Surgery for soft tissue sarcoma

Surgery is usually used to treat soft tissue sarcoma. The type of surgery you have depends mainly on where the tumour is in the body. When planning surgery, your healthcare team will also consider other factors, such as your overall heath.

Surgery may be done for different reasons. You may have surgery to:

• completely remove the tumour
• repair or rebuild the area where the cancer was removed
• control pain and other symptoms

The following types of surgery are used to treat soft tissue sarcoma. You may also have other treatments before or after surgery.

Wide local excision removes the cancer along with some normal tissue around it (called the surgical margin). It is a common treatment for many soft tissue sarcomas. Wide local excision may be the only treatment needed for early stage soft tissue sarcoma. It may also be used to treat soft tissue sarcoma that comes back (recurs).

The size of the surgical margin is usually 1 to 2 cm wide to ensure there are no cancer cells found around the tumour (called a negative or clean margin). It may be hard to remove enough normal tissue around tumours in certain areas, such as the head and neck area. Sometimes a smaller surgical margin may be used so there is no damage to important body parts.

The type of anesthetic used for a wide local excision depends on the size of the tumour and where it is in the body. During a wide local excision, the doctor uses a surgical knife (scalpel) to cut out the cancer. The area is closed using stitches. Depending on the amount of tissue removed, the surgeon may use reconstructive surgery to fix the area. The tissue removed is sent to a lab to make sure there are no cancer cells in the surgical margin and that all the cancer has been removed.

Limb-sparing surgery (also called limb-salvage surgery) removes a tumour by wide local excision from an arm or a leg (a limb) without removing the whole arm or leg. The surgeon works to save and protect nearby tendons, muscles, nerves and blood vessels to keep the arm or leg working as normally as possible. Reconstructive surgery may be used to help fix the look and use of the arm or leg. The surgeon keeps enough soft tissue, skin and muscle to rebuild the limb.

Soft tissue sarcomas in arms or legs are usually treated with limb-sparing surgery. In most cases, the goal of surgery is to completely remove the cancer and prevent amputation.

Reconstructive surgery is done to help improve how an area looks and works after surgery to remove the tumour. Sometimes the doctor has to remove a large amount of tissue to make sure all of the cancer is gone. You may need reconstructive surgery to fix the area and make it look better.

A skin graft is a piece of skin taken from another part of your body (called the donor site) and placed over the area where the cancer was removed. It is usually done by a plastic surgeon at the same time as the wide local excision.

The surgery is done using a local anesthetic (freezing) or general anesthetic (you will be unconscious). The surgeon removes skin from the donor site, such as the inner thigh or buttock. The skin graft is placed over the area where the cancer was removed and stitched in place. Both the skin graft and donor site are covered by a bandage and sometimes you are given stitches or staples. The skin graft usually takes 1 to 2 weeks to heal. Your healthcare team will tell you how to protect and care for the skin graft while it heals.

A tissue flap is a thick piece of tissue with its own blood supply. Like a skin graft, a tissue flap covers the area where the cancer was removed.

The surgeon takes the tissue flap, which includes skin, fat and sometimes muscle, from an area close to where the cancer was removed. The tissue flap often remains partly attached to its original location and blood vessels are still connected. In some cases, the tissue flap is completely removed (called a free flap) and the blood vessels of the tissue flap need to be connected to vessels at the new site. The tissue flap is positioned over the wound and stitched in place.

Most soft tissue sarcomas do not spread directly into the bone, so bone doesn’t usually need to be removed. If the bone must be removed, the surgeon may replace it with a bone graft. A bone graft is a piece of bone taken from another part of the body to rebuild the area that has had bone removed. The bone graft is attached to the bone where it is needed during surgery. More surgery may be needed in the future because the bone graft can become loose or break over time.

An endoprosthesisis an internal prosthesis used to replace joints that have been removed by surgery, like the knee, hip or shoulder joints. This allows the joints to move and bend. An endoprosthesis is usually made of metal and plastic. If an endoprosthesis is placed during limb-sparing surgery, more surgery may be needed in the future because it can become loose or break over time.

Surgery for a soft tissue sarcoma that develops in an arm or leg may involve removing the cancer and all or part of the limb. This is called amputation. Years ago, about half of all soft tissue sarcomas in a limb were treated by amputation. Today, amputations are done less than 5% of the time.

Amputation may be the only option if the tumour is large and has spread into important nerves, blood vessels or muscles. Removing these vital structures would leave a limb that doesn’t work well or would cause long-term problems. In these cases, a limb amputation may be the best option. An amputation may also be needed if the sarcoma has come back in the same limb after limb-sparing surgery.

The surgeon looks at imaging tests, such as MRI scans, to help decide how much of an arm or leg needs to be amputated. Muscle, soft tissue and skin are used to form a cuff around the amputated bone, which is called the stump. Right after amputation surgery, the stump is covered with a tight-fitting bandage to help shape it. Once the tissues of the stump are healed enough, you can be fitted for an artificial limb (prosthesis).

Modern prostheses have improved the lives of many people who need to have a limb amputated. Most major centres have clinics devoted to caring for amputees. People who need to have their legs amputated below the knee can have near normal function. People with amputation above the knee can also return to activities quite well.

Find out more about rehabilitation after treatment, including living with an artificial limb.

A lymph node dissection is surgery to remove several lymph nodes from the body. It may be done if imaging tests show that lymph nodes contain cancer cells. But it is not usually used for soft tissue sarcomas because these tumours don’t usually spread to lymph nodes.

A lymph node dissection is done using a general anesthetic (you will be unconscious) in a hospital operating room. The surgeon makes a cut to remove lymph nodes. Other nearby tissue may also be removed.

Find out more about lymph node dissection.

In certain cases of advanced soft tissue sarcoma, surgery may be used to treat cancer that has spread to the lung (metastases). Surgery to remove a lung metastasis may be called a lung resection or lung metastasectomy.

Surgery to remove lung metastases may be an option if:

• the primary cancer can be removed as well
• the cancer has only spread to a few places in the lungs and there are no other sites of metastases
• you are healthy enough to have surgery

Find out more about lung metastases.

Side effects can happen with any type of treatment for soft tissue sarcoma, but everyone’s experience is different. Some people have many side effects. Other people have only a few side effects.

If you develop side effects, they can happen any time during, immediately after or a few days or weeks after surgery. Sometimes late side effects develop months or years after surgery. Most side effects will go away on their own or can be treated, but some may last a long time or become permanent.

Side effects of surgery will depend mainly on the type of surgery, where the tumour is in the body and your overall health.

Surgery for soft tissue sarcoma may cause these side effects:

• pain
• swelling
• bleeding
• wound infection or wound separation (edges of the wound don’t meet together) or both
• poor wound healing
• blood clots
• scarring

Tell your healthcare team if you have these side effects or others you think might be from surgery. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Find out more about surgery and side effects of surgery. To make the decisions that are right for you, ask your healthcare team questions about surgery.