Reexcision of Soft Tissue Sarcoma: Sufficient Local Control but Increased Rate of Metastasis

Rehders, Alexander; Stoecklein, Nikolas H.; Poremba, Christopher; Alexander, A.; Knoefel, Wolfram Trudo; Peiper, Matthias

doi:10.1007/s00268-009-0262-5

Cited by 44 publications

(44 citation statements)

References 31 publications

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“…This is so despite that for those cases with positive surgical margins referred from LH, re‐surgery is a standard procedure in the RC involved in this analysis (HSE). Other authors too have found survival impact for cases referred after unplanned surgeries, with the prognostic impact being higher in cases with residual disease at the time of re‐excision . Data of microscopical residual disease at re‐excision were not analyzed in our series, so we cannot confirm this finding as critical for worse RFS.…”

Section: Discussionmentioning

confidence: 75%

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: Discussionmentioning

confidence: 75%

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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“…2, 3, 8–10 However, when comparing tumor bed excision following unplanned excision to planned complete excision as the initial procedure, some studies have observed inferior overall oncologic outcomes even when repeat resection is performed, suggesting that there is an adverse oncologic effect of unplanned excision. 6, 7 Conversely, other studies have shown equivalent oncologic outcomes between matched cohorts of tumor bed excision patients after unplanned excision compared to planned complete excision as the initial procedure, suggesting that oncologic outcomes are dictated by final surgical results.…”

Section: Discussionmentioning

confidence: 99%

Predictors of residual disease after unplanned excision of soft tissue sarcomas

Gingrich

Elias

Lee

et al. 2017

Journal of Surgical Research

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Background Unplanned excision of soft tissue sarcomas (STS) is an important quality of care issue given the morbidity related to tumor bed excision. Since not all patients harbor residual disease at the time of re-excision, we sought to determine predictors of residual STS following unplanned excision. Methods We identified 76 patients from a prospective database (1/1/2008 – 9/30/2014) who received a diagnosis of primary STS following unplanned excision on the trunk or extremities. We used univariable and multivariable analyses to evaluate predictors of residual STS as the primary endpoint. We calculated the sensitivity/specificity and accuracy of interval magnetic resonance imaging (MRI) to predict residual sarcoma at re-excision. Results Mean age was 52 years, and 63.2% were male. 50% had fragmented unplanned excision. Among patients undergoing re-excision, residual STS was identified in 70%. On univariable analysis, MRI showing gross disease and fragmented excision were significant predictors of residual STS (OR 10.59, 95% CI 2.14–52.49, P=0.004 and OR 3.61, 95% CI 1.09–11.94, P=0.035, respectively). On multivariable analysis, tumor size predicted distant recurrence and overall survival. When we combined equivocal and positive MRI, the sensitivity and specificity of MRI for predicting residual STS were 86.7% (95% CI 73.2–95.0%) and 57.9% (95% CI 33.5–79.8%), with an overall accuracy of 78.1% (95% CI 66.0–87.5%). Conclusions 70% of patients undergoing repeat excision after unplanned excision of STS harbor residual sarcoma. Although interval MRI and fragmented excision appear to be the most significant predictors of residual STS, the accuracy of MRI remains modest, especially given the incidence of equivocal MRI.

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“…Principally, adequate re-excision has been said to improve local and systemic tumor control, or even overall survival, compared to single adequate primary tumor excision [ 23 , 24 ]. Other studies, however, have shown higher local recurrence rates, impaired prognosis and increased rates of metastasis even after sufficient re-excision [ 3 , 6 , 25 , 26 ].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2015

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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.

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Reexcision of Soft Tissue Sarcoma: Sufficient Local Control but Increased Rate of Metastasis

Cited by 44 publications

References 31 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)

Predictors of residual disease after unplanned excision of soft tissue sarcomas

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

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