What is the best course of treatment for a 63-year-old female patient with a complex soft tissue mass on her left foot, who has a history of hypertension, diabetes mellitus type 2, bronchial asthma, and a family history of small bowel cancer?

Recommended Treatment Approach

This patient requires wide excision of the soft tissue mass with negative margins (R0 resection), performed by a surgeon trained in sarcoma management, followed by adjuvant radiation therapy if the final pathology confirms high-grade sarcoma >5 cm or deep location. 1

Immediate Pre-Operative Considerations

Mandatory Referral and Evaluation

• All patients with deep soft tissue masses or superficial lesions >5 cm should be referred to a sarcoma center before any excision. 1 This patient's 1.9 cm mass appears small, but the CT findings of ill-defined margins and inability to rule out malignancy warrant expert evaluation.
• The history of prior foot trauma with infected wound 2 years ago does not exclude malignancy, particularly given the progressive growth over 1 year. 2, 3

Critical Pitfall to Avoid

• Unplanned excision without proper preoperative evaluation significantly worsens outcomes. Studies demonstrate that unplanned excisions of foot sarcomas lead to more extensive subsequent surgeries, increased need for adjuvant radiotherapy, higher complication rates, and worse event-free survival despite additional re-excisions. 2, 3, 4
• Even small foot tumors should undergo appropriate preoperative evaluation before excision. 2

Optimal Surgical Approach

Standard Surgical Procedure

• Wide excision with en bloc resection achieving negative margins (R0) is the standard treatment. 1 This requires removing the tumor with a rim of normal tissue around it.
• The minimal adequate margin depends on histological subtype, but 1 cm is generally accepted, with exceptions for anatomical barriers like fasciae or periosteum. 1
• The biopsy tract (if core biopsy was performed) should be excised en bloc with the specimen. 5

Plastic Surgery Involvement

• Plastic surgery consultation should be obtained preoperatively if extensive tissue loss is anticipated or if reconstruction may be needed to achieve adequate margins while preserving function. 6, 7
• For foot defects after sarcoma resection, local flaps may suffice for smaller defects, but free flap transfers (anterolateral thigh, parascapular, or latissimus dorsi flaps) may be required for larger defects. 7, 8
• Modern plastic surgical techniques enable limb-sparing surgery even with locally advanced tumors. 7

Post-Operative Management Based on Final Pathology

If High-Grade (G2-3), Deep, or >5 cm

• Adjuvant radiation therapy (50-60 Gy postoperatively) is standard treatment. 1 This should be administered with 1.8-2 Gy fractions, with possible boosts to 66 Gy depending on surgical quality and presentation. 1
• Radiation therapy may be avoided only for G1, R0, <5 cm, superficial tumors. 1

If Margins Are Positive (R1) or Inadequate

• Re-excision should be strongly considered if adequate margins can be achieved without major morbidity. 1 This is particularly important given that re-excision to achieve negative margins achieves 88% 10-year local control in foot sarcomas versus 58% without re-excision. 4
• If re-excision cannot achieve adequate margins, adjuvant radiation therapy is mandatory. 1

If R2 Resection (Macroscopic Residual)

• Re-operation is mandatory, possibly with preoperative treatments if adequate margins cannot be achieved. 1

Adjuvant Chemotherapy Consideration

• Adjuvant chemotherapy is NOT standard treatment but may be offered as an option for high-risk patients (G2-3, deep, >5 cm tumors) after shared decision-making. 1 Evidence is conflicting with only limited survival benefit demonstrated in meta-analyses.
• Chemotherapy should be considered based on histological subtype, as some types (synovial sarcoma, the most common foot sarcoma) are more chemosensitive. 1, 2

Patient-Specific Factors

Comorbidity Management

• Optimize diabetes control (current HbA1c 6.96% is acceptable but should be maintained <7%) to reduce surgical complications and promote wound healing. 1
• Bronchial asthma must be well-controlled before surgery and anesthesia.
• Mildly elevated ALT (1.3x normal) should be monitored but does not contraindicate surgery.

Staging Workup Required

• Chest CT scan is mandatory to assess for lung metastases before definitive surgery. 1
• Abdominal/pelvic CT should be considered if final pathology shows high metastatic potential histotypes (myxoid liposarcoma, epithelioid sarcoma, angiosarcoma, leiomyosarcoma). 1

Key Algorithmic Decision Points

1. Confirm sarcoma center referral → Proceed only if surgeon has sarcoma training 1
2. Complete staging workup → Chest CT at minimum 1
3. Perform wide excision with R0 margins → Consider plastic surgery involvement 1, 6
4. Await final pathology → Determines need for adjuvant therapy
5. If high-grade/deep/>5cm → Adjuvant radiation therapy 1
6. If positive margins → Re-excision or radiation therapy 1
7. Consider adjuvant chemotherapy → Only for high-risk disease after discussion 1