Surgical Procedures: Surgery and Staging for Soft Tissue Sarcomas

When cancer cells form within our soft tissues, it is called a soft tissue sarcoma (STS). Much of our body is made up of soft tissue, such as:

• Muscles.
• Tendons.
• Fat.
• Blood and lymph vessels.
• Nerves and the tissue around bony joints.
• Fibrous tissue.
• Deep skin tissues.

There are over 50 types of sarcomas, classified and named based on the type of tissue where they started. Some of the more common types are undifferentiated pleomorphic sarcoma, liposarcoma, and leiomyosarcoma. 

What is staging and how is it done?

Staging is a way to find out if and how far the cancer has spread in your body. Your provider will have you get a few tests to figure out the stage of your cancer. For STS, these tests may be:

Physical Exam: This is an exam to look at your body and to talk about your past health issues.

Imaging: Radiology tests can look inside your body to look at the cancer and see if it has spread. These tests can include: 

• Chest X-Ray, general X-Ray.
• CAT scan (CT scan).
• Positron emission tomography scan (PET scan). 
• Magnetic resonance imaging (MRI).
• Ultrasound. 

Procedures:  These may include:

• Incisional biopsy:  A small part of tumor or abnormal tissue is removed for testing.
• Fine needle aspiration (FNA): A thin needle removes a piece of tissue for testing. This may be done using an ultrasound or CT scan to help guide your provider.
• Core biopsy:  A larger piece of tissue is removed with a thick needle. This may be done with an ultrasound or CT scan to guide your provider.
• Excisional biopsy: The whole tumor is removed.

In some cases, lymph nodes or other tissues may also be tested. The biopsy samples are taken to the lab where they are looked at under a microscope by a pathologist (a doctor that specializes in looking at tissues). The samples may have more testing to figure out the type of STS. This information is used to write a pathology report that is sent to your healthcare provider.

Staging of soft tissue sarcoma is based on many factors, such as:

• Tumor grade (how abnormal it looks under a microscope).
• Tumor size.
• How close it is to the surface of the skin (superficial or deep).
• If the lymph nodes have cancer in them.

Soft tissue sarcomas are described as stages I-IV (1-4). Your care team will talk with you about your stage of STS.

Surgical Procedures Used in the Treatment of STS

Surgery can be used to treat some cases of STS. The type of surgery depends on a few things, such as the size of the cancer and where it is found.

Some surgeries that may be used to treat STS are:

• Mohs microsurgery:  Thin layers of skin are removed until cancer is no longer seen under the microscope. This is used when there are skin lesions you can see with the eye.
• Wide local excision:  Removal of the tumor and some normal-looking tissue that is around the cancer, trying to leave a “clean margin” of cancer-free tissue. By removing some healthy-looking tissue, there is less chance cancer cells will be left in the body.
• Limb-sparing surgery:  This procedure is used to keep as much of the limb’s function as possible, and to help save the appearance of the affected limb. Only the bone and tissue affected by the sarcoma is removed, to avoid amputation (total removal of the limb). During the surgery, the cancerous bone and tissue is removed and replaced with bone and tissue grafts and/or artificial (manmade) bone implants or other material.
• Amputation:  Part of or all of the affected limb is removed.
• Lymphadenectomy: Lymph nodes are removed to test them for cancer.

Other surgical procedures may be used depending on the location of the STS, your health, and other factors. You may also receive chemotherapy and/or radiation therapy before or after surgery. Treatment before surgery is called neoadjuvant treatment and is done to shrink the tumor as much as possible before removing it. Chemotherapy or radiation given after surgery is called adjuvant treatment, used to kill cancer cells that may be left in the body.

What are the risks of surgery to treat STS?

As with any surgery, there are risks and possible side effects. These can be:

• Reaction to anesthesia (Anesthesia is the medication you are given to help you sleep through the surgery, to not remember it, and to manage pain. Reactions can include wheezing, rash, swelling and low blood pressure).
• Bleeding.
• Blood clots.
• Infection.
• Urinary retention (not being able to urinate normally).

Before surgery, your surgeon will talk to you about any other risks based on your health and the surgery you are having. 

What is recovery like?

Recovery from surgery to treat STS depends on the type of procedure you had. A hospital stay and rehabilitation therapy may be needed.

You will be told how to care for your incisions (surgical cuts) and given any other instructions before leaving the hospital.

Your medical team will talk with you about the medications you will be taking, such as those for pain, blood clot, infection, and constipation prevention and/or other conditions.

Your healthcare provider will talk with you about any changes you should make to your activity level, which depends on the surgery you have had.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation. 

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.