Is revisional surgery mandatory when an unexpected sarcoma diagnosis is made following primary surgery?

Abstract

BackgroundSoft tissue sarcomas (STS) are often diagnosed unexpectedly after surgery, and many excisions are incomplete. As histopathological assessments are challenging, patients later referred to comprehensive cancer centers (CCC) often come with an unclear status. This can make treatment planning problematic. We investigated the reliability of primary histopathological assessments, whether revisional surgery improved resection status, and the prognostic value of residual tumor at re-excision.MethodsWe analyzed the demographic and clinical characteristics of all patients referred to our CCC between 2003 and 2013. We compared patients treated exclusively at our CCC with those who had primary surgery elsewhere, and focused on resection margins, re-excision type, residual tumor, resection status after re-excision, and oncological outcome.ResultsOver half (n = 110) of all patients (n = 204) were referred from elsewhere. Seventy-one had undergone an excision without suspicion of malignancy. Resection status in referred patients was significantly inferior to the CCC group (p < 0.0001), although the latter had significantly more serious tumors and advanced disease stages (p < 0.05). The residual tumor rate was 53.13 %, with a significantly higher probability in an upper extremity (p = 0.001). Initial histopathological classification was misleading in 46.9 % of cases. Re-excision improved resection status in 69 % of cases. Residual tumor presumably leads to higher rates of local recurrence (p = 0.057) and significantly shorter times to recurrence (p < 0.05).ConclusionsRe-excision should always follow unplanned STS excisions. Resection margins and histopathological assessments from referring institutions are often unreliable and unsuitable for treatment planning. Residual tumor is a risk factor for earlier and more likely local recurrence.

The Prognostic Impact of Unplanned Excisions in a Cohort of 728 Soft Tissue Sarcoma Patients: A Multicentre Study

“…– 5 In our cohort, 38.6% of patients treated at one of the three centres had undergone UE outwards. The rates that we found are comparable to the 37% reported by Lewis et al and 34.8% observed by Koulaxouzidis et al6,11 …”

Soft Tissue Sarcoma of the Hand and Wrist: Epidemiology and Management Challenges

“…Residual tumor at re-excision correlates with a risk of earlier and more likely local recurrence. 6 Although not a statistically significant difference, 3 of the 7 (43%) lesions in our results excised elsewhere, or when not initially treated as sarcoma, developed metastases, compared with 2 of 9 (22%) excised after formal workup via sarcoma MDT.…”

“…2 When an "unplanned" excision of a sarcoma is performed outside of an STS MDT, initial histopathologic assessment is considered unreliable and should not be used to plan future treatment. 6 It should always be discussed at an MDT and followed by a re-excision of the affected area if appropriate, though this may be dependent on anatomical constraints such as adjacent neurovascular structures, the additional morbidity it may cause, and potential efficacy of adjuvant therapy. Residual tumor at re-excision correlates with a risk of earlier and more likely local recurrence.…”

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

“…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.…”