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Wednesday, 24 July 2013

ICMR issues guidelines for diagnosis & treatment of bone and soft tissue sarcoma

The Indian Council of Medical Research (ICMR) has issued guidelines for diagnosis and treatment of bone and soft tissue sarcoma which will help in identifying the areas that need to be strengthened and resources that are required with ultimate aim of delivery of optimum healthcare to one and all.
These guidelines are by no means mandatory nor do they cover all clinical situations. The need for a guideline was felt as sarcomas can be poorly recognised, diagnosed late and treated inconsistently due to its rarity. Bone and Soft Tissue Sarcoma (STS) encompasses a broad array of malignant tumours that arise in the mesenchymal tissues at any anatomical site. The practice of evidence based medicine is incomplete till the latest evidence is incorporated in day to day work yielding to practice guidelines depending on the need and of a community or a country and availability of resources. The guidelines are a step towards standardization of care.
Soft tissue sarcomas are rare tumors. They usually constitute about one per cent of all malignant neoplasm. The incidence of different histologies differs in children and in adults and by geographical areas. In India, among children the incidence varies between 3.6 per cent at Delhi to 14.8 per cent at Barshi among males and 3.7 per cent at Bengaluru to 9.5 per cent at Bhopal among females.
As per the guidelines, the standard approach to tissue diagnosis is multiple core needle biopsies or a large wedge biopsy for all deep seated lesions and for large superficial lesions. Biopsies often bleed heavily during surgery but generally managed by patient packing. The biopsy could be in form of excision biopsy if the lesions are superficial, less then 5 cm or located in areas where the needle biopsy is either contraindicated or may prove dangerous. This biopsy should always be performed by the expert surgeon. If performing an excisional or incisional biopsy care should be taken to place the biopsy scar properly so that it can be excised later with definite surgery without compromising the limb conservation. Care should also be taken that imaging of the lesion should precede biopsy. It is imperative that the site of biopsy should be properly recorded along with the depth of the lesion, as this entails a prognostic value.
A core biopsy may underestimate the grade of lesion, hence when planning a preoperative treatment, correlation with imaging findings may help in reaching a decision. The pathological diagnosis of STS is based not only in morphology but also on immunohistiochemistry that helps in identifying the tissue of origin, whenever there is a doubt or in presence of high grade lesions. A definite diagnosis should always be obtained before starting any form of treatment. If required or if indicated it should always be supplemented with molecular pathology (FISH, PCR etc.). The pathological interpretation should always be done by a pathologist who is well versed with soft tissue pathology and special tests should be performed in a laboratory that is enrolled in quality control programs. Biopsy related delays are common and must be avoided by anticipating the common problems and preferably a senior surgeon should obtain a reasonable tissue.
Though the gold standard for diagnosis of soft tissue sarcomas is a biopsy, less invasive procedures like fine needle aspiration cytology can be used.

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