Diagnosis of Soft tissue mass

DIAGNOSTIC IMAGING
Diagnostic imaging should be performed before any invasive
procedure to avoid the possibility of soft tissue swelling or
hemorrhage complicating the image interpretation.

Pretreatmentdiagnostic imaging is helpful for the ff:

1. Defining the size and anatomic location of a tumor and its
proximity to adjacent structures
2. Staging disease with respect to regional or metastatic
spread
3. Guiding percutaneous biopsy
4. Establishing whether a tumor is benign or malignant and
low grade or high grade
Ultrasonography
Ultrasonography may have a diagnostic role in
patients with soft tissue sarcoma who cannot
undergo MRI. Ultrasonography can also be a useful
adjunct to MRI when findings on MRI are
indeterminate and for delineating adjacent vascular
structures. Finally, ultrasonography can be used for
postoperative surveillance and to guide biopsies.
Computed Tomography
Chest CT should be performed to evaluate for
lung metastasis at presentation and before
any radical treatment. CT is also the preferred
imaging technique for evaluating
retroperitoneal sarcomas.
Magnetic Resonance Imaging.
• MRI is the most useful imaging modality for extremity
sarcomas because of its superior soft tissue contrast
resolution and multiplanar capabilities. MRI accurately
delineates muscle groups and distinguishes among bone,
vascular structures, and tumor.
• MRI may also be an important adjunct to cytologic analysis in
distinguishing benign lesions such as lipomas, hemangiomas,
schwannomas, neurofibromas, and intramuscular myxomas
from their malignant counterparts.
BIOPSY TECHNIQUE
Fine-Needle Aspiration
• At centers where cytopathologists have experience
with evaluation of mesenchymal tumors, fine-needle
aspiration is an acceptable method of diagnosing most
soft tissue sarcomas, particularly when the results
correlate closely with clinical and radiologic findings.
Fine-needle aspiration of primary tumors has a lower
diagnostic accuracy rate (60%–90%) than core needle
biopsy and is often not sufficient for establishing a
specific histologic diagnosis and grade.
Core needle biopsy
• safe, accurate, and economical and has become the preferred
technique for diagnosing soft tissue lesions
• accuracy of 93% in patients with musculoskeletal neoplasms.
• Sonography/CT guidance can prevent sampling of nondiagnostic
necrotic or cystic areas of the tumor and thus increase the positive
yield rate. Sonography/CT guidance also permits biopsy of tumors
in otherwise inaccessible locations and tumors located near vital
structures.
• The tissue sample obtained from core needle biopsy is usually
sufficient for several diagnostic tests, such as electron microscopy,
cytogenetic analysis, and flow cytometry. The reported
complication rate for core needle biopsy is less than 1%.
Incisional Biopsy
• recommend incisional biopsy when core needle biopsy cannot
produce adequate tissue for diagnosis or when findings on core
needle biopsy are nondiagnostic.
• Disadvantages of incisional biopsy include:
1. The need to schedule the procedure
2. The need for general anesthesia
3. High costs
4. Inappropriately placed incisions can necessitate more extensive
definitive resection to encompass the biopsy site
5. Complication ates up to 17% have been reported. Potential
complications include hematoma, infection, wound dehiscence,
and tumor fungation, any of which can delay definitive treatment.
Excisional Biopsy.
• Performed for easily accessible (superficial) extremity or truncal
lesions smaller than 3 cm.
• Rarely provides benefits over other biopsy techniques
• Wide en bloc excision is seldom performed as a diagnostic
procedure.
• When en bloc excision is done for diagnosis, the margin status is
often not adequately evaluated during pathologic assessment of
the specimen. Unless detailed descriptions of the surgical
procedure and the pathology specimen are provided, the margins
should be classified as uncertain or unknown, a classification
associated with the same prognosis as resection margins that are
positive for tumor cells.