MANAGEMENT OF METASTATIC DISEASE TO SOFT TISSUE

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Despite the prevalence of metastatic disease, metastases to soft tissue are rare. Interest in the evaluation and management of metastases to this unusual site is increasing, however. Little more than scattered case reports were available to guide care of patients with these problems* ; now, with more recent series and a comprehensive review of the literature, some conclusions can be drawn with respect to the epidemiology, clinical features, radiologic and histologic evaluation, treatment, and prognostic factors.24, 25, 62, 72 This article reviews the available information on each of these aspects of metastases to the soft tissue to provide a basis for clinical management.

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Prevalence and Definition

The true prevalence of metastases to soft tissue is unknown. The true prevalence of this entity depends on its definition. A broad definition includes distant hematogenous metastases to skin, subcutaneous tissue, and muscle; metastases to noncontiguous lymph node chains; direct extension of visceral tumors to soft tissue; transplant metastases in surgical and laparoscopic incisions; and the well-described local satellite metastases frequently observed in breast cancer. Although these entities

Clinical Setting of Presentation

Metastases to soft tissue may be diagnosed clinically as the presenting symptom of an occult malignancy, as an isolated finding in patients with a known prior malignancy, or in the setting of disseminated metastatic disease. The most common clinical presentation is that of an occult malignancy, accounting for greater than 40% of the cases in the literature (Fig. 1).* Next most commonly reported have

RADIOLOGIC EVALUATION

No radiologic features specific to metastatic soft tissue masses have been identified. There is no good way to differentiate the solitary soft tissue metastasis from a soft tissue sarcoma before biopsy (Fig. 3).

HISTOLOGIC EVALUATION

In a previous review of the authors' cases of soft tissue metastases and similar cases from the literature combined with more recent reports, carcinoma accounted for 95 of 113 cases (Table 2).24, 25 Carcinoma is the predominant histology for soft tissue metastases presenting as the initial manifestation of previously occult disease (39 of 41), presenting as late metastases in the absence of other sites (28 of 33), and in the presence of disseminated metastases (12 of 17). Most carcinomas

TREATMENT

Among the 113 previously reported cases, details of treatment were reported for only 86 cases. The retrospective nature of the patients reported in the literature makes analysis of results of these various modes of treatment almost futile. The following discussion details the means of treatment previously employed with some description of the type of patients for whom the specific treatments were used.

PROGNOSIS

Overall, prognosis for patients with soft tissue metastases is poor. For the group of 68 cases with outcomes identified, 45 were dead of disease (DOD), 18 were alive with disease (AWD), and only 5 survived with no evidence of disease (NED) at the time of their reports.24, 25 Mean survival among those who had died was only 8.4 months. In most series, few patients survived beyond 12 months after diagnosis of the disseminated metastasis.

Patients with carcinomas metastastic to the soft tissue

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    Address reprint requests to Timothy A. Damron, MD, Department of Orthopedics, Upstate Medical University, State University of New York at Syracuse, 550 Harrison Center, Suite 100, Syracuse, NY 13202, e-mail: [email protected]

    *

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