CASE PRESENTATION , DISCUSSION AND SHARING OF INFORMATION ON HEAD TUMORS
Roberto N. Gonzales Jr. MD.
Department of Surgery
Ospital ng Maynila Medical
Center
R.C.
40/M
From Tondo, Manila
CHIEF COMPLAINT:
Mass on Occipital area
HISTORY OF PRESENT ILLNESS
3 years PTA (+) small
mass (1x1 cm) on occipital area
(-) accompanying ssx
(-) consultation
(-) meds
8 mos PTA (+)
increase in size of occipital mass
(-) pain
No consultation
1 Day PTA (+) further increase
in size
CONSULT
Past Medical History:
No
history of previous hospitalization nor operation
(-)
DM, (-) Asthma (-) heart dse
Family History
no heredofamilial dse
Personal and Social History
Non- smoker, non- alcoholic beverage drinker
Review of System
(+) weight loss (30% in 8 mos)
(+) easy fatiguability
(+) Dyspnea on effort
(+) loss of appetite
PHYSICAL EXAMINATION
Conscious, coherent, ambulatory
BP 100/70 PR 98 RR 26
T 37.9’C
SHEENT: Pale skin and palpebral conjunctiva, anicteric
sclerae, no TPC, no CLAD
PHYSICAL EXAMINATION
15x16 cm Fungating, Fleshy, foul smelling mass on occipital area
(6x6 cm )
PHYSICAL EXAMINATION
CHEST/LUNGS: SCE, no retractions, clear BS
HEART: adynamic precordium, NRRR, no
murmur
ABDOMEN: Soft abdomen with normoactive bowel sounds,
(-) tenderness , (-) organomegaly , (-) mass
PHYSICAL EXAMINATION
Extremities:
No inguinal lymph nodes
Pull and equal pulses
SALIENT FEATURES
40/M
Mass on Occipital area
Fungating, Fleshy, foul smelling
Signs & Symptoms of anemia
Pallor, easy fatiguability, Dyspnea
on effort
weight loss (30% in 8 mos)
PARACLINICAL DIAGNOSTIC PROCEDURE
DO I NEED A PARACLINICAL DIAGNOSTIC PROCEDURE?
yes
To increase the degree of certainty of my primary clinical diagnosis
To know the extent of the tumor
Paraclinicals
Paraclinicals
Biopsy
Paraclinicals
Paraclinicals
Skull X-Ray
PRE-TREATMENT DIAGNOSIS
PRIMARY DIAGNOSIS:
Malignant
soft tissue tumor (95%)
SECONDARY DIAGNOSIS:
Benign
soft tissue tumor (5%)
PARACLINICAL DIAGNOSTIC PROCEDURE
DO I NEED ANOTHER PARACLINICAL DIAGNOSTIC PROCEDURE?
yes
To ascertain absence of metastasis
Paraclinicals
Paraclinicals
Chest X- Ray
Normal
PRE-TREATMENT DIAGNOSIS
PRIMARY DIAGNOSIS:
Soft tissue Sarcoma without metastasis
( T2b, N0, M0 Stage III) (95%)
SECONDARY DIAGNOSIS:
Soft tissue Sarcoma with
metastasis
( T2b, N0, M1 Stage IV)
(5%)
TREATMENT GOALS
Soft Tissue Sarcoma
Remove the lesion
Prevent recurrence
Reconstruction/Cosmesis
Malignant Soft-Tissue Lesion
Malignant Soft-Tissue Lesion
TREATMENT PLAN
Wide Excision with Trapezius Myocutaneous Flap
PREPARATION and MONITORING
PSYCHOSOCIAL SUPPORT
SCREENING FOR MEDICAL PROBLEMS:
CHEST X-RAY - normal
ECG - normal
CBC
PREPARATION and MONITORING
OPTIMIZE PHYSICAL CONDITION
Correct anemia
Adequate hydration
PROPHYLACTIC ANTIBIOTICS
PREPARATION and MONITORING
Operative Technique
Patient in prone position under GETA
Asepsis/Antisepsis
Sterile drapes placed
Operative Technique
Elliptical incision around the base of the mass with 2 cm margin of normal tissue, carried down to the
periosteum
Operative Technique
Trapezius myocutaneous flap created
Operative Technique
Secondary defect closed by creating rotational local flap (spinwheel)
Operative Technique
Closure with staples
Operative Technique
Correct instrument, needle and sponge count
Patient tolerated the procedure
Peri-operative Monitoring
Total fluid given - 1,000 cc + 500
Dextran
Total Blood given – 1 u FWB
Estimated Blood loss – 1, 000 cc
Urine output – 300 cc
OR time ( 1pm- 5:30 pm) 4 ½ hrs
OPERATION DONE
Wide Excision with Trapezius Myocutaneous Flap
POSTOPERATIVE DIAGNOSIS
Histopathology Report
High-Grade Spindle cell Sarcoma
Differentials include
Myofibroblastic Sarcoma
Angiosarcoma
Negative for tumor- Basal Surgical margin
SURGICAL TREATMENT
POST-OPERATIVE CARE
SUPPLY THE BASIC NEEDS OF THE PATIENT
COMFORT
ANALGESICS
MEDICATIONS – ANTIBIOTICS
FLUIDS AND ELECTROLYTES
SUPPORT ORGAN FUNCTION
WOUND CARE
MONITORING FOR COMPLICATIONS
ADVICE ON
PSYCHOLOGICAL AND FUNCTIONAL REHABILITATION
HOME CARE
FOLLOW-UP PLAN
Follow-up Plan
Follow-up Plan
Postoperative Radiation Therapy
given 3 to 4 weeks after surgery
Conventional fractionation is 1.8 to 2 Gy per day, administered 5 days each week
for 3 to 7 weeks. (30-70 Gy)
SURGICAL TREATMENT
POST-OPERATIVE CARE
RESOLUTION OF THE HEALTH PROBLEM
LIVE PATIENT
NO COMPLICATION
NO DISABILITY
SATISFIED PATIENT
NO MEDICO-LEGAL SUIT
DISCUSSION AND SHARING OF INFORMATION
Sarcomas
are a heterogeneous group of tumors that arise predominantly from the embryonic
mesoderm, but also can originate, as does the peripheral nervous system, from the ectoderm.
Subtypes
<!--[if !supportLists]-->q <!--[endif]-->Soft
tissue sarcomas- largest of these groups
<!--[if !supportLists]-->q <!--[endif]-->bone
sarcomas (osteosarcomas and chondrosarcomas, Ewing's sarcomas )
<!--[if !supportLists]-->q <!--[endif]-->Peripheral
primitive neuroectodermal tumors.
Clinical Presentation
most commonly presents as an asymptomatic mass.
often grow in a centrifugal fashion and compress surrounding normal structures.
impingement on bone or neurovascular bundles produces pain,
edema, and swelling.
soft tissue sarcomas
annual incidence in the United States for 2007 is estimated
to be about 9,220 cases
overall mortality rate of approximately 3,560 cases per year, which includes adults
and children
5-year survival rate 50-60%.
soft tissue sarcomas
account for 1% of all adult malignancies and 15% of pediatric malignancies
most commonly metastasize to the lungs
tumors arising in the abdominal cavity more commonly metastasize to the liver
and peritoneum.
Lymphnode invasion
Epitheloid sarcoma
Rhabdomyosarcoma
Clear cell Sarcoma
Angiosarcoma
Relative Frequency of Histologic Subtypes of Soft Tissue Sarcoma
Malignant fibrous
histiocytomas - 28%
Liposarcoma-
15%
Leiomyosarcoma -
12%
Unclassified sarcoma -
11%
Synovial sarcoma -
10%
Malignant peripheral nerve sheath
tumor -
6%
Rhabdomyosarcoma -
5%
Soft tissue Sarcomas
Relative Frequency as to Location
Extremity
59%
Trunk
19%
retroperitoneum
13%
and head and neck
9%
2002 American Joint Committee on Cancer staging system
Low grade
(G1) well differentiated
(G2) moderately differentiated
High grade
(G3) poorly differentiated
(G4) undifferentiated
2002 American Joint Committee on Cancer staging system
Tumor Size
T1 lesions are 5 cm or smaller
T 2 lesions are larger than 5 cm.
2002 American Joint Committee on Cancer staging system
Anatomic location
above the superficial investing fascia- "a" lesions in the
T score
invading or deep to the fascia as well as all retroperitoneal, mediastinal,
and visceral tumors -"b" lesions.
2002 American Joint Committee on Cancer staging system
French Federation of Cancer Centers system
5-year survival rates
grade 1- 90%
2- 70%
3- 40%
Metastatic potentials as to Tumor Grades
5 to 10% for low-grade lesions
25 to 30% for intermediate-grade lesions
50 to 60% for high-grade tumors
Adjuvant Radiation Therapy
The goal of is to decrease localregional recurrence rates.
Can be given before surgery, after surgery, or in selected cases, during surgery.
Adjuvant Radiation Therapy
1. Preoperative radiation therapy
minimize seeding of the tumor during surgery
Achieve adequate reduction for inoperable tumor to make them operable.
Disadvantages - increased risk of postoperative wound healing problem
Adjuvant Radiation Therapy
2. postoperative radiation therapy
given 3 to 4 weeks after surgery to allow for wound healing.
advantage - surgical specimen can be evaluated histologically
and
radiation therapy can be reserved for patients who are most
likely to benefit from it.
Adjuvant Radiation Therapy
3. brachytherapy, unlike external beam
therapy, the radiation source is in contact with the tissue
being irradiated.
cesium, gold, iridium, or radium.
administered with temporary or permanent implants such as needles, seeds, or catheters.
International
Commission on Radiological Units
1 rad equal to 0.01 joule per kilogram of the absorber doses
quantified in gray (Gy) units, with 1 Gy
= 100 rad = 1 joule per kilogram of the absorber, and 1 cGy = 1 rad.
Extended Vertical Trapezius Myocutaneous
Flap in Head and Neck Reconstruction as a Salvage Procedure.
This article describes the authors' experience with the extended vertical trapezius
myocutaneous flap for head and neck complicated soft-tissue defects in nine patients ranging in
age from 17 to 72 years
Extended Vertical Trapezius Myocutaneous
Flap in Head and Neck Reconstruction as a Salvage Procedure.
The mean flap size was 7 x 34 cm.
The flap was based solely on the transverse cervical artery.
Superior muscle fibers of the trapezius were preserved and the caudal end of
the flap was extended from 10 to 13 cm beyond the caudal end of the trapezius muscle.
Extended Vertical Trapezius Myocutaneous
Flap in Head and Neck Reconstruction as a Salvage Procedure.
In conclusion, for complicated soft-tissue defects of the head and neck, the extended vertical trapezius
flap can be preferred as a salvage procedure because it is a simple, reliable, large flap that is located far enough from
the damaged area.
THANK YOU!
REFERENCES
SCHWARTZ'S PRINCIPLES OF SURGERY - 8th Ed. (2005)
The National Cancer Data Base report on soft tissue sarcoma. Cancer
78:2247, 1996. 3. Lawrence W Jr., Donegan WL, Natarajan N,
et al:
Adult soft tissue sarcomas. A pattern of care survey of the
American College of Surgeons. Ann Surg205:349, 1987. 4. Coindre
JM, Terrier P, Guillou L, et al:
MCQ
1. What is the most important prognostic factor for patients with sarcomas.
- Age
- Tumor size
- Histologic grade
- Location
MCQ
1. What is the most important prognostic factor for patients with sarcomas.
- Age
- Tumor size
- Histologic grade
- Location
MCQ
2. According to AJCC Staging System, Nodal disease is designated as
- stage I
- stage II
- stage III
- stage IV
MCQ
2. According to AJCC Staging System, Nodal disease is designated as
- stage I
- stage II
- stage III
- stage IV
MCQ
3. Soft tissue sarcomas most commonly metastasize to the
- Bones
- Lungs
- Brains
- liver
MCQ
3. Soft tissue sarcomas most commonly metastasize to the
- Bones
- Lungs
- Brains
- liver
MCR
1. The current version of the American Joint Committee on Cancer staging criteria for soft tissue sarcomas
relies on
- histologic grade
- tumor size
- depth
- distant or nodal metastases
1. The current version of the American Joint Committee on Cancer staging criteria for soft tissue sarcomas
relies on
- histologic grade
- tumor size
- depth
- distant or nodal metastases
MCQ
2. The following subtypes has a higher rate of lymph node metastasis in soft tissue sarcomas
- Rhabdomyosarcoma
- epithelioid sarcoma
- malignant fibrous histiocytoma
- liposarcoma
MCQ
2. The following subtypes has a higher rate of lymph node metastasis in soft tissue sarcomas
- Rhabdomyosarcoma
- epithelioid sarcoma
- malignant fibrous histiocytoma
- liposarcoma
MCR
3. Oncogenes are genes that can induce malignant transformation
and tend to drive cells toward proliferation. The following oncogenes
have been identified in association with soft tissue sarcomas.
- c-erbB2
- retinoblastoma (Rb)
- Nmyc
- P53
3. Oncogenes are genes that can induce malignant transformation
and tend to drive cells toward proliferation. The following oncogenes
have been identified in association with soft tissue sarcomas.
- c-erbB2
- retinoblastoma (Rb)
- Nmyc
- P53
