Surgical Treatment

Surgical access and the extent of resection depend upon the location of the tumor, and a few examples will be used to illustrate the general principles of surgical treatment (Figures 17-6 to 17-9).

Histologic types associated with a higher than usual risk of lymphatic metastasis include embryonal rhabdomyosarcoma, epithelioid sarcoma, clear cell sarcoma, synovial cell sarcoma and vascular sarcoma. However, in view of the overall low risk of lymph node metastasis, neck dissection is indicated only in

Figure 17-6. A, A 12-year-old boy presented with a large, firm, diffuse swelling of the left neck which had been diagnosed as a desmoid tumor on previous biopsy. B, CT scan of the neck showed an avascular, homogeneous mass pushing the viscera of the central compartment over to the opposite side and obliterating the internal jugular vein. C, The patient underwent exploration and excision of the mass that was found to have invaded the left internal jugular vein, vagus and hypoglossal nerves. These structures had to be sacrificed but the mass could be dissected off the common carotid artery and the brachial plexus, leaving gross residual disease for which afterloading brachytherapy catheters were placed. The tumor was fleshy and relatively avascular on cut section and histopatho-logic examination confirmed the diagnosis of a fibrosarcoma.

the presence of palpable nodes, or if the neck needs to be entered for resection of the primary lesion.

A particularly difficult problem is the patient referred with no gross clinical findings after unplanned excision of a mass that turned out to be a sarcoma on histopathologic examination. A recent study reported a 59 percent incidence of microscopic residual disease in 95 STSs that were re-excised following inadequate surgery elsewhere; 4 out of 5 head and neck tumors in this report had residual disease.61 Re-resection followed by postoperative radiotherapy is generally indicated in such a situation, but for some tumors of the head and neck where one does not expect to gain extra margins, the dilemma is whether to subject the patient to the morbidity of another operation. The decision for reoperation, as opposed to radiotherapy alone, will in most instances be guided by the treating surgeon's impression of the adequacy of the original operation, appropriate radiologic eval

Figure 17-6. A, A 12-year-old boy presented with a large, firm, diffuse swelling of the left neck which had been diagnosed as a desmoid tumor on previous biopsy. B, CT scan of the neck showed an avascular, homogeneous mass pushing the viscera of the central compartment over to the opposite side and obliterating the internal jugular vein. C, The patient underwent exploration and excision of the mass that was found to have invaded the left internal jugular vein, vagus and hypoglossal nerves. These structures had to be sacrificed but the mass could be dissected off the common carotid artery and the brachial plexus, leaving gross residual disease for which afterloading brachytherapy catheters were placed. The tumor was fleshy and relatively avascular on cut section and histopatho-logic examination confirmed the diagnosis of a fibrosarcoma.

uation, the anatomic site of the lesion, the histologic grade, its predicted radiosensitivity, and its proximity to neurovascular structures. In the final analysis, the risks of recurrence and/or morbidity have to be weighed against the benefits of excision on an individual basis.

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