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

Abstract

BackgroundUnplanned excisions (UE) of soft tissue sarcomas (STS) carry a high risk for local recurrence (LR) due to marginal/intralesional resections. However, there are reports about improved prognosis for UE patients who have re-resection compared with patients who undergo planned surgery. The present multicentre study was designed to define characteristics of UE patients and to investigate the impact of UE on subsequent therapy and patient outcomes.MethodsA total of 728 STS patients (376 males, 352 females; mean age: 58 years) who underwent definite surgery at one of three tumour centres were retrospectively included. Time-to-event analyses were calculated with log-rank and Gray’s tests, excluding patients with primary metastasis (n = 59). A propensity-score (PS) of being in the UE group was estimated, based on differences at baseline between the UE group and non-UE group. An inverse-probability-of-UE weight (IPUEW) was generated and time-to-event analyses calculated after IPUEW weighting.ResultsBefore referral, 38.6% of patients (n = 281) had undergone UE. Unplanned excision patients were younger (p = 0.036), rather male (p = 0.05), and had smaller (p < 0.005), superficially located tumours (p < 0.005). Plastic reconstructions (p < 0.005) and adjuvant radiotherapy (p = 0.041) more often were needed at re-resection. In univariable analysis, re-resected patients had improved overall survival (OS; p = 0.027) and lower risk of distant metastasis (DM; p = 0.002) than primarily resected patients, whereas risk of LR was similar (p = 0.359). After weighting for the IPUEW, however, differences in terms of OS (p = 0.459) and risk of DM (p = 0.405) disappeared.ConclusionsThe present study does not support prior findings of improved outcome for UE patients. Unplanned excisions have a major impact on subsequent therapy, yet they do not seem to affect negatively the long-term oncology outcome.

Incidence, treatment and outcome of abdominal metastases in extremity soft tissue sarcoma: Results from a multi‐centre study

“…Soft tissue sarcomas of the extremity and trunk (STS) are rare tumours with an estimated incidence of 2.4 cases per 100 000 persons per year 1 . About 15% of STS‐patients develop local recurrences and 30% distant metastases at 5 years, most commonly to the lungs 2‐5 . Other metastatic sites are described (bone and lymph nodes), however abdominal metastases (AM) from STS, are very uncommon 6,7 .…”

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

“…However, after the re‐excision of an STS with wide or negative resection margins, some studies have found local recurrence, metastasis, and survival rates similar to those after an initial primary surgery . Several publications have even stated that patients who undergo re‐excision surgery have superior oncologic outcomes in comparison with those who undergo primary surgery . These previous studies included all patients with unplanned excisions of extremity STS, including those with small and superficial tumors, whose outcomes are expected to be superior, and those with large and deep tumors, which would be associated with worse prognoses.…”

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

“…The impact of unplanned, nononcologic excisions on oncologic outcomes for patients with truncal or extremity STS is disputed. Previous studies demonstrate conflicting results as some groups report worse outcomes with patients who undergo UE primarily, while others report similar or even improved outcomes compared with patients who undergo PE . This incongruence in results is explained by the difficulty in comparing patients who undergo UE to patients who undergo PE given the more favorable tumor characteristics (smaller size and more superficial location) in patients who undergo UE primarily.…”

“…The cornerstone of curative treatment for patients with localized soft tissue sarcoma (STS) of the trunk or extremity is oncologic surgical resection with or without radiation . 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 …”

“…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 . 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 . These differing results are likely due to the disparate, prognostic tumor features between patients who have undergone unplanned and planned excision: patients with larger, deeper tumors tend to be referred for oncologic workup while those with smaller, more superficial tumors are more prone to undergo an UE.…”