus Lateralis being the commonly involved muscle. Liposarcoma was the commonest tumour (22) followed by Leiomyosarcoma (19), Fibro sarcoma (14), Synovial Sarcoma (12), Rhabdomyosarcoma (10), Histiocytoma (9) and other rare sarcomas. 61 patients had wide local excision, 17 had radical excision and 12 had marginal excision. 6 patients had palliative treatment only due to extensive metastasis (mets). 38 patients had post op radiotherapy. The average interval between presentation and definitive treatment was 28 days. 22 of the 71 patients (31 %) with no mets pre op. developed mets during follow up. The commonest problem in the post op period is inadequate skin cover which required skin grafting in 17 cases and flap cover in 3. Three of the skin grafts got necrosed due to radiotherapy. Local recurrence was the next most common complication (12 patients) along with equal number of patients with lymphaedema. Seroma/Haematoma was noted in 8 patients but none required drainage. There were 7 cases of superficial infection and one deep infection. Fixed Flexion Deformity at knee of > 10 0 was noted in 5 cases. Intractable neurological pain was noted in 3 cases involving the upper limb and one involving the lower limb. 3 developed skin rashes after radiotherapy. 2 had ulnar nerve palsy and one had foot drop. DVT occurred in 3 patients. Stump neuroma created problems in 2 cases and 2 patients ended up with below knee amputation. Another notable feature was the fear psychosis among the patients about benign swellings that were present in other parts of their body either before or after surgery which resulted in 11 surgeries but none proved to be malignant. As on 31-3-2005, 39 were dead and the rest were alive. The average life span of the patients who died from the time of confirmed diagnosis was 23 months.

Discussion – There is a plethora of complications that can occur following extensive resection of huge tumours in the extremities. This may involve sacrificing neuro-vascular structures to achieve adequate clearance. In spite of this, there is evidence of frequent local recurrences and distant metastatic spread. There is still some lack of awareness among the public about innocuous looking swellings and they present late with distant metastasis when the prognosis becomes poor.

Conclusion –

Significant complications can occur after sarcoma surgeries.

Background: To look into the incidence of lymphatic spread in Soft Tissue Sarcomas (STS) of the extremities and its relevance to the patient’s prognosis.

Patients & Methods: Retrospective review of 96 patients over a period of 5 years from 1999 to 2004 with a minimum follow up of 8 months. Complete data of every patient was reviewed with particular emphasis on lymph node and distant metastasis. All the patients were seen by one consultant and the histology reports were given by one Pathologist. 2 consultant radiologists were also involved in giving reports.

Results: There were 39 males and 57 females with an average age of 51 years. The average duration of swelling at presentation was 6 months. There was a strong family history of cancer in first degree relatives in 23 patients (24%). Liposarcoma was the commonest tumour (22) followed by Leiomyosarcoma (19), Fibro sarcoma (14), Synovial Sarcoma (12), Rhabdomyosarcoma (10), Histiocytoma (9) and other rare sarcomas. The Trojani grade of the tumours was Grade 1 = 36, Grade 2 = 39 & Grade 3 = 21. No metastasis (mets) were found during pre op. screening in 71 patients (74%) while 11 (12%) had lung mets, 9 (10 %) had lymph node involvement and 5 had liver involvement (4 %). 4 had multiple organ involvement on presentation. All except 6 patients had either wide local or radical excision of the tumour. The average interval between presentation and definitive treatment was 28 days. 9 of the patients with lymph node mets underwent nodal clearance during primary surgery. 2 turned out to be reactive hyperplasia while 7 proved to be malignant. 22 of the 71 patients (31 %) with no mets pre op. developed mets during follow up at an average duration of 11 months (11 to lungs, 8 to regional lymph nodes, 2 to liver and one to bone. 4 patients had multiple mets) In addition to this, there was local recurrence in 12 patients of whom 9 had incomplete excision during primary surgery. Of the total 15 patients who had proven lymph node mets, 5 came from Rhabdomyosarcoma, 4 from Leiomyosarcoma, 3 each from Lipo & Synovial sarcoma. The average life span in patients with lymph node involvement was 13 months in total when compared to 31 months for others. As on 31-3-2005, 39 were dead and the rest were alive. The average life span of the patients who died from the time of confirmed diagnosis was 23 months. The average life span for Rhabdomyosarcoma was 8 months, Histiocytoma was 12 months, Liposarcoma was 19 months, Leiomyosarcoma was 28 months and Synovial sarcoma was 36 months. Patients with Trojani grade 3 STS died at an average of 9 months when compared to 38 months for grade 1.

Discussion: There is a 16% spread to regional lymph nodes. It appears that lymph node involvement is indicative of micrometastatic disease elsewhere. Excision of the lymph nodes during primary surgery did not improve the life expectancy.

Conclusion:

Lymph node involvement is a poor prognostic sign

Purpose of Study – The unusual presentation of this case posed a diagnostic dilemma between a chronic haematoma and soft tissue sarcoma even after full investigation and biopsy. Salient points to differentiate between the two are discussed along with literature review.

Case Report – A 61 year old gentleman presented with sudden increase in size of an already existing swelling over the mid third of right leg associated with throbbing pain & foot drop of 4 months duration. There was no recent history of trauma or bleeding abnormalities but there was a vague history of injury to his leg during his late teens. Clinical signs showed features suggestive of malignancy with engorged veins and diffuse margins with complete foot drop (Fig 1 & 2). X-rays showed calcifications within the substance of the swelling along with proximal tibiofibular synostosis (Fig 3). MRI scan revealed a well encapsulated mass between the peroneal muscles mechanically compressing the common peroneal nerve (Fig 4). Trucut biopsy showed cholesterol clefts and areas of dystrophic calcification characteristic of chronic haematoma (Fig 5). Patient successfully underwent enucleation of the swelling along with cutaneofascial suture to obliterate the dead space leading to complete recovery of foot drop. Biopsy confirmed a Chronic Haematoma.

Discussion – Reid et al first used the term chronic expanding haematoma for haematomas that persisted and increased in size more than a month after the initiating haemorrhage. The cause of initial haemorrhage is most commonly trauma which results in displacement of skin and subcutaneous fatty tissue from more deeply located fixed fascia with formation of blood filled cysts surrounded by dense fibrous tissue. Factors in the blood-clotting cascade are said to be associated with an inflammatory reaction leading to additional bleeding from fragile capillaries and thus to additional inflammation, hence setting up a self-perpetuating process.

Although the MRI & biopsy results in this case were reassuring, the clinical scenario of sudden foot drop with increase in pain point more towards a malignant process rather than a benign condition. Some salient points to differentiate the two include that sarcoma have no history of trauma and the duration of symptoms is longer in haematoma than sarcoma. Also, sarcomas usually involve deeper structures while haematoma occur in superficial layers. It should also be noted that several soft tissue sarcoma themselves commonly reveal haemorrhagic or cystic changes. Other differential diagnosis includes myositis ossificans and tumoral calcinosis.

Conclusion – It is difficult to differentiate between chronic haematoma and soft tissue sarcoma based on clinical findings alone. X-ray and biochemical tests are always essential to rule out any fracture or bony mass but MRI is the gold standard and biopsy is the only way to rule out a malignant tumour. Surgical excision of the swelling including the fibrous pseudocapsule along with cutaneofascial suture to obliterate the dead space is the treatment of choice for chronic haematoma because aspiration of the fluid or incomplete excision could lead to recurrence, continued growth or a chronic draining sinus with or without infection.