Diagnosis and treatment of soft tissue tumors

In the management of soft-tissue tumors, accurate diagnosis, using a combination of clinical, radiographic, and histological data, is critical in optimizing outcome. Radiographic diagnoses can be useful, but they cannot accurately predict histology or whether a lesion is benign or malignant. Therefore, all soft lumps that persist or grow should be biopsied if possible. Fine-needle aspiration biopsy is useful in differentiating benign from malignant lesions. Core-needle biopsies can yield a histological diagnosis when the sample is sufficiently large. When open biopsy is required, the skin incision must be carefully placed so that the biopsy site can be completely excised if the lesion is subsequently found to be malignant. Excisional biopsy should be used only for small lesions or when the surgeon is confident that the lesion is benign. If, following excision, the lesion is found to be malignant or desmoid, additional surgery with an adequate excision margin should be performed. In the resection of high-grade sarcomas treated by surgery alone or resistant to preoperative adjuvant therapies, a "curative (wide) margin" must be achieved. We occasionally use preoperative radiation with or without hyperthermia for malignant lesions in the vicinity of neurovascular structures where adequate surgical margins are unlikely to be achieved. The use of chemotherapy is justified only in small-cell sarcomas in which metastasis occurs frequently and chemotherapy is known to be effective. For high-grade spindle-cell or pleomorphic sarcomas, the value of adjuvant chemotherapy remains controversial and needs investigation.