CASE PRESENTATION

A. PATIENT IDENTITY
Name
: Mr. W
Age
: 58 years old
Sex
: Male
Address
: Sumber
Religion
: Moslem
Marital Status
: Married
MR Number
: 872517
B. ANAMNESIS
Main Grievance
There is a mass in the left lower hand

Historical of Present Disease

The patient came to the hospital Arjawinangun because there is a mass in the left

lower hand since 3 years ago. The mass increasingly enlarged until as bis as the egg of
chicken. The patient complained thats disturb his activity because was founded a
movement disorder in his hand. The patient didnt feel the pain at left lower hand, theres
no hyperemic and other inflammatory reaction. The patient said there is no another
complaints.
Historical of Past Disease
Hipertension (-)
Diabetes Melitus (-)
Historical of Family Disease
Hipertension (-)
Diabetes Melitus (-)
The patient said there was no one of his family member that have a disease like him

C. MEDICAL EXAMINATION
Present Status
General Condition
: Moderate
Awareness
: Composmantis
Blood Pressure
: 130/80
Pulse
: 82 x/minute
Breathing
: 19 x/minute
Temperature
: 36,4 C
General Status
Head
Form
: Normal, Simetrical
Hair
: Black Colour, No hair fall
Eye
: Anemic Conjungtival -/Icteric Schlera -/Light Refleks (+)
Isocor pupil right = left
: Normal form, cerumen (-), tympani membrane intac
: Normal form, No septum deviation, epitaction -/: Normal

Ear
Nose
Mouth
Neck
Enlargement lymph nodes (-)
Trachea in the middle
No mass
Thorax
Lungs - pulmonary
Inspection
: The chest shape is symmetrical both ofleft and right
Palpation
: Fremitus tactile and vocal symmetrical right and left,

Percussion
Auscultation

crepitus (-), tenderness (-), rebound tenderness (-)

: Sound of resonant in both lung fields
: Sound of vesicular and bronchial the entire lung field,

ronkhi -/-, wheezing -/Heart

Inspection
: Ictus cordis is not visible
Palpation
: Ictus cordis palpable on the left midclavicula ICS line 5
Percussion
: Upper limit ICS 3 linea parasternalis sinistra
Right limit ICS 4 linea sternalis dextra

Left limit ICS 5 linea midclavicula sinistra

Auscultation : Heart sound 1 2 pure regular, murmur (-), gallops (-)

Abdomen
2

Inspection
Palpation
Percussion
Auscultation

Ektremitas
o Superior
hand
o Inferior
Genitalia
Localist Status:
Inspection
Palpation

: flat abdomen shape, supple, not visible skin disorders

: tenderness (-), rebound tenderness (-)
: There was a whole field tympanic abdomen
: Bowel (+) Normal
: Akral warm, Edema -/-, CTR < 2, mass in the left lower

: Akral wamt, Edema -/-, CTR < 2

: No abnormalities

: the left lower hand looks convex

: theres a mass palpable, fixed, immobile, size 6 x 7 cm, the surface is

soft, pressing pain ( - ), release pain ( - ), inflammatory reaction ( - )

INVESTIGATIONS
Laboratory Examination
Complete Blood
Leukocytes :6160/mm3
Red Blood Cell : 230000/mm3
Hb : 13,4 gr/dL
BT : 1
CT : 2 30
LED : 70 mm/hour
E. DIAGNOSIS OF WORK
Antebrachii Mass
F. DIFFERENTIAL DIAGNOSIS
G. MANAGEMENT PLAN
Non-medical (surgery) :
a. Compartement Excition
b. Repair W plasty
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medical:

Infusion RL 20 GTT / min

Keterolac 2 x 1

Ranitidine 2 x 1

Cefazoline 3 x 1

H Prognosis
Quo ad vitam

: Ad Bonam

Quo ad functionam

: Ad Bonam

Quo ad sanactionam : Ad Bonam

LITERATURE REVIEW
Background
The large majority of soft tissue tumours are benign, with a very high cure rate after surgical
exicion. Malignant mesenchymal neoplasm amount to less than 1%of the overall human burden
of malignant tumours but they are life threatening and may pose s significant diagnostic and
therapeutic challenge since there are more than 50 histological subtype of STS, which are often
associated with unique clinical, prognostic and therapeutic features. Over the past decade, our
understanding of these neoplasms has increased significantly, both from a histopathological and
genetic point of view. The close interaction of surgical pathologists, surgeon and oncologists has
brought about a significant increase in disease-free survival for tumours which were previously
almost invariably fatal, the overall 5-years survival rate for STS in the limbs now being in the
order of 65 75%. Careful physical examination and radiographic evaluation to evaluate the
size, depth and location of the mass, along with signs of neurovascular involvement are essential
for designing the best therapeutic approach.
Epidemiology
Benign mesenchymal tumours outnumber sarcomas by a factor of at least 100 annual clinical
insidens (number of new patients consulting a doctor) of benign soft tissue tumours has been
estimated as up to 300/million population whereas the annual incidence of soft tissue sarcoma is
around 30/million i.e. less than 1 % of all malignant tumours. There are no data to indicate a
change in the incidence of sarcoma nor are there significant geographic differences.
Etiology
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The etiology of most benign and malignant soft tissue tumours is unknown. In rare case, genetic
and environmental factors, irradiation, viral infections and immune deficiency have been found
associated with the development of usually malignant soft tissue tumours. There are also isolated
reports of soft tissue sarcomas arising in scare tissue, at fracture sites and close to surgical
implants. However, the large majority of soft tissue sarcomas seem to arise denovo, without an
apparent causative factors. Some malignant mesenchymal neoplasms occur in the setting of
familial cancer syndromes. Multistages tumourigenesis sequences with gradual accumulation of
genetic alterations and increasing histological malignancy have not yet been clearly identified in
soft tissue tumours.
Chemical Carscinogens
Several studies, many of them from Sweden, have reported an aincreased incidence of soft tissue
sarcoma after exposure to phenoxyacetic herbicides, chlorophenols, and their contaminants
(dioxin) in agricultural of forestry work. Other studies have not found this association. One
explanation for different findings may be the use of herbicides with different dioxin
contaminations.
Radiation
The reported incidence of post irradiation sarcoma ranges from some few per thousand to nearly
one percent. Most incidence estimates are basend on breast cancer patients treated with radiation
as adjuvant therapy. The risk increases with dose; most patients have received 50 Gy or more and
the median time between exposure and tumour diagnosis is about 10 years, although tere is some
evidence that this latent interval is decreasing. More than half of the tumours have been
classified as so called malignant fibrous histiocytomamost often highly malignant. Patient with a
germline mutation in the retinoblastomas gene (RB 1) have a significantly elevated risk of
developing post irradiation sarcomas, usually osteosarcomas. Viral infection and
immunodeficiency Human Herpes Virus 8 plays a key role in the development of Kaposi
Sarcoma and the clinical course is dependent on the immune status of the patient. Epstein Barr
virus is associated with smooth muscel tumours in patients with immunodeficiency. Stewart
Treves Syndrome, development of angiosarcoma in chronic lympoedema, particularly after
radical mastectomy, has by some authors been attributed to regional acquired immunodeficiency.
Genetic Susceptibility
Several types of benign soft tissue tumours have been reported to occur on a familial of inherited
basis. However these reports are rare and comprise an insignificant number of tumours. The most
common example is probably hereditary multiple lipomas (often angiolipomas). Desmoid
tumours occur in patient with familial Gardner syndrome (including adenomatous polyposis,
osteomas and epidermalcysts) Neurofibromatosis (type 1 and 2) is associated with multiple
benign nerve tumours (and sometimes also non-neural tumours). In around 2% of the patients
with neurofibromatosis tye 1 malignant peripheral nerve sheath tumours develop in a benign
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nerve sheath tumour the Li-Fraumeni syndrome is a rare autosomal dominant disease cause by
germline mutations in the TP53 tumour suppressor gene, which seem to be of for
sarcomagenesis. Half of the patients have already developed malignant tumors at age 30, among
them, in more than 30% of cases, soft tissue and bone sarcomas. The inherited, or bilateral form
of retinoblastoma, with a germline mutation of the RB 1 locus, may also be associated with
sarcoma development.
Clinical Features
Benign soft tissue tumours outnumber sarcomas by at least 100 to 1, although it is almost
impossible to derive accurate numbers in this regard. Most benigns lessions are located in
superficial (dermal or subcutaneous) soft tissue. By far the most frequent benign lesion is lipoma,
which often goes untreated. Some benign lesions have distinct clinical feaures but most do not.
Some non-metastasizing lesions, such as desmoid-type fibromatosis or intramuscular
haemangioma, require wide excision comparable to a sarcoma, otherwise local recurrence is very
frequent. Since excisional biopsy or shelling out of a sarcoma is inappropriate and often may
cause difficulties in further patient management, then it is generally advisable to obtain a
diagnostic biopsy (prior to definitive treatment) for all soft tissue masses >5cm (unless a very
obvious subcutaneous lipoma) and for all subfascial or deep seated masses, almost irrespective of
size. Most of tissue sarcomas of the extremities and trunk wall present as painless, accidentaly
observed tumours, which do not influence function or general health despite the often large
tumour volume. The seemingly innocent presentation and the rarity of soft tissue sarcomas often
lead to misinterpretation as benign conditions. Epidemiological data regarding size and depth
distribution for benign and malignant soft tissue tumours in Sweden have been used to formulate
simple guideline for the suspicion of a sarcoma; superficial soft tissue lesions that are larger than
5 cm and all deep seated (irrespective of size) have such a high risk (around 10%) of being a
sarcoma that such patients should ideally be referred to a specialized tumour center before
surgery for optimal treatment.
Diagnosis
MRI is the modality of choice for detecting characterizing, and staging soft tissue tumours due to
its ability to distinguish tumour tissue from adjacent muscle and fat, as well as to define
relationships to key neurovascular bundles. Additionally, it aids in guiding biopsy, planning
surgery, evaluating response to chemotherapy, restaging, and in the long term follow up for local
recurrence. Although MRI may not always reliably predict the histological diagnosis of a mass or
its potential biologic activity, several conditions can be reliably diagnosed based on their
characterisctic pathological and signal pattern, location of mass, relationship to adjacent
structures, multiplicity, and clinical history. MRI accurately define tumour size, relationship to
muscle compartments, fascial planes, and bone and neurovascular structures in multiple planes; it
provides information on haemorrhage, necrosis, oedema, cystic, and myxoid degeneration, and
fibrosis. MRI provides better tissue discrimination between normal and abnormal tissue than any
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other imaging modality. Most masses show a long T1 and long T2. However, there are a group of
lesions that show a short T1 and short T2. Masses with relatively high signal intensity on T1 are
lipoma, well-differentiated lposarcoma, haemangioma, subacute haemmorhage, and some
examples of Ewing sarcoma/peripheral PNET. Clumps or streak of high signal within the low
signal intensity mass on T1 weighted sequences might be encountered in haemangioma, myxoid
liposarcoma, infiltrative intramuscular lipoma, and lipomatosis of nerve. Tumours that may have
a low signal on T2 include diffuse type giant cell tumour, clear cell sarcoma and fibromatosis.
Soft tissue masses that do not demonstrate tumour specific features on MRI should be considered
indeterminate and biopsy should always be obtained to exlude malignancy.

Biopsy
Given the prognostic and therapeutic importance of accurate diagnosis, a biopsy is necessary
(and appropriate) to establish malignancy, to assess hitstological grade, and to determine the
specific hitological type of sarcoma, if possible. A treatment plan can then be designed that is
trailored to a lesions predicted pattern of local growth, risk of metastasis, and likely sites of
distant spread. A large enough sample from a viable area of sarcoma is usually reuired for
definitive diagnosis and accurate grading. Most limb masses are generally best sampled through
a longitudinally oriented incision, so that the entire biopsy tract can be compeletely excised at the
time of definitive resection. An incisional biopsy with minimal extension into adjacent tissue
planes in the ideal approach for most extremity masses. Excicional biopsy should be avoided,
particularly for lesions greater than 2 cm in size, since such an approach will make definitive reexcision more extensive due to the contamination of surrounding tissue planes. For deep seated
lesions, a core biopsy approach may be used to establish a diagnosis, however, the limited tissue
obtained with this technique may make definitive grading and prognostication difficult.
Benign
Most benign soft tissue tumours do not recur locally. Those that do recur do so in a non
destructive fashion and are almost always readily cured by complete local excision. Exceedingly
rarely (almost certainly <1/50.000 cases, and probably much less than that). A morphologically
benign lesion may give rise to distant metastases. Thi ih entirely unpredictable on tha basis of
conventional histological examination and, to date has been best documented in cutaneous
benign fibrous histiocytoma. Intermediate (locally aggressive) soft tissue tumours in this
category often recur locally and are associated with an infiltrative and locally destructive growth
pattern. Lesions in this category do not have any evident potential to metastasize but typically
require wide excision with a margin of normal tissue in order to ensure local control.
Malignant
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In addition to the potential for locally destructive growth and recurrence, malignant soft tissue
tumours (lnown as soft tissue sarcoma) have significant risk of distant metastasis, ranging in the
most instances from 20% to almost 100%, depending upon histological type and grade. Some
(but not all) histologically low grade sarcomas have metastatic risk of only 2-10%, but such
lesions may advance in grade in a local recurrence, and thereby acquire a higher risk of distant
spread (e.g, myxofibrosarcoma and leiomiosarcoma). It is important to note, that in this new
classification scheme, the intermediate categories do not correspond to the ICD-O/1 category
described as uncertain whether benign or malignant. The locally aggressive subset with no
metastatic potential, as defined above, are generally given ICD-O/1 codes, while the rarely
metastasizing lesions are given ICD-O/3 codes. Histological grading of soft tissue sarcomas the
histological type of sarcomas does not always provide sufficient information for predicting the
clinical course abd therefore for planning therapy. Grading, based on histological parameters
only, evaluates the degree of malignancy and mainly the probability of distant metastasis.
Staging, based on both clinical and histopatological parameters, provide information on the
extent of the tumour. The concept of grading in STS was first properly introduced by Russell et
al in 1977 and was the most important facor of their clinicopathological classification. Several
grading systems, based on various histological parameters, have been published ond proved to
correlate with prognosis. The two most impartant parameters seem to be the mitotic index and
the extent of tumour necrosis. A three grade system in recommended, retaining and intermediate
histological grade (grade 2) of malignancy. Grade particularly indicates the probability of distant
metastasis and overall survival but is of poor value for predicting local recurrence which is
mainly related to the quality of surgical margins. Moreover, the initial response to chemotherapy
has been reported to be better in patients with a high grade tumour than in patient with a low
grade one the Two most widely used systems are the NCI system and the FNCLCC system
according to the methodology defined in 1984 and refine in 1999 the NCI system uses a
combination of hitological type, cellularity, pleomorphism and mitotic rate for attributing grade 1
or 3.
Treatment
In general treatment for soft tissue tumors depend on the stage of tumor. Tumor stage basen on
the size and extent of the tumor. Treatment options for soft tissue tumors include surgery,
radiation therapy, and chemotherapy.
a. Therapy surgery
Surgery is the most common treatment for soft tissue tumors. If possible, the doctor will remove
the cancer and a safe margin of healthy tissue around it. It is important to obtain tumor-free
margins to reduce the likelihood of local recurrence and provide the best for the eradication of
the tumor. Depending on the size and location of the tumor, may, rarely, be required to remove
all or part of an arm or leg.
8

b. Radiation therapy
Radiation therapy can be used for both operations shrink tumors before or after surgery to kill
any cancer cells that might remain. In some cases, it can be used to treat tumor that can not be
removed by surgically. In some studies, radiation therapy has been found to inprove the local
level, but no one has an effect on the whole of life.

c. Chemotherapy
Chemotherapy can be used with radiation therapy, either before or after surgery to try to hide in
the tumor or kill any remaining cancer cells. The use of chemotherapy to prevent the spread of
soft tissue tumors have not been proven to be more effective. If the cancer has spread to the
others area of the body, chemotherapy may be used for shrink tumors and reduce pain and
anxiety they cause, but it is not possible to eradicate the disease.

Prognosis.
Prognosis depends on :
1. Size of tumor
2. Location of the tumor
3. Depth of tumor
4. The degree of malignancy
5. Cell necrosis (assessed at histopatological examination)
5 years survival rate
1. Stage I : low grade 85 90%
2. Stage II : high grade 70-80%
3. Stage III : huge grade 45-55%
4. Stage IV : any grade 0-20%

DAFTAR PUSTAKA
Jong WD, Syamsuhidayat R.2002 Buku Ajar Ilmu Bedah edisi 3. EGC. Jakarta
Utama HSY 2012. Soft Tissue Tumor Diagnosis And Management. Available online at
http://www.dokterbedahherryyudha.com/2012//softtissue tumordiagnosisandmanagement

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SURGERY CASE PRESENTATION

MASS ANTEBRACHII

NAME: TEGUH SONI REKSA

1102009283
PRECEPTOR: dr.H.HERRY SETYA YUDHA UTAMA SP.B, MH.Kes. FINACS
196211061987101001

MEDICAL FACULTY OF YARSI UNIVERSITY

11