How can tumour recurrence on my thigh be prevented?
Q: I am a 31 years old male who had a lump on the right thigh just an inch above my knee. I consulted a doctor and was advised FNAC, MRI and X-ray. FNAC showed spindle cell tumour, MRI showed a neurogenic tumour with no links to bone or muscle and with a blood supply to it from the arteries. Even the X-ray said the same. I underwent surgery and the tumour was removed .The biopsy report revealed it to be a benign tumour with few mitotic figures and put a question mark on sarcoma, neurofibrosarcoma, liposarcoma and fibrosarcoma. A second opinion, where they did several other tests, reported it as a spindle cell tumour of probably neurogenic origin. The surgeon said that he will excise it more, clean the area and will remove some part of the thigh muscle. This has created lot of confusion and fear in my mind as earlier the doctor reported a benign tumour and now suddenly he is not sure. I asked the doctor the outcome of not getting operated again and he said that the tumour will recur. How can tumour recurrence be prevented?
A:The diagnosis in your case is essentially that of a spindle cell tumour. Spindle cells are possible in fibrosarcoma, in neurofibrosarcoma and several other variances of soft tissue sarcomas. The swelling you had was noticed only 4 months back but you have not mentioned the size of the swelling. This is important because the size has a bearing on the prognosis. You have also not given the details of the MRI though you do mention that there are no links to bones or muscles. This is useful to know because if the muscle compartment is not been involved primarily then resection (removal) is more likely to be complete.
The treatment for such lesions is usually what is known as a wide resection. The term wide resection is used when the surgeon dissects through normal tissue without ever cutting to the surrounding layer of the tumour known as capsule (sometimes a false capsule called pseudo capsule). If at any time this capsule is breached during surgery then there is a worry of recurrence. The exact margin that can be considered safe is not a fixed measure but five centimeter clear of the tumour on all sides is considered safe. Your surgeon who has done the excision is a best person to understand the nature of excision that he has done. If on deep dissection the compartment seems to have been breached then there is a higher chance of recurrence (it is a probability and not a necessity). Sometime even when we are sure that there has been no breach, we want to be giving a better chance of recurrence free life to be patient based on the tumour histology. In such cases a second look more radical resection may be wise. This decision is at times difficult but both for the patient and the surgeon who will be worried for your sake because of the pathologist’s reporting. Patient is worried because of repeat surgery, loss of muscle and possible function and need for additional coverage by plastic procedure for the defect left. Surgeon will be worried because of the fear of recurrence and second look surgery is always technically more demanding and he will also be more concerned about the recurrence. At times the pathologists and an experienced onco-surgeon / radiotherapist may help make a rational decision. This is because histopathologically some tumours are very sensitive to radiation therapy. Modern radiation therapy can be done safely, localised precisely and done without any significant side effect with good long term results. However, this decision can be taken only by a tumour board with an experienced radiotherapist.
In any case, if I were to choose for my patient I would weigh the risk of recurrence in consultation with my pathologist and available literature and plan for repeat surgery or radiotherapy. At times even keeping a close watch on the tumour resected area for evidence of any recurrence may also be worthwhile. In such cases you could defer a radical procedure to a recurrence. But this again is a technical procedure.
I would recommend you go back to your surgeon and have an honest discussion with him putting before him all your fears and then make a conscious decision in consultation with him. If you want to double check you could take a second opinion from an onco-surgeon/ radiotherapist.