A 61-year-old male from Lucena City (located 134 km south of Manila), right-hand dominant with 20 pack-year smoking history, presented with a painful soft tissue lump on the posterolateral aspect of his left distal arm with no other accompanying symptoms, at our institution in Metro Manila in May 2020 when the entire island of Luzon was under a state of enhanced community quarantine (ECQ). Our institution then catered to both patients with and without COVID-19. The patient underwent core-needle biopsy at another hospital a month prior to consult, revealing fibrocollagenous tissue with nonspecific chronic inflammation on final histopathology. On physical examination, there were no neurological deficits, although Tinel's sign was positive. Review of left arm radiographs done at another hospital shows cortical erosion of the distal humerus with periosteal elevation (Figure 1a and b), while magnetic resonance imaging (MRI) confirmed a heterogeneously enhancing intramuscular mass involving the triceps measuring 3 cm x 4 cm x 4.5 cm (Figure 2a), associated with cortical destruction of, and abnormal marrow signals in the posterolateral humerus (Figure 2b), and partial tumoural encasement of the radial nerve (Figure 2c). Our differential diagnoses included benign and malignant primary soft tissue tumours, but upon review of chest radiographs done at another hospital, we noted finding of heterogenous ill-defined opacity in the right upper lobe that was officially read as tuberculosis (Figure 3). Although pulmonary tuberculosis was a possibility, we were then highly considering presence of sarcomatous metastasis in the lung. Financial constraints prevented further evaluation by chest computed tomography (CT).
During the ECQ, travel was restricted for most people, and many cities controlled their borders in an attempt to contain local transmission of COVID-19. The patient tested negative for COVID-19 by reverse transcriptase polymerase chain reaction (PCR) testing and therefore, requested to be admitted for continuation of care. But for fear of getting nosocomial SARS-CoV-2 infection, he pleaded for a short inpatient stay and an expedited hospital care. Citing early reports having found cancer patients especially vulnerable to SARS-CoV-2 infection, and cancer diagnosis a predictor of perioperative mortality, we agreed to forego performing preoperative biopsy. Imaging findings demonstrating aggressive biology and the possibility of pulmonary metastasis added up to a primary consideration of soft tissue sarcoma for our case. Thus, without benefit of a biopsy-proven diagnosis, our team decided to request for intraoperative frozen section to rule out malignancy, and prepare for wide tumour resection with frozen autograft reconstruction of the humerus. Without advantages of having an active cancer tumour board in the interim, we adopted recommendation by the French Sarcoma Group to pursue surgery even for high grade soft tissue sarcomas with distant metastasis in operable patients without COVID-19 symptoms.
The surgery was performed under general anaesthetic, with members of the surgical team additionally wearing Tyvek  coveralls (DuPont ; Delaware, USA), N95 respirators (3M ; Minnesota, USA) and face masks. We approached the tumour posterolaterally (Figure 4a), with the patient on right lateral decubitus position. Prior to resection of the tumour, tumoural tissue was obtained and sent intraoperatively for histopathological analysis, revealing signs of malignancy by frozen section. We therefore ruled in soft tissue sarcoma, and decided to resect the tumour with wide margins. Upon dissection, radial nerve was adherent to tumour and cortical bone was visibly eroded (Figure 4b). Wide bone margins were identified by C-arm guidance, and humeral segment together with involved radial nerve was included in the resection (Figure 4c). Resected tumour-bearing bone was freed of tumoural tissues then soaked in liquid nitrogen (Figure 4d), thawed, washed with distilled water and re-applied to humerus by fixation using plates and screws (Figure 4e). The operation lasted 361 minutes from induction to skin closure with no intraoperative complications, and estimated blood loss was 300 mL. After the surgery, patient's left elbow was immobilised with arm sling, and postoperative arm radiographs showed stable humeral reconstruction with acceptable alignment (Figure 5a and b). We strategised to start physical therapy upon notice of bridging callus by radiographic surveillance, and patient was discharged well with unremarkable inpatient course.
Final histopathological findings of the operative sample, with immunohistochemistry study, concluded the diagnosis of metastasis of an adenocarcinoma of lung origin (Figure 6a and b). The resection margins were negative for tumoural involvement. Positron emission tomography scan was done, which showed a lobulated, calcified lung mass within the right apical segment measuring 2.4 cm x 1.9 cm x 3.2 cm, as well as two rim-enhancing nodules in both frontal lobes suggestive of brain metastases. Patient was then referred to medical and radiation oncology services for palliative treatment, and at the time of writing, has completed ten sessions of whole-brain radiation therapy at another hospital and is to start adjuvant pemetrexed (Alimta ; Eli Lilly and Co.; Indiana, USA) and carboplatin (Biovinate ; Unilab, Inc.; Mandaluyong City, PH) treatment. Physical therapy is also done regularly on outpatient basis.