Statistically speaking, a soft tissue mass in the extremities is likely to be a lipoma and is appropriately managed by general surgeons. However, there are occasions when it is actually a mischaracterized soft tissue sarcoma. These are best dealt with by specialized orthopaedic oncologists in order to avoid spreading the cancer to surrounding areas.
Robert Henshaw, MD, a board-certified orthopaedic oncology surgeon at Medstar Washington Hospital Center, discusses how to recognize when a mass is not a lipoma and when additional imaging and referrals should be made.
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Removals of Soft-Tissue Sarcomas: When to Make a Referral to a Specialist
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Learn more about Robert Henshaw, MD
Robert Henshaw, MD
Robert Henshaw, MD, is a board-certified orthopedic surgeon specializing in oncologic oncology, a field dedicated to the treatment of musculoskeletal tumors. Such tumors are rare and include a wide variety of benign and malignant diseases such as bone sarcomas (such as osteosarcoma, chondrosarcoma, Ewing's sarcoma), soft tissue sarcomas (such as synovial sarcoma, liposarcoma, malignant fibrous histiocytoma), as well as metastatic cancers affecting the extremities. As these diseases can occur at any age, Dr Henshaw routinely treats pediatric and adult patients, having operated on over 2700 tumor patients in his first 18 years of practice in Washington, D.C. Dr. Henshaw sees and treats patients from the entire mid-Atlantic region, along with referred patients from around the country and the world.Learn more about Robert Henshaw, MD
Transcription:
Removals of Soft-Tissue Sarcomas: When to Make a Referral to a Specialist
Melanie Cole (Host): Removal of soft tissue sarcomas by general surgeons can often fail and end up spreading the cancer to surrounding areas. When should a general surgeon make a referral to a specialist rather than performing the procedure themselves? My guest today is Dr. Robert Henshaw. He’s a Professor in Clinical Orthopedic Surgery and Orthopedic Oncology and the Vice Chairman of Orthopedic Surgery at MedStar Washington Hospital Center. Welcome to the show, Dr. Henshaw. Tell us typically how are soft tissue sarcomas treated and by whom?
Dr. Robert Henshaw (Guest): First of all thanks for having me on. This is a subject that’s dear to our heart because in my practice of over 20 years treating soft tissue sarcomas, we see a lot of patients that have had an unplanned procedure thinking that the mass that they had was in fact a lipoma. It was only after the fact that it was identified as a sarcoma. In general, the treatment of a soft tissue sarcoma is going to consist of a wide to radical resection, in other words a margin of a good normal tissue around the tumor itself, in order to minimize the risk of local recurrence.
Melanie: So, you are doing the wide local excision. Who is doing this typically and is there a reason a general surgeon should or should not be doing this procedure?
Dr. Henshaw: We do these wide local resections routinely for these tumors. The problem that we see time and time again is that tumor is misidentified from the get-go. The reason for this is because soft tissue sarcomas oftentimes present as a mass that’s painless in one of the extremities and can frequently be mischaracterized as a simple lipoma. So, the key to the proper treatment is knowing what you’re dealing with before you commit to any type of surgery.
Melanie: What is a good situation for the general surgeon?
Dr. Henshaw: General surgeons have always taken care of the majority of simple lipomas that patients present. From a statistical perspective, a soft tissue mass in the extremity is most likely going to be a lipoma. Our job is to try to help doctors recognize when a mass is not a lipoma and if there’s any question about it, that’s when additional imaging and referrals should always be made.
Melanie: And to whom? Are we looking at oncologists, orthopedic oncologists? Who is it you would like them to refer to?
Dr. Henshaw: The field of orthopedic oncology, which really has been present now for well over forty years, is devoted to dealing with sarcomas of the extremities but there are surgical oncologists that also deal with these type of tumors. I think the key to the proper treatment of any cancer patient is that the doctor taking care of the patient be familiar with the disease, know how to surgically remove it, and, most importantly, provide any additional aftercare.
Melanie: Why is that even more important when you’re talking about limb-sparing sarcoma surgery?
Dr. Henshaw: MSTS, which is the Musculoskeletal Tumor Society, has done several studies over the decades looking at causes for amputation and one of the identified risk factors is an inappropriately placed biopsy or surgical procedure prior to proper referral of the patient. So, in order to ensure that patients get the optimal care, we want to identify the tumor and make an appropriate referral.
Melanie: And, are grafts, or muscles, tendons replacing bones and joints, done at the same time as the tumor removal?
Dr. Henshaw: Many times, a complex resection will require some form of reconstruction and we often times will do that at the time of the primary resection. But these, of course, are for very large deep-seated tumors. The ones where the general surgeon may run into problems is the patient presenting with a superficial or seemingly superficial mass that he mistakes for a lipoma when, in fact, it’s a sarcoma, and these are the cases that often times can result in litigation.
Melanie: What about some adjunct therapies to go along with this type of surgery, the intra-arterial chemotherapy or radiation? Are you doing some of these at the same time?
Dr. Henshaw: Depending upon the size and the stage and the aggressiveness of the tumor, some form of preoperative or adjuvant treatment, whether it is chemotherapy or radiation or a combination of both, many times we will offer to the patient. But, for relatively small lesions, especially if they’re low grade, often times a good surgical procedure in and of itself can be curative.
Melanie: For the patient, is this laparoscopic when you do the wide local incision?
Dr. Henshaw: No, laparoscopic techniques are useful for looking inside of cavities, such as the abdominal cavity, or arthroscopic techniques for looking inside the chest. What we’re dealing with are tumors that are actually arising within muscle bone and soft tissues. There’s no cavity to put a scope into.
Melanie: In just the last few minutes, would you like to cite some case studies that give evidence to the fact of a general surgeon and to submitting this to another surgeon that might be more qualified in this area?
Dr. Henshaw: We actually just published a paper in the Journal of the American Academy of Orthopedic Surgeons looking at the risk factors leading to an inappropriate surgery or biopsy for patients presenting with soft tissue masses. In there, we present numerous case examples of what can happen if a patient is not appropriately imaged and worked up prior to surgery. It turns out that patients that have had an inappropriate or unplanned surgical resection are at higher risk of complications, they require more extensive surgery, are more likely to require flap reconstruction, radiation and other adjuvant techniques, and there is a significant increase in the risk of litigation regarding the original surgery that was done for that patient.
Melanie: Dr. Henshaw, would you like to just speak very quickly about the pathology and the stage in the clinical presentation so that other surgeons listening can know what to look for?
Dr. Henshaw: Again, it comes down to the appropriate identification of a soft tissue mass. If you have a very typical subcutaneous, rubbery, non-tender mobile mass, statistically that’s going to be a lipoma. It’s those cases where something is a little bit different: the tumor feels different, there’s skin involvement, the tumor’s not mobile, it might extend deeper than a standard lipoma. Those are the cases that should raise a red flag that this is something that should be imaged and evaluated before attempting any type of surgical procedure. And for soft tissue tumors, MRI is by far the easiest and best study to evaluate the tumor. If it is, in fact, a benign lipoma, the scan will suggest that and the simple excision can then be performed. But, if there’s anything abnormal or worrisome on the MRI, that then is a perfect segway into a referral to somebody who has an oncologic background.
Melanie: Thank you so much for being with us today, doctor, it’s really great information. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to medstarwashington.org. That’s medstarwashington.org. This is Melanie Cole. Thanks so much for listening.
Removals of Soft-Tissue Sarcomas: When to Make a Referral to a Specialist
Melanie Cole (Host): Removal of soft tissue sarcomas by general surgeons can often fail and end up spreading the cancer to surrounding areas. When should a general surgeon make a referral to a specialist rather than performing the procedure themselves? My guest today is Dr. Robert Henshaw. He’s a Professor in Clinical Orthopedic Surgery and Orthopedic Oncology and the Vice Chairman of Orthopedic Surgery at MedStar Washington Hospital Center. Welcome to the show, Dr. Henshaw. Tell us typically how are soft tissue sarcomas treated and by whom?
Dr. Robert Henshaw (Guest): First of all thanks for having me on. This is a subject that’s dear to our heart because in my practice of over 20 years treating soft tissue sarcomas, we see a lot of patients that have had an unplanned procedure thinking that the mass that they had was in fact a lipoma. It was only after the fact that it was identified as a sarcoma. In general, the treatment of a soft tissue sarcoma is going to consist of a wide to radical resection, in other words a margin of a good normal tissue around the tumor itself, in order to minimize the risk of local recurrence.
Melanie: So, you are doing the wide local excision. Who is doing this typically and is there a reason a general surgeon should or should not be doing this procedure?
Dr. Henshaw: We do these wide local resections routinely for these tumors. The problem that we see time and time again is that tumor is misidentified from the get-go. The reason for this is because soft tissue sarcomas oftentimes present as a mass that’s painless in one of the extremities and can frequently be mischaracterized as a simple lipoma. So, the key to the proper treatment is knowing what you’re dealing with before you commit to any type of surgery.
Melanie: What is a good situation for the general surgeon?
Dr. Henshaw: General surgeons have always taken care of the majority of simple lipomas that patients present. From a statistical perspective, a soft tissue mass in the extremity is most likely going to be a lipoma. Our job is to try to help doctors recognize when a mass is not a lipoma and if there’s any question about it, that’s when additional imaging and referrals should always be made.
Melanie: And to whom? Are we looking at oncologists, orthopedic oncologists? Who is it you would like them to refer to?
Dr. Henshaw: The field of orthopedic oncology, which really has been present now for well over forty years, is devoted to dealing with sarcomas of the extremities but there are surgical oncologists that also deal with these type of tumors. I think the key to the proper treatment of any cancer patient is that the doctor taking care of the patient be familiar with the disease, know how to surgically remove it, and, most importantly, provide any additional aftercare.
Melanie: Why is that even more important when you’re talking about limb-sparing sarcoma surgery?
Dr. Henshaw: MSTS, which is the Musculoskeletal Tumor Society, has done several studies over the decades looking at causes for amputation and one of the identified risk factors is an inappropriately placed biopsy or surgical procedure prior to proper referral of the patient. So, in order to ensure that patients get the optimal care, we want to identify the tumor and make an appropriate referral.
Melanie: And, are grafts, or muscles, tendons replacing bones and joints, done at the same time as the tumor removal?
Dr. Henshaw: Many times, a complex resection will require some form of reconstruction and we often times will do that at the time of the primary resection. But these, of course, are for very large deep-seated tumors. The ones where the general surgeon may run into problems is the patient presenting with a superficial or seemingly superficial mass that he mistakes for a lipoma when, in fact, it’s a sarcoma, and these are the cases that often times can result in litigation.
Melanie: What about some adjunct therapies to go along with this type of surgery, the intra-arterial chemotherapy or radiation? Are you doing some of these at the same time?
Dr. Henshaw: Depending upon the size and the stage and the aggressiveness of the tumor, some form of preoperative or adjuvant treatment, whether it is chemotherapy or radiation or a combination of both, many times we will offer to the patient. But, for relatively small lesions, especially if they’re low grade, often times a good surgical procedure in and of itself can be curative.
Melanie: For the patient, is this laparoscopic when you do the wide local incision?
Dr. Henshaw: No, laparoscopic techniques are useful for looking inside of cavities, such as the abdominal cavity, or arthroscopic techniques for looking inside the chest. What we’re dealing with are tumors that are actually arising within muscle bone and soft tissues. There’s no cavity to put a scope into.
Melanie: In just the last few minutes, would you like to cite some case studies that give evidence to the fact of a general surgeon and to submitting this to another surgeon that might be more qualified in this area?
Dr. Henshaw: We actually just published a paper in the Journal of the American Academy of Orthopedic Surgeons looking at the risk factors leading to an inappropriate surgery or biopsy for patients presenting with soft tissue masses. In there, we present numerous case examples of what can happen if a patient is not appropriately imaged and worked up prior to surgery. It turns out that patients that have had an inappropriate or unplanned surgical resection are at higher risk of complications, they require more extensive surgery, are more likely to require flap reconstruction, radiation and other adjuvant techniques, and there is a significant increase in the risk of litigation regarding the original surgery that was done for that patient.
Melanie: Dr. Henshaw, would you like to just speak very quickly about the pathology and the stage in the clinical presentation so that other surgeons listening can know what to look for?
Dr. Henshaw: Again, it comes down to the appropriate identification of a soft tissue mass. If you have a very typical subcutaneous, rubbery, non-tender mobile mass, statistically that’s going to be a lipoma. It’s those cases where something is a little bit different: the tumor feels different, there’s skin involvement, the tumor’s not mobile, it might extend deeper than a standard lipoma. Those are the cases that should raise a red flag that this is something that should be imaged and evaluated before attempting any type of surgical procedure. And for soft tissue tumors, MRI is by far the easiest and best study to evaluate the tumor. If it is, in fact, a benign lipoma, the scan will suggest that and the simple excision can then be performed. But, if there’s anything abnormal or worrisome on the MRI, that then is a perfect segway into a referral to somebody who has an oncologic background.
Melanie: Thank you so much for being with us today, doctor, it’s really great information. You’re listening to Medical Intel with MedStar Washington Hospital Center. For more information you can go to medstarwashington.org. That’s medstarwashington.org. This is Melanie Cole. Thanks so much for listening.