Principes du traitement des sarcomes des tissus mous de l'adulte

Abstract

Improving the quality of life of patients with a soft tissue sarcoma necessitates first the initiation of a first-line carcinologic treatment aimed at reducing the risk of local recurrence and reiterated surgeries likely to lead to mutilation; second, it necessitates a functional surgery which is increasingly feasible since the implementation of adequate multidisciplinary therapeutic management by a specialized team. No surgery should be undertaken without prior adapted imaging. Performing preoperating biopsy following the MRI allows a straightaway definition of the therapeutic management. Decision making should be based on definitive histological result since extemporaneous examination is associated with a high risk of error. Carcinologic surgery consists on a large exeresis with histologically healthy resection margins. A priori amputation is an outdated management, first of all because in this procedure the margins are not always healthy. The surgical access follows the member axis orientation. The biopsy scar, the tumour, and a round margin of non-tumoural tissue (a 2-cm depth of muscle, or a fibrous anatomical barrier such an aponeurosis) must be removed all together in order to avoid the occurrence of tumoural break-in and spreading. Advances in reconstructive surgery allow attenuating the functional consequences of a wide exeresis. The good quality of the surgery is determined by the histological analysis of the margins, i.e., the amount of peritumoural healthy tissue. Surgical re-intervention should be discussed in case of unhealthy margins because radiotherapy does not correct non-adapted surgery. In the standard procedure, radiotherapy is associated to carcinologic surgery. However, according to retrospective studies, the carcinologic surgical exeresis of some low-grade, superficially localized, small tumours may be sufficient, but this remains to be validated by prospective studies. Chemotherapy is discussed in young patients whose sarcoma is of high-grade malignancy. Finally, the technique of the isolated limb perfusion, using extra-corporeal circulation, allows perfusing high doses of chemotherapy, and improves the carcinologic and functional result of the second-line surgery undertaken for some recurrent tumours or locally advanced tumours. The organization and realization of such therapies is a matter for specialized multidisciplinary teams.