Influence of unplanned excisions on the outcomes of patients with stage III extremity soft‐tissue sarcoma

Abstract

BACKGROUND Soft‐tissue sarcomas (STSs) are a heterogeneous group of malignant tumors that can be difficult to treat. This is particularly true after incomplete or unplanned excisions and especially for patients with American Joint Committee on Cancer stage III tumors, who are at high risk for relapse. Numerous studies have shown that an inadequate sarcoma excision is associated with a worse prognosis. However, other reports have suggested an improved prognosis for patients with an initial unplanned excision and subsequent re‐excision in comparison with patients who undergo planned primary surgery. The purpose of this study was to determine the impact of an unplanned excision on treatment and subsequent oncologic and functional outcomes for patients with stage III extremity STS. METHODS From the prospectively collected database at a tertiary‐referral sarcoma center, all patients with stage III STS of the extremities treated between 1989 and 2010 were identified. Patient records were reviewed to identify patient demographics, tumor details, treatments, complications, and functional and oncologic outcomes. RESULTS Five hundred patients with stage III STSs of the extremities were identified, and 94 of these patients (18.8%) were referred after inadequate excisions had been performed elsewhere. All 94 patients with unplanned excisions underwent re‐excision in an attempt to achieve clear margins, and 83% of these patients had residual tumor in the re‐excision specimen. In the re‐excision group, the rates of plastic reconstruction (eg, skin grafts and rotational or free flaps) and amputation were significantly higher in comparison with the rates for patients who underwent a primary planned resection (P = .023 and P = .03, respectively). The rates of local recurrence, metastasis‐free survival, and overall survival were not significantly different between the 2 groups, nor were the functional outcomes. CONCLUSIONS Unplanned excision of stage III STS leads to an unfavorable clinical course and necessitates more extensive surgery. As a result of aggressive re‐excision and multidisciplinary treatment, a negative effect on oncologic outcomes cannot be confirmed.

Sarcoma treatment in the era of molecular medicine

“…In fact, treatment in such specialized centers has been shown to result in improved surgical and oncologic outcomes (Blay et al , 2017). In addition, due to the potentially devastating consequences that can arise from poorly performed biopsies, biopsies of lesions suspected of being a sarcoma should be carried out in (or directed by) a specialized center (Mankin et al , 1982; Potter et al , 2008; Pretell‐Mazzini et al , 2015; Traub et al , 2018). The cornerstone of bone sarcoma and STS management is surgical resection of the primary tumor, which is typically accompanied by neoadjuvant and/or adjuvant chemotherapy and/or irradiation.…”

Actual Long-Term Survival After Resection of Stage III Soft Tissue Sarcoma

“…[22,23] It is without doubt that unplanned excision causes high morbidity and may lead to poor functional outcomes; however, its relation with disease-speci c survival remains unclear. A previous study [24] has shown noninferior oncological outcomes in patients who underwent aggressive re-excisions after unplanned excision of stage III STS. No conclusion could be made in our study because only a small number of patients with stage III STS (n = 6) were referred to our institute after unplanned excision.…”

The impact of unplanned excisions of truncal/extremity soft tissue sarcomas: A multi‐institutional propensity score analysis from the US Sarcoma Collaborative

“…Although on propensity score analysis, we did not find a difference in DSS or DMFS, the earlier LRFS in high‐grade STS can confer significant morbidity. Our study did not capture surgical operations needed after surgery; however, previous studies have reported higher rates of plastic reconstruction and amputation in patients who have undergone UE, especially if the residual tumor was noted on re‐excision . Further, the utility of radiation therapy before or after repeat resection after UE needs to be further investigated as a method to achieve local disease control.…”

“…Due to the rarity of STS compared to the prevalence of benign soft tissue masses, up to 50% of patients with STS will undergo a nononcologic, unplanned excision (UE) for a mass initially presumed to be benign . Patients who undergo unplanned, nononcologic resections are commonly referred to tertiary referral centers, and due to the high probability of residual tumor left in the surgical bed after UE, the current standard of care recommends re‐excision with or without radiation of the tumor bed in an effort to achieve appropriate oncologic margins and local control …”

“…[4][5][6][7] Patients who undergo unplanned, nononcologic resections are commonly referred to tertiary referral centers, and due to the high probability of residual tumor left in the surgical bed after UE, the current standard of care recommends re-excision with or without radiation of the tumor bed in an effort to achieve appropriate oncologic margins and local control. 6,[8][9][10][11][12][13][14][15][16] Historically, patients who undergo UE have been described as having worse oncologic outcomes compared with patients who undergo planned oncologic excision (PE) primarily, explained by fragmented excisions and disruptions of the tumor capsule associated with UE. 15,17 Subsequent reports have shown that patients who undergo UE have similar, or even improved, recurrence-free, metastasis-free, and disease-specific survivals compared with patients with planned excisions.…”