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

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          Abstract

          Background

          Unplanned 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.

          Methods

          A 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.

          Results

          Before 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.

          Conclusions

          The 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.

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          Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities.

          P Pisters, D H Leung, J. Woodruff … (1996)
          To identify specific independent adverse clinicopathologic factors for event-free survival in a cohort of consecutively treated patients with extremity soft tissue sarcomas. Prospectively collected data from a population of 1,041 adult patients with localized (American Joint Committee on Cancer [AJCC] stage IA to IIIB) extremity soft tissue sarcomas were analyzed. Patients were treated at a single institution between 1982 and 1994. Patient, tumor, and pathologic factors were analyzed by univariate and multivariate techniques to identify independent prognostic factors for the end points of local recurrence, distant recurrence, disease-specific survival, and post-metastasis survival. The 5-year survival rate for this cohort of patients was 76%, with a median follow-up time of 3.95 years. Significant independent adverse prognostic factors for local recurrence were age greater than 50 years, recurrent disease at presentation, microscopically positive surgical margins, and the histologic subtypes fibrosarcoma and malignant peripheral-nerve tumor. For distant recurrence, intermediate tumor size, high histologic grade, deep location, recurrent disease at presentation, leiomyosarcoma, and nonliposarcoma histology were independent adverse prognostic factors. For disease-specific survival, large tumor size, high grade, deep location, recurrent disease at presentation, the histologic subtypes leiomyosarcoma and malignant peripheral-nerve tumor, microscopically positive surgical margins, and lower extremity site were adverse factors. For post-metastasis survival, only large tumor size ( > 10 cm) was an adverse prognostic factor. The independent adverse prognostic factors for distant recurrence and disease specific survival differ from those identified for subsequent local recurrence. Patients with microscopically positive surgical margins or patients who present with locally recurrent disease are at increased risk for subsequent local recurrence and tumor-related mortality. Specific histopathologic subtypes are associated with increased risks for local failure and tumor-related mortality.
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            Soft tissue sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.

            P.G. Casali, J-Y Blay (2010)
            Article 0 comments Cited 63 times – based on 0 reviews     Review now
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              Residual disease following unplanned excision of soft-tissue sarcoma of an extremity.

              J Lévesque, E Kandel, J. S. Wunder … (1996)
              Sixty-five patients who had been referred to our unit for additional management after an unplanned excision of a soft-tissue sarcoma of an extremity at another institution were studied retrospectively to determine the prevalence of residual tumor and to identify factors that predict which patients will have a tumor following such an excision. Unplanned excision was defined as excisional biopsy or unplanned resection of the lesion without benefit of preoperative imaging and without regard for the necessity to resect the lesion with a margin of normal tissue. In each patient, histological evaluation of the specimen removed at the unplanned excision had demonstrated positive resection margins, but postoperative physical examination on our unit revealed no gross evidence of residual tumor and no tumor was identified on cross-sectional imaging of the local site. Patients who had evidence of residual disease on physical examination or on imaging were thought to have definite evidence of sarcoma at the site of the operative wound and were therefore excluded from the study. After multidisciplinary consultation, all patients had a repeat resection at our cancer center. Extensive pathological sampling of the specimen from this second procedure was carried out, with sections obtained at mean intervals of 1.2 +/- 0.7 centimeters. Nodules initially thought to indicate disease were identified grossly in twenty-seven (42 percent) of the sixty-five patients, but histological evaluation confirmed the presence of tumor in only sixteen (59 percent). Histological evidence of sarcoma was identified in seven additional patients in whom gross nodules were not apparent in the specimen. Thus, sarcoma was identified in a total of twenty-three (35 percent) of the sixty-five patients. The mean duration of follow-up was forty-six months (range, twenty-four to eighty months; median, thirty-nine months). The margins of the second resection were positive in nine (39 percent) of the twenty-three patients who had residual sarcoma. Five (22 percent) of the twenty-three had a local recurrence. Four of the five patients who had a local recurrence had positive margins on repeat resection. This rate of local recurrence (five of twenty-three patients) was significantly higher than that in the remainder of our patients who had a soft-tissue sarcoma of an extremity (sixteen [7 percent] of 227) (p = 0.03). There was no association between the detection of sarcoma at the second procedure and the initial size or grade of the tumor, the use of irradiation preoperatively, or the interval between the initial, unplanned excision and referral to our cancer center. These data indicate that it is not possible to predict which patients will have residual tumor at the site of the operative wound. Therefore, it is prudent to advise repeat excision for all patients who have had an unplanned excision of a soft-tissue sarcoma of an extremity. Unplanned excision complicates decision-making in the treatment of this disease and should be avoided.
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                Author and article information

                Contributors
                Maria Anna Smolle: +43 664 88506951 , maria.smolle@cbmed.at
                Journal
                Journal ID (nlm-ta): Ann Surg Oncol
                Journal ID (iso-abbrev): Ann. Surg. Oncol
                Title: Annals of Surgical Oncology
                Publisher: Springer International Publishing (Cham )
                ISSN (Print): 1068-9265
                ISSN (Electronic): 1534-4681
                Publication date (Electronic): 20 January 2017
                Publication date PMC-release: 20 January 2017
                Publication date (Print): 2017
                Volume: 24
                Issue: 6
                Pages: 1596-1605
                Affiliations
                [1 ]ISNI 0000 0000 8988 2476, GRID grid.11598.34, Department of Orthopaedic Surgery, , Medical University of Graz, ; Graz, Austria
                [2 ]ISNI 0000 0001 0549 9953, GRID grid.418468.7, , Sarcoma Centre HELIOS Klinikum Berlin-Buch, ; Berlin, Germany
                [3 ]Orthopaedic Hospital Gersthof, Vienna, Austria
                [4 ]ISNI 0000 0000 8988 2476, GRID grid.11598.34, Division of Clinical Oncology, , Medical University of Graz, ; Graz, Austria
                [5 ]ISNI 0000 0000 8988 2476, GRID grid.11598.34, Institute of Pathology, , Medical University of Graz, ; Graz, Austria
                Article
                Publisher ID: 5776
                DOI: 10.1245/s10434-017-5776-8
                PMC ID: 5413518
                PubMed ID: 28108827
                SO-VID: c33327b0-3e89-43b4-aea0-3461987fc5ad
                Copyright © © The Author(s) 2017
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 12 October 2016
                Categories
                Subject: Bone and Soft Tissue Sarcomas
                Custom metadata
                issue-copyright-statement © Society of Surgical Oncology 2017

                ScienceOpen disciplines: Oncology & Radiotherapy
                Data availability:
                ScienceOpen disciplines: Oncology & Radiotherapy

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