Outcomes of unplanned sarcoma excision: impact of residual disease

Charoenlap, Chris; Imanishi, Jungo; Tanaka, Takaaki; Slavin, John; Ngan, Samuel Y; Chander, Sarat; Dowsey, Michelle M.; Goyal, Chatar; Choong, Peter F. M.

doi:10.1002/cam4.615

Cited by 62 publications

(73 citation statements)

References 24 publications

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“…This indicates that there were still a substantial number of unplanned surgeries that led to a reversal of the rational sequence of obtaining diagnosis first of all and subsequently designing the therapeutic plan, the latter being an issue to be addressed by a multidisciplinary team. In our series, 46% of somatic sarcomas were diagnosed through excisional biopsy; this figure compares unfavorably with other recent series that exhibit a range of 26%–45% of excisional biopsies . Nevertheless, there was a trend towards improvement in the number of excisional biopsies in large tumors (>5 cm) of limbs and trunk wall; there were fewer of these over time, decreasing from 50% to 31% in our series.…”

Section: Discussionsupporting

confidence: 73%

Relevance of Reference Centers in Sarcoma Care and Quality Item Evaluation: Results from the Prospective Registry of the Spanish Group for Research in Sarcoma (GEIS)

et al. 2018

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Background Reference centers (RCs) are a key point for improving the survival of patients with soft‐tissue sarcomas (STS). The aim of this study was to evaluate selected items in the management of patients with STS, comparing results between RC and local hospitals (LHs). Materials and Methods Diagnostic and therapeutic data from patients diagnosed between January 2004 and December 2011 were collected. Correlation with outcome was performed. Results A total of 622 sarcomas were analyzed, with a median follow‐up of 40 months. Imaging of primary tumor preoperatively (yes vs. no) correlated with a higher probability of free surgical margins (77.4% versus 53.7%; p = .006). The provenance of the biopsy (RC vs. LH) significantly affected relapse‐free survival (RFS; 3‐year RFS 66% vs. 46%, respectively; p = .019). Likewise, 3‐year RFS was significantly worse in cases with infiltrated (55.6%) or unknown (43.4%) microscopic surgical margins compared with free margins (63.6%; p < .001). Patients managed by RCs had a better 3‐year overall survival compared with those managed by LHs (82% vs. 70.4%, respectively; p = .003). Perioperative chemotherapy in high‐risk STS, more frequently administered in RCs than in LHs, resulted in significantly better 3‐year RFS (66% vs. 44%; p = .011). In addition, patients with stage IV disease treated in RCs survived significantly longer compared with those in LHs (30.4 months vs. 18.5 months; p = .036). Conclusion Our series indicate that selected quality‐of‐care items were accomplished better by RCs over LHs, all with significant prognostic value in patients with STS. Early referral to an RC should be mandatory if the aim is to improve the survival of patients with STS. Implications for Practice This prospective study in patients diagnosed with soft‐tissue sarcoma shows the prognostic impact of reference centers in the management of these patients. The magnitude of this impact encompasses all steps of the process, from the initial management (performing diagnostic biopsy) to the advanced disease setting. This is the first prospective evidence showing improvement in outcomes of patients with metastatic disease when they are managed in centers with expertise. This study provides extra data supporting referral of patients with sarcoma to reference centers.

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Section: Discussionsupporting

confidence: 73%

Relevance of Reference Centers in Sarcoma Care and Quality Item Evaluation: Results from the Prospective Registry of the Spanish Group for Research in Sarcoma (GEIS)

et al. 2018

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“…The rate of residual disease following unplanned ESTS resection is consistent with a range of 45-53 % from prior reports. [8][9][10] Despite the present study not demonstrating a significant association between residual tumor and LR, other groups have reported that initial unplanned ESTS resection and residual disease predicted LR. 8,9 In a study of 142 unplanned ESTS resections from Charoenlap, the amputation rate was significantly higher in patients with residual disease (18.5 vs. 1.8 %, p = 0.003).…”

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confidence: 95%

Tailoring Surgical Therapy for Extremity Soft Tissue Sarcoma

Katz

2016

Ann Surg Oncol

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Limb-sparing multimodality therapy for extremity soft tissue sarcoma (ESTS) affords excellent disease control and functional outcomes in the majority of patients.1 In a study of 4977 extremity and superficial trunk STS, 20-25 % experienced recurrence, with some recurrent events occurring more than two decades after initial treatment. 2Determining the optimal surgical approach to minimize the risk of ESTS recurrence is a complex undertaking due to extreme biologic heterogeneity, with more than 100 histologic subtypes.3 The consideration of ESTS as a single entity is a matter of necessity rather than reason. The wide range of ESTS biologic behavior makes it exceedingly difficult to define broad policies or recommendations for most management dilemmas. 4 Bonvalot et al. conducted a retrospective study of 541 ESTS patients to examine the minimum necessary margin and the issue of mandatory re-excision followed unplanned resections.5 As stated in the title, the authors also set out to examine the relationship between local control of ESTS and survival. The lack of a causal link between ESTS local control and survival has been thoroughly verified previously and, as such, will not be the focus of this editorial. 6 Among all patients, 82 % underwent R0 resection and the median margin was 2 mm. The median follow-up of 7 years allows for reasonable survival and recurrence estimates. Local recurrences (LR) were experienced by 8 % and 20 % of patients died from all causes. Predictors of worse OS were grade, leiomyosarcoma subtype, and presence of residual disease upon re-excision. Importantly, 47 % of patients were treated following unplanned excision at other hospitals; 58 % of those patients had residual disease upon re-excision. LR was predicted by specific subtypes, such as myxofibrosarcoma, and a margin less than 1 mm.The impact of residual disease, likelihood of LR occurring before death due to distant metastases, and hence importance of re-excision after unplanned ESTS resection will vary by histologic subtype. In the present study, 22 % of patients had leiomyosarcoma, a disease in which distant recurrence predominates, with only 11 % experiencing isolated LR.7 Fewer than 10 % of patients had subtypes with highly aggressive LR patterns, including myxofibrosarcoma and dermatofibrosarcoma protuberans. Whereas deferring re-excision following an unplanned lower-extremity leiomyosarcoma resection may be appropriate in selected cases given that the outcome is driven by distant recurrence, omission in a myxofibrosarcoma patient would generally be inadvisable. As acknowledged by the authors, consideration of subtype biologic behavior is a critical factor when deciding if re-excision following unplanned ESTS surgery is warranted.The goal of reoperation following unplanned ESTS resection is to eradicate potential residual disease, prevent LR, and improve the likelihood of limb salvage. The majority of unplanned ESTS resections in the present study were indeed inadequate, because 58 % of patient who underwent re-excision were fo...

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“…Residual tumors after unplanned resections were previously described as being poor prognostic factors [4]. None of the patients had residual tumors following additional excision.…”

Section: Discussionmentioning

confidence: 78%

“…Moreover, flaps are also required because of the additional wide resection that is performed [3]. For these reasons, soft tissue sarcomas should be treated at specific hospitals because of their complexity [4]. However, other previous studies found that unplanned excision does not constitute a poor prognostic factor [5,6], particularly when the additional resection is performed adequately [5].…”

Section: Introductionmentioning

confidence: 99%

Clinical outcomes of patients who undergo additional excision after unplanned excision surgery for soft tissue sarcoma

Hashimoto¹,

Nishimura²,

Hara³

et al. 2018

biomedicalresearch

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Surgeons who operate on benign soft tissue masses that are presumed to be benign often encounter malignancies that require wider excision, a procedure referred to as an 'unplanned excision'. These patients then undergo additional excision after being diagnosed with malignancies. We aimed to investigate the outcomes of patients with soft tissue sarcomas who underwent unplanned excisions of their tumors followed by additional excisions at our institution. We examined 6 patients with soft tissue sarcomas, 3 men and 3 women, who underwent additional excisions after an unplanned excision between 2004 and 2015 at our hospital. Their mean age was 59.5 y, their mean primary tumor size was 9.0 cm, and 3 each had superficial and deep tumors, respectively. No residual tumor cells were observed in patient specimens following additional excision. None of the patients required plastic reconstructions. The 5-y survival rate was 100%, while the 5-y local recurrence-free rate was 83% after 1 patient experienced local recurrence and underwent a second additional resection. Our data suggest that patients who undergo unplanned excisions should also undergo additional excisions to avoid tumor recurrence.

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Outcomes of unplanned sarcoma excision: impact of residual disease

Cited by 62 publications

References 24 publications

Relevance of Reference Centers in Sarcoma Care and Quality Item Evaluation: Results from the Prospective Registry of the Spanish Group for Research in Sarcoma (GEIS)

Relevance of Reference Centers in Sarcoma Care and Quality Item Evaluation: Results from the Prospective Registry of the Spanish Group for Research in Sarcoma (GEIS)

Tailoring Surgical Therapy for Extremity Soft Tissue Sarcoma

Clinical outcomes of patients who undergo additional excision after unplanned excision surgery for soft tissue sarcoma

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