When a Leg Lump Means Cancer: Soft Tissue Sarcoma

Most lumps or masses that develop on the thigh or leg are from trauma or benign causes. In rare cases, however, a leg lump can be the presenting sign of an aggressive cancer called a soft tissue sarcoma (STS). Although uncommon, STS can be  lethal. My wife and I lost a close friend this week to metastatic STS. In addition to her devoted husband, she is survived by her three teenage children. Another good friend’s girlfriend was diagnosed recently with a high grade (aggressive) STS of the leg that had already metastasized (spread) to multiple sites in her lungs, making the disease essentially incurable. Given these recent events affecting my friends’ lives, I’m taking the opportunity to revisit the topic of STS (first posted with “Sean’s Story” in January 2011).

Historically, patients who developed soft tissue sarcomas  were at risk of losing “life and limb,” quite literally.  This type of cancer is much less common than many carcinomas.  The most common site in the body to develop STS is the thigh.  Because of the local aggressiveness of these tumors, as recently as the 1970s the local treatment of STS was amputation of the affected limb.  Fortunately, that type of drastic surgery is rarely needed today. In the U.S., it’s estimated that over 10,000 patients will be diagnosed and 4,000 patients will die of STS each year.  Although the median age at diagnosis is 65, these tumors may occur in children, young adults (our friends), and the elderly.  The lifetime risk of developing STS is about 0.3%, or 1 in 300 people.  According to the most recent NCI’s SEER Cancer Statistics Review, the relative 5-year survival following a diagnosis of STS for all stages combined is 67%.  If the disease is localized, then the 5-year survival is 84%.  Patients with regional spread to lymph nodes have a 5-year survival rate of 62%.  Those with distant, metastatic disease (most commonly to the lungs) have a 17% survival rate at 5 years following diagnosis.

Risks & Causes

Most who are diagnosed with STS don’t have specific risk factors.  Some patients will relate a history of recent trauma to the area prior to diagnosis.  However, it’s thought that the trauma merely makes the patient aware of the mass, rather than serving as a cause of the cancer.  (“Doc, I fell on my leg a couple of weeks ago and it’s still swollen and hard.”) Uncommon genetic abnormalities such as neurofibromatosis, Li Fraumeni, and Gardners syndromes place patients at a high risk of developing STS relative to the general population.  Regular exposure to certain chemicals including arsenic, certain herbicides, and vinyl chloride may also increase risk.  Lastly, radiation exposure, including RT for cancer treatment, places patients at a low (much less than 1%) risk for radiation-induced STS.

Signs & Symptoms

The classic presentation of a patient with STS is a painless mass in the thigh, or any other muscular or soft tissue area of the body.  The patient may describe the mass as appearing suddenly and/or enlarging rapidly.  Occasionally the mass will cause discomfort or pain due to pressure on nearby structures and nerves.  Soft tissue sarcoma may also arise in an area call the retroperitoneum, the back of the abdomen.  A mass occasionally may be seen or felt in these cases.

Diagnosis

When a suspicious mass is seen or felt by the patient or his/her primary doctor, a referral should be made to an orthopedic or other surgical oncologist who has significant experience with these types of tumors.  Ideally, if STS is suspected, the biopsy should remove a piece of the tumor and the incision should be placed over the central portion of the mass.  This type of biopsy is termed an incisional biopsy.  Common subtypes of STS include malignant fibrous histiocytoma (MFH), liposarcoma, and fibrosarcoma, though there are many others.

Staging

The American Joint Commission on Cancer (AJCC) Tumor Node Metastasis (TNM) system is utilized for staging STS.  In addition to standard laboratory evaluation, patients should undergo CT or MRI of the affected area.  MRI is preferred to provide detailed anatomical information if the primary STS arises within an extremity or joint.  Patients with masses in the retroperitoneum will generally be served well with CT imaging.  Pathologists play a very important part in not only diagnosis but also staging of STS, since tumor grade (how aggressive the cells appear under the microscope) is a critical component of the staging of STS.

Patients with high grade (grade 3 or 4; very aggressive) STS have a very high risk of cancer spreading to distant sites, most commonly the lungs.  In fact, roughly 50% of patients with grade 3 STS will develop lung metastasis.  For all but the earliest, low-grade tumors, CT of the chest should be obtained to ensure no evidence of lung metastases at the time of diagnosis.  Unlike many carcinomas and lymphomas, most types of STS don’t commonly spread to lymph nodes.  The few subtypes that are known to do so include clear cell, rhabdomyosarcoma (the most common type of STS to occur in children), embryonal, alveolar and synovial cell types.  In addition to tumor grade, size, and depth of invasion (all of which are part of the AJCC staging system), patient age and overall condition are important factors for the patient’s outcome.  The overall survival 5 years following diagnosis by AJCC stage is: 90% for stage I, 80% for stage II, 55% for stage III, and 20% for stage IV.

Treatment

For small superficial, low-grade STS, surgical removal with a wide margin of normal tissue around the tumor is generally adequate.  These tumors have low risk of returning locally and/or spreading to distant sites, so cure rates are excellent. Unfortunately, STS are commonly intermediate to high grade, often large, and deep.  They present two problems: local and distant.  As mentioned earlier, historically patients with STS of the extremities underwent amputations to control the local tumor, since it had been shown that removing only the tumor itself resulted in an unacceptably high rate of the cancer returning and patients dying.  Thanks to work by investigators at the National Cancer Institute (NCI), it was determined in major RCTs that wide local excision of the tumor followed by postoperative radiation therapy (RT) to the region resulted in a recurrence rate of <10% and spared patients’ limbs. Amputation was no longer required for the majority of patients. A major trial that tested the role of preoperative versus postoperative RT revealed that overall survival was sightly better in the preoperative group.  Preoperative RT resulted in a higher risk of wound complications.  The current standard of care at many major cancer centers incorporates preoperative RT followed by surgery.  The RT dose is delivered daily, 5 days per week over 5-5.5 weeks preoperatively.  Patients who are treated postoperatively require a longer, 6.5-7 week course, usually encompassing a much larger area.

Systemic treatment for patients with high grade STS that hasn’t metastasized (spread to distant sites such as the lungs) has shown a small but real benefit in terms of improving patients’ survival without disease returning.  Unfortunately, the active chemotherapy drugs for STS are strong IV medications including adriamycin and ifosfamide.  Side effects include hair loss and nausea, significant fatigue, weakness, and a very low risk of permanent heart damage.

Those patients who develop spread to the lungs or other distant sites are generally incurable.  Chemotherapy for this group of patients may extend their survival and improve long-term quality of life, albeit with the risk of side effects as noted above.  For patients who have limited metastatic disease, such as one or two nodules in the lungs, there’s a potential survival benefit if they’re able to have these metastases surgically removed.  While the majority of these patients will still have their cancer return later, a small subset will be cured.

- Patrick Maguire MD

56 Comments to When a Leg Lump Means Cancer: Soft Tissue Sarcoma

  1. vwortham's Gravatar vwortham
    April 21, 2013 at 2:00 am | Permalink

    my grand son has large bags hanging down on each of his inside of thigh . some doctors claim this is only fatty cells ggrowing in his legs instead of his buttocks. they are very large and very hard. i have never seen anything like this . they are heavy and he can only walk very slowly. they hang almost to his knees. he is overweight but they must weigh about 50 pounds each and they are very bumpy.it scares me but he won’t go to dr. he is 23 years old

  2. May 15, 2013 at 1:45 am | Permalink

    I noticed a small bruise in the mirror then realized there was a lump under it.At first I thought it might be a bug bite but it never hurt or itched. The bruise is now gone but the lump remains and may be a little larger and now feels harder. Its on my upper left thigh. Its been about a week or so and the last three day may legs have been hurting. Not sure if the two are even related. Any ideas?

  3. Wstewart's Gravatar Wstewart
    May 22, 2013 at 9:37 pm | Permalink

    My wife has been diagnosed with a mass in the calf of one of her legs. She has had an indention in the place for a number of years, but has noticed a lump of late. She began feeling an aching pain in the area.

    She had a surgical consult today and the doctor said he isn’t sure what the mass is, but doesn’t think it is cancerous. The only option he recommended was surgery to remove most of it (not all because it would leave a larger scar) and said they would determine what exactly it is from that procedure. I’m concerned about the following:

    1. The general danger of it spreading from the surgery if it is malignant.

    2. If it turns out to be malignant, wouldn’t removing only part of it increase the risk of it spreading?

    I assume that if it is determined to be benign then there would be no danger of it spreading?

    I would appreciate your thoughts for us to consider in determining if it should be safe to proceed with the surgery to remove most of the mass.

  4. Wstewart's Gravatar Wstewart
    May 28, 2013 at 12:48 am | Permalink

    Hi Patrick,

    We are actually going to get a second opinion with a doctor in a surgical practice in 2 weeks.

    Thanks for your advice,

    –Wstewart

  5. Amanda Rice's Gravatar Amanda Rice
    June 20, 2013 at 4:03 am | Permalink

    I have a large lump on the top left side of my left leg (under the knee, to the left) it appears to be in the muscle, I noticed it about 1 1/2 yrs ago. Also, about 2 yrs ago, I noticed an egg sized lump on the right side of my upper chest ( close to the sternum) I had it x-rayed and nothing appeared on that. Neither of which bothered me, until today….the place on my chest feels tender/sore. There s no redness around it. I have no insurance so I m not able to see a doctor at t his time.Any advice would be appreciated.

  6. jerry's Gravatar jerry
    June 26, 2013 at 4:33 pm | Permalink

    I have a lump on the side of my leg around 12 inches up from my ankle. The lump is soft and near or on the bone. I dont think I beleive the lump showed up a few days ago. I am a 46 year old male and having my primary Dr look at it this Thursday. I hope its not cancer any ideas

  7. Scott whyte's Gravatar Scott whyte
    June 30, 2013 at 11:02 pm | Permalink

    My 17yr old son has been diagnosed with a non specific sarcoma in his hip. He has had surgery and all but 10% of the tumor was removed.

    My question is related to what I think amounts to a serious and possibly life threatening mistake by whomever has done my sons biopsy.
    After a year of going to different doctors with an ever increasing pain in his hip my son Greg was sent for an mri scan. He was subsequently sent for a biopsy of the tumor. However after waiting for al ost 4 months we wer told that the doctor who had performed the biopsy hadnt given the orthopedic surgeon any relevant information at all on this tumor, whether it was malignant or benign.

    Another 4 months went by and Greg has had his surgery 2 weeks ago and upon pathology of the tumor he has been told it is a type of sarcoma.

    I would like your opinion as to whether this amounts to a deriliction of duty on behaf of the doctor who done the biopsy because in my mind the doctor has seriously reduced my sons chances of surviving this disease. He has further body scans and tests this week and starts chemo next week. I feel very let down by these doctors

    Any reply would be greatly appreciated

  8. Sophia's Gravatar Sophia
    July 1, 2013 at 11:18 pm | Permalink

    I have a small, hard bump on the inside of my upper left thigh. It is not painful. It seems too small to be a big deal; is there a way to tell whether I should go to a doctor?

  9. A Clarke's Gravatar A Clarke
    July 2, 2013 at 3:06 pm | Permalink

    A small lump on the back of my mums lower thigh has steadily grown over the past few months. It first appeared in February and has got steadily bigger. It used to be painless but now aches her constantly. She also says that she feels it burst (inside, as outside it hasnt broken). When this happens it stings and she says she feels sick to her stomach. shes going for an MRI scan on Sunday, but they havnt even mentioned taking a sample for analysis. Is that right? and is the 5 months since the lump appeared long enough for a cancer to form and spread to other areas if (god forbid & hopefully i pray not) it is cancer.

  10. Jill's Gravatar Jill
    July 3, 2013 at 12:22 am | Permalink

    2010 noticed a lump directly above rt knee. Smooth oval 2″ across both ways. Went to dr had MRI nothing showed up in MRI. Although dr could see feel lump. 1 yr later saw orthopedic had MRI again it showed nothing but lump is very visible to dr. Had several drs examin it but no one has any idea. They mentioned lipoma but since MRI showed nothing they said to not worry. It’s recently been causing swelling stiffness radiating to knee. In my mind I just keep fearing they have overlooked some cancer. I’m 40, no risk factors. Dr I saw was with large teaching hospital.

  11. Rumeshka's Gravatar Rumeshka
    July 3, 2013 at 8:22 am | Permalink

    I have a small lump on my left thigh for over 5 yrs now and im not really sure how it came. I can feel a hard ball sort of mass inside it and it does not hurt and have not grown. I showed it to a Dr. in she just looked at it and said its a lump of pus and i should wait for it to grow bigger to have it removed. That was over a yr ago.
    Im really worried now after reading your article, could you please advice me the procedure to get myself checked. Do i start with a general physician or a specialist if so which?
    I also want to thank you Dr. for your article. It was really an eye opener for me.

  12. Katie's Gravatar Katie
    July 5, 2013 at 9:20 pm | Permalink

    Hi Patrick,

    I had been getting a pins and needles sensation in my right leg for a few days and thought nothing of it. Last night I was standing in front of the mirror and noticed quite a large lump in my upper right thigh, not painful to the touch but hugely noticeable. I went to the GP today and he said it looks like a muscle spasm directly linked to my pregnancy (I have a new baby now) I thought this was a bit of an odd diagnosis, surely a muscle spasm would come and go whereas this lump looks pretty set to stay? Are there any other symptoms I could look for or does this sound pretty unrelated? Would really like someone to put my mind at rest really.

    Thanks!

  13. Love all's Gravatar Love all
    July 6, 2013 at 6:19 pm | Permalink

    My mom has this lump on the left leg…an inch above the knee(inner thigh).It’s been there for about two years. It isn’t too big and not painful at all. She has vericose veins too. I hope it’s not cancer. Am a little worries. She’ll see a doctor soon but I thought u could give some idea…

  14. D.Blaney's Gravatar D.Blaney
    July 7, 2013 at 10:46 pm | Permalink

    Hello, About 7 months ago I noticed a hard lump on my shin, went to the doctors and she said it could just be nothing:/ 6 months later ther is more of them and a big lump in my calf next to where the hard lump is. I also have developed a limp after walking for abit, and have pains in my leg, my knee and now my back and my neck feels like I have whiplash. Also I am tired alot. I am due for an x ray on friday but am quite worried as it gets worse each day. I used to do thai boxing and used to hit my shin on hard objects. Any help/info would be highly appreciated.

  15. July 16, 2013 at 5:55 am | Permalink

    Well today I had a visit with a surgeon for the first time regarding two lumps on my leg that I thought were csyst. The surgeon said there tumors and is sending me for a ct scan. He asked if I had any questions an at that moment I couldn’t think of anything. I have had these lumps for years an maybe a year go was kicked in leg an felt fluid rush inside from what I believed was cyst fluid. Ever since I can now feel pain from the lumps when I run, excersize, or stand for long periods. Will the ct tell him everything he needs to know? If benign should I still have them removed? Anything at this point would be of help. Don’t want to freak myself out, but want to make sure I ask the right things. Thank you for your time!

  16. ZUI's Gravatar ZUI
    July 16, 2013 at 1:50 pm | Permalink

    My mother has been diagnosed with Mesenchymal lesion via ultrasound of the upper left thigh. There is very less information on the Internet. Am really worried. Kindly enlighten me about the term. Is it life threatening. It’s intermediate grade! What’s the treatment! Can it be removed?
    Please reply and help!

  17. Christi's Gravatar Christi
    July 26, 2013 at 10:00 pm | Permalink

    I started working out over 2 years ago. In the weight loss journey I’ve lost 80lbs. I recently noticed in Feb of this year a lump or knot on my outer right thigh. I dismissed as muscle and kept going to Bootcamp workout. As I’ve continued to tone the lump seems larger, not sure the depth but the diameter is at least half dollar. I’m in between jobs and I didn’t want anything pre-existing so I saw a MD who is a friend…. She feels like it should be biopsied right away. I have a scheduled biopsy with my dermatologist on the 5th of August. 2 questions, first being what might I be dealing with? Secondly, I have had a second smaller one come up close to it. Is there really a need for biopsy at this point? My dermatologist has not seen my leg yet. I just wanted to see what other things I could be dealing with. I am an RN so if course I have read everything on the web.. Good and bad. Am I dealing with a possible malignancy? How worried should I be? Thanks.

  18. Brenda's Gravatar Brenda
    July 27, 2013 at 12:45 am | Permalink

    my sister had a biopsy done by an oncologist, lump on the back of her thigh, results, malignant tumor 5 centimeters, Soft Tissue Sarcoma, aggressive tumor, high grade,
    tier 2, stage 3, What does tier 2
    mean? And stage 3 mean? she is going to have, radiation everyday, for 6 weeks, her oncologist is on vacation, we are going to ask that she have a chest xray done, in her situation would you say, this is a good idea? how she discovered this, while she was taking yoga classes.

  19. Jalen Johnson's Gravatar Jalen Johnson
    August 6, 2013 at 3:12 am | Permalink

    I have have a large lump above my knee cap and it kind of hurts. I noticed it about a couple days or so ago and it has spread from the mid right side of my thigh and it has spread since. I originally noticed it a day after doing a hard leg work out. I thought if I used a foam roller that it would help. But it hasn’t. should I schedule an appointment or continue to ice it, drink water and use my foam roller?

  20. Grace's Gravatar Grace
    August 11, 2013 at 9:13 pm | Permalink

    My partner has had lumps come and go for just under a year now, these past few months they have started to appear bigger. They feel hard and only appear on his lower legs. He seems to think its nothing and wont go to the doctors, but I’m starting I become concerned.
    Do you have any advice or thoughts?

    Thank you.

  21. Saffi's Gravatar Saffi
    September 2, 2013 at 7:28 am | Permalink

    Sorry, folks! It is no longer appropriate for patrickmacquire to comment…Blah! Blah! Blah! then why have this blog? These poor people are desperate for answers.

  22. kate's Gravatar kate
    September 5, 2013 at 8:01 pm | Permalink

    Hi there. About 6 months ago, I notice a large, round mass on my front left thigh, just above the knee. I have a history of cancer (malignant melanoma in 3 difference places) and wasn’t sure if my medical history possibly has anything to do with this mass. I’m seeing and MD next week.
    What do you think?
    Thank you :)

  23. Mary's Gravatar Mary
    September 12, 2013 at 11:19 pm | Permalink

    Can cancer sarcoma mask itself on an MRI as a “soft tissue swelling?” I have 4″x3″lump (hard) on my inner left thigh. I am going to see a orthopedic oncologist next Monday.

  24. Mary's Gravatar Mary
    September 12, 2013 at 11:22 pm | Permalink

    Can cancer sarcoma mask itself on an MRI as a “soft tissue swelling?” I have 4″x3″lump (hard) on my inner left thigh. I am going to see a orthopedic oncologist next Monday.

    I am resubmitting this because the e-mail was incorrect the first time.

  25. Rusty's Gravatar Rusty
    September 20, 2013 at 6:41 am | Permalink

    I am a 53 year old male & in good health. I’ve had a lump (about the size of a strawberry) in my left inner thigh for the last 5 years. I have experienced some intermittent pain in the area. I’ve gone to see 4 different doctors/surgeons (including a cancer specialist). I’ve had blood tests, an ultrasound scan, & 3 MRIs (with & without contrast) done. All the test results have come back normal, with the exception of one of the MRIs, which revealed a “small fatty prominence” in my thigh. The doctor said it was nothing to worry about & that surgery would not be necessary. The lump is still there (however, it has not grown) & I’m still experiencing some intermittent pain. Should I just ignore it, learn to live with the lump/pain or should I go see a 5th doctor & have him run more tests?

  26. Chris Craig's Gravatar Chris Craig
    September 29, 2013 at 3:34 am | Permalink

    Hi,
    I am a 2 time Non-Hodgkins Lymphoma survivor and over the past few months 3 lumps in my upper right leg.

    2 are in upper thigh and 1 is tight in my groin, where the cancer was both times.

    I am having pain at the site, which is different than past 2 times.

    Also I am having very bad muscle pains, especially in my legs and arms, a dry cough that won’t go away, I am always tired and I am always very warm at night.

    The last time I had stem cell transplant, with high doses of chemo. I thought I beat it, but now I am worried.

    I don’t have health insurance and I can’t get any, cause ofmhistory. I don’t know what to do.

  27. Susan Fleming's Gravatar Susan Fleming
    October 5, 2013 at 5:24 am | Permalink

    Dr. Patrick

    I developed a very hard lump on my shin, which grew rapidly. From a pea in August to three quarters in September. My doctor removed the lump, sent it to pathology. Lipoma with necrotic substance in the middle (old injury?). Well it has only been three weeks and now my lump grew back and is slightly larger than when it was excised. What are your thoughts? It feels hard. But when the doctor took the first lump out it was softer than I thought and it was not attached to the bone. Dang, back again.. ~Susan 56 years old
    I did walk my first 1/2 marathon this past summer.

  28. nicola wilkins's Gravatar nicola wilkins
    October 17, 2013 at 8:27 pm | Permalink

    My boy is 13years old and has had a lump sicking out from his right side knee. Dr sent for xray and blood tests. Worried what it could be as he plays for football academy and doing well until now.He gets tired alot every day.

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