SOFT TISSUE TUMOR DIAGNOSIS AND MANAGEMENT

SOFT TISSUE TUMOR

 Tumor is an abnormal lump or swelling in the body, but in terms of specific tumor is a lump caused by neoplasms. Clinically, the tumor divided into groups such as cystic neoplasms and nonneoplasma, due to inflammation or hypertrophy.
 Neoplasms may be malignant or benign. Malignant neoplasms or cancers occur because of the rise and proliferation of cells in an uncontrolled manner so that these cells continue to grow and deform the growth of organ function. Cancer, carcinoma, or sarcoma growth infiltrate (infiltrative) into the surrounding tissue while destroying (destructive), can spread to other parts of the body, and is generally fatal if left unchecked. Benign neoplasms grow with firm boundaries and does not creep, no damage, but pressing up and the surrounding tissue (expansive), and generally do not metastasize, such as lipoma.
 Tumor cells are the body's cells are transformed and grow out of control autonomic normal cell growth so that these cells differ from normal cells in the form and structure. Differences in the nature of tumor cells depends on the magnitude of the deviation in growth, and ability to conduct infiltration and cause metastasis.

TUMOR AND CANCER
 When the skin over the lump is still good and no injuries in the form of ulcers, possibly derived from the lump under the skin of an existing soft tissue under the skin or can be of the ribs, but the greatest possibility of soft tissue is relatively fast when the magnifying power in a brief.
Soft tissue is part of the body that lies between the epidermis and the bone and visceral organs derived from mesoderm. Belonging to the soft tissues include muscles, tendons, connective tissue, fat and synovial tissue. Soft tissue tumors can occur throughout the body from head to toe. There are soft tissue tumors are benign and some malignant. Malignant tumors or cancers known as soft tissue or soft tissue sarcoma Soft Tissue Sarcoma (STS).
Malignant tumors mesenchym not from bone, tissue or visceral parenchym commonly called Soft Tissue Sarcoma. (SJL). Malignancy is found in all age groups from infants to adults or older. Although the number of events is only 1-2% of all malignancies, but sarcomas have specific biological temperament that has the ability to infiltrate into surrounding tissue and often lead to rapid recurrence after surgery. Usually occurs in the body parts that have a thicker fat tissues, such as the buttocks, forearms, upper arms retroperitonium.



 Soft tissue cancers, including cancers of rare, insidensnya only about 1% of all malignancies were found in adults and 7-15% of all malignancies in children. Can be found in all age groups. In children, most often around age 4 years and in adults most at the age of 45-50 years.
Etiology
No one is certain
A. Trauma: although not yet proven, but found the relationship between the occurrence of trauma, burns, fractures with SJL
2. Chemicals: Vinylchloride, Herbicides, Chlorophenol
3. Post-radiotherapy
4. Exposed to radium
5. Predisposition to certain conditions:
• Lymphoedema post-mastectomy
• Neurofibromatosis
• Paget's disease
• Retinoblastoma
6. Virus

 The most common location is on the lower limbs that is equal to 46% where 75% of them are above the knee, especially in the thigh.
In the upper limb from the upper arm, forearm until your palm around 13%. 30% of the body parts on the outside and inside, such as the abdominal wall, and also the soft tissue in the abdomen or near the kidneys or called the retroperitoneum. In the head and neck about 9% and 1% in other places, including in the chest.
Or metastatic spread of cancer is most often via the blood vessels to the lungs (most commonly), to the liver, bone. Rarely spreads through the lymph nodes.
Symptoms and signs are non-specific soft tissue cancer, depending on the location where the tumor is located, the symptoms are generally in the form of a lump under the skin that does not hurt. Only a few patients who complain of pain, which usually occurs due to hemorrhage or necrosis in the tumor, and it could be because of the emphasis on the edge of the nerves.
Benign soft tissue tumors usually grow slowly, not rapidly enlarging, soft when touched and moved when the tumor is still relatively easy to be moved from the surrounding tissue and spread to distant places.
Soft tissue cancers generally grow relatively fast growing, evolving into a hard lump, when it moved a bit difficult to move and can spread to distant places to the lungs, liver and bones.
If the size of the cancer was so large, it can cause ulcers and bleeding in the skin above it.
 The most common method of diagnosis in addition to clinical examination, is by examination of biopsy, could be by fine needle aspiration biopsy (FNAB) or direct tumor tissue biopsies from incisional biopsy of the tumor tissue biopsy to take part as an example when a large tumor size.
When the size of a small tumor, a biopsy can be performed with the removal of the tumor. Tissue biopsy examined by a doctor of anatomic pathology, and can be known whether a soft tissue tumor is benign or malignant. When malignant, it can also be viewed and determined tumor histologic subtype, which is very useful for determining selantutnya action.
Pathologic tumor classification based on the results of microscopic examination of tissue and tumor cells. Microscopic examination of this seems a very varied picture of malignancy, ranging from relatively benign to the most malignant. At one organ may occur one or more neoplasms that are different.
 When the diagnosis is established, then the treatment depends on the type of soft tissue tumor itself. If benign, then simply just benjolannnya is being named and no other additional measures.
 If the result is a malignant soft tissue tumor or cancer, the treatment is not only the tumor is being named, but also the surrounding tissue to tumor-free according to predetermined rules, depending on where the location of this cancer. Action in the form of treatment is wide excision surgery.
The use of radiotherapy and chemotherapy only as a complement, but not so good response, except for soft tissue cancers derived from embryonal rhabdomyosarcoma muscle called.
 For the large size of cancer, after surgery, plus radiotherapy. In the soft tissue cancer that is advanced, with a large size, the risk of recurrence after surgery can still occur. Therefore, after surgery the patient usually must often control to monitor the presence or absence of recurrence in the operative area or place of distant recurrence of metastasis in the lung, liver or bones.
Here is one example of soft tissue tumors (Soft Tissue Tumors).

C. Lipoma
A. Definition
Lipoma is a benign mesenchymal tumor (benign mesenchymal tumors) derived from adipose tissue (adipocytes).

2. Lipoma Variant
a. Adenolipoma, variations in breast lipoma. Often have marked fibrotic component. Usually regarded as a hamartoma.
b. Angiolipoma contains many small blood vessels.
c. Lipoma of the heart (cardiac lipomas) can calcify following fat necrosis.

3. Liposarcoma originating from lipoma, depending on the clinical picture of the location of the tumor and usually as a mass may be palpable. Radiological picture of the mass contained in the fat tissue is not specific. Fat usually is not detected. In general the picture is more radioopaq.
Liposarcoma is a soft tissue tumor that most radiosensitif.

Pathologic classification
Tumor (tumere derived from the Latin, meaning "swelling"), is one of the five characteristics of inflammation. However, the term is now used to describe the growth of biological tissue is not normal. As a malignant growth can diogolongkan (alignan) or benign (benign).
Malignant tumors are called cancer. Cancer has the potential to invade and destroy adjacent tissues and create metastases. Benign tumors do not invade nearby tissue and spread the seeds of metastasis, but can be grown locally to be great. They usually did not recur after removal by surgery.
Based on the initial tissue, tumors can be divided into:
• tumors of epithelial origin.
o squamous epithelium: squamous cell papilloma, squamous cell carcinoma
o transitional epithelium: transitional cell papilloma, transitional cell carcinoma
o Basal cell (skin only): basal cell carcinoma
o glandular epithelium: adenoma, cystadenoma, adenocarcinoma
o tubules epithelium (kidney) renal tubular adenomas, renal cell carcinoma (tumor Grawitz)
o hepatocytes: hepatocellular adenoma, hepatocellular carcinoma
o bile ducts epithelium: cholangiocellular adenoma, cholangiocellular carcinoma
o melanocytes: melanocytic nevus, malignant melanoma
• tumors of mesenchymal origin:
o related tissue:
 fibroma, fibrosarcoma
 myxoma, myxosarcoma
 chondroma, chondrosarcoma
 osteoma, osteosarcoma (osteogenic sarcoma)
 lipoma, liposarcoma
o muscle:
 leiomyoma, leiomyosarcoma
 rhabdomyoma, rhabdomyosarcoma
o endothelium:
 hemangioma (capillary h., Cavernous h.), Glomus tumor, hemangiosarcoma, Kaposi sarcoma
 lymphangioma, lymphangiosarcoma
• Tumor blood cells:
o hematopoietic cells: leukemia
o lymphoid cells: non-Hodgkin lymphoma, Hodgkin lymphoma
• germ cell tumors:
o Teratoma (mature teratoma, immature teratoma)
Based on histopathological examination can be divided into:
• G1: Well differentiated (good)
• G2: Moderately differentiated (moderate)
• G3: poorly differentiated (bad)
Based on metastasis
SJL biological temperament is usually haematogenous spread to surrounding organs such as lungs, brain, bone.

Stage / Staging
The system used is G (Grade), T (tumor), N (nodules), M (metastasis) used by the UICC (Union Internationale Contre de Cancer) and AJS (American Join Comittee for Cancer Staging and End Result Reporting)
G (Grading)  assess the degree of malignancy
• G1: Low Grade
• G2: Moderate Grade
• G3: High Grade
T (Primary Tumour)  assess tumor size and infiltration into surrounding tissue
• T0: no palpable tumor
• T1: tumor <5 cm
• T2: tumor> 5 cm
• T3: tumor has invaded the bone, blood vessels and nerves.
N (Nodal)  assess the size of lymph nodes
• N0: no lymph node metastasis
• N1: There is metastasis to lymph nodes
M (metastasis Far)  rate of metastases to other organs (such as lung, bone, brain)
• M0: no distant metastasis
• M1: distant metastases are



Stadium Group
A Stage I: T1 N0 M0 G1
IB: T2 N0 M0 G1
IIA: T1 N0 G2 MO
IIB: T2 N0 M0 G2
IIIA: T1 N0 M0 G3
IIIB: T2 N0 M0 G3
IIIC: Any G T1-2 N1 M0
IVA: Any N M0 T3 G
IV B: Every G each T3 any N M1
Diagnostic
• SJL is still small: no complaints, no pain
• The new enlarged SJL will cause complaints in people, which gives emphasis on signs around the network include:
- Neuralgia
- Paralysis
- Ischemia
- Symptoms of obstructive if there is an emphasis on the digestive system
• To determine the grading, required a biopsy of the tumor tissue
Tumors> 3 cm incision and a biopsy is performed in <3 cm biopsy done eksisional. Information of this type of sarcoma and its ferocity deerajat very important for treatment strategies.

Investigations
- Photos of thoracic
- CT Scan in the vicinity of the tumor: see invasion of tissue and bone destruction
- Angiography: if there are signs of pressure vessels
Treatment:
A. Primary Tumor
• Tumor resektabel
i. Radical surgery, performed with the following requirements:
• Tumors can be lifted all
• Limit the incision, free of malignant tumor cells
There are two kinds of surgical procedures are:
- Local wide excision: for G1 and the tumor is still localized
- Wide excision radical: to G3 and the tumor has spread regionally / KGB
If necessary can be given combination therapy are:
Surgery + radiotherapy / chemotherapy
To prevent the micrometastases:
Surgery + radiotherapy + chemotherapy
• The tumor is inoperable
Radiation + chemotherapy
2. Recurrent tumors (relapse):
Surgery is not adekwat and tumor manipulation during surgery is a cause of local recurrences. Some things to note are:
• Re-evaluate the degree of malignancy by incisional biopsy
• The return value in considering the existence of tumor re-excision of the tumor for curative purposes.
The type of operation
• extensive resection
• Resection compartemen
• Limb-Sparing surgery
• Amputation
Prognosis
Prognosis depends on:
• The size of tumor
• Location of tumor
• Depth of tumor
• The degree of malignancy
• Cells necrosis (assessed on histopathologic examination)

5 Years Survival Rate
Stage I: Low Grade 85-90%
Stage II: High Grade 70 -80%
Stage III: Hugh Grade 45-55%
Stage IV: Any Grade 0-20%

Follow Up
In the first 2 years
• Control every 3 months
• Photos thoracic every 6 months
Within 2-5 years
Controls every 6 months
After 5 years
Photo thoracic and control every year
 sarkomaekstremitas optimal therapy after recurrence 5-10 years
75% of recurrences occurred within the first two years of follow-up should be intensive 

REFERENCES



Copelnd, E.M dan Bland, F.I., Buku Ajar Bedah, Sabbiston Bagian 1, EGC, Jakarta, 1995.
Reksoprodjo S.arkoma Jaringan Lunak, Kumpulan Kuliah Ilmu Bedah cetakan pertama, Jakarta : Binarupa Aksara, 1995 : 401
Sjamsuhidajat R, de Jong W, Buku Ajar Ilmu Bedah Edisi revisi, Jakarta : EGC, 1997 : 131
http://emedicine.medscape.com/article/391272-overview
http://www.elitha-eri.net/2008/01/04/lipoma-gumpalan-lemak-lembut/
http://en.wikipedia.org/wiki/Liposarcoma