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Larios F, Gonzalez MR, Ruiz-Arellanos K, Aquilino E Silva G, Pretell-Mazzini J. Is Unplanned Excision of Soft Tissue Sarcomas Associated with Worse Oncological Outcomes?-A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:443. [PMID: 38275885 PMCID: PMC10814439 DOI: 10.3390/cancers16020443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 12/28/2023] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Soft tissue sarcomas are a group of rare neoplasms which can be mistaken for benign masses and be excised in a non-oncologic fashion (unplanned excision). Whether unplanned excision (UE) is associated with worse outcomes is highly debated due to conflicting evidence. METHODS We performed a systematic review and meta-analysis following PRISMA guidelines. Main outcomes analyzed were five-year overall survival (OS), five-year local recurrence-free survival (LRFS), amputation rate and plastic reconstruction surgery rate. Risk ratios were used to compare outcomes between patients treated with planned and unplanned excision. RESULTS We included 16,946 patients with STS, 6017 (35.5%) with UE. UE was associated with worse five-year LRFS (RR 1.35, p = 0.019). Residual tumor on the tumor bed was associated with lower five-year LRFS (RR = 2.59, p < 0.001). Local recurrence was associated with worse five-year OS (RR = 1.82, p < 0.001). UE was not associated with a worse five-year OS (RR = 0.90, p = 0.16), higher amputation rate (RR = 0.77, p = 0.134), or a worse plastic reconstruction surgery rate (RR = 1.25, p = 0.244). CONCLUSIONS Unplanned excision of Soft Tissue Sarcomas and the presence of disease in tumor bed after one were associated with worse five-year LRFS. Tumor bed excision should remain the standard approach, with special consideration to the presence of residual disease.
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Affiliation(s)
- Felipe Larios
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima 15102, Peru; (F.L.); (K.R.-A.)
| | - Marcos R. Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Kim Ruiz-Arellanos
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima 15102, Peru; (F.L.); (K.R.-A.)
| | | | - Juan Pretell-Mazzini
- Miami Cancer Institute, Division of Orthopedic Oncology, Baptist Health System South Florida, Plantation, FL 33324, USA
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2
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Chung YL, Huang TT, Chen CF. Differential impacts of initial treatment status on long-term survival in patients with sarcomas treated in a referral center according to histologic type and anatomic site. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106927. [PMID: 37149404 DOI: 10.1016/j.ejso.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/07/2023] [Accepted: 05/02/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE The aim of this work was to estimate the magnitude of the differential impacts of initial treatment status relative to the impact of classic clinicopathologic factors on the long-term overall survival (OS) of sarcoma patients in a referral cancer center. METHODS From the institutional database, we identified 2185 patients who presented to the institutional multidisciplinary team (MDT) prior to (N = 717, 32.8%) or after (N = 1468, 67.2%) initial treatment, with a first diagnosis of sarcoma from January 1999 to December 2018. Descriptive, univariate and multivariate analyses were applied to identify the factors related to OS. By performing propensity score matching of each completely MDT-treated patient to a referral patient with similar characteristics, the differential impacts of the identified risk and prognostic factors on OS in the 2 groups were estimated by the Kaplan‒Meier survival curves, log-rank test and Cox proportional hazard regression; the results were compared using calibrated nomograph models and forest plots. RESULTS Adjusted for the clinicopathologic factors of patient age, sex, primary site, tumor grade, tumor size, resection margin and histology, hazard ratio-based modeling analysis indicated that the initial treatment status was an independent but intermediate prognostic factor associated with long-term OS. The major impacts of the initial and comprehensive MDT-based management on significant improvement of the 20-year OS of sarcomas were reflected in the subgroup of patients with stromal, undifferentiated pleomorphic, fibromatous, fibroepithelial, or synovial neoplasms and tumors in the breast, gastrointestinal tract, or soft tissues of limb and trunk. CONCLUSIONS This retrospective study supports early referral of patients with soft tissue masses of unknown identity to a specialized MDT before biopsy and initial resection to reduce the risk of death but highlights an unmet need for a greater understanding of some of the most difficult sarcoma subtypes and subsites and their management.
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Affiliation(s)
- Yih-Lin Chung
- Department of Radiation Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
| | - Tzu-Ting Huang
- Departments of Research, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Cheng-Feng Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
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3
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Peschek LS, Hobusch GM, Funovics PT, Willegger M, Schmid MP, Amann G, Lamm W, Brodowicz T, Ay C, Windhager R, Panotopoulos J. High fibrinogen levels are associated with poor survival in patients with liposarcoma. Sci Rep 2023; 13:8608. [PMID: 37244918 DOI: 10.1038/s41598-023-31527-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 03/14/2023] [Indexed: 05/29/2023] Open
Abstract
The aim of this study was to evaluate whether (preoperative) plasma levels of fibrinogen, an essential clotting and acute phase protein, are associated with the prognosis of patients with a liposarcoma, a subtype of sarcoma derived from adipose tissue. We performed a retrospective cohort study of 158 patients with liposarcoma treated at the Department of Orthopaedics of the Medical University of Vienna in Austria from May 1994 to October 2021. Kaplan-Meier curves as well as uni- and multivariable Cox proportional hazard models were performed to evaluate the association between fibrinogen levels and overall survival. Elevated fibrinogen was associated with adverse overall survival in cause specific hazards analysis of mortality (hazard ratio [HR] per 10 mg/dL increase: 1.04; 95% CI 1.02-1.06; p < 0.001). This association prevailed in multivariable analysis after adjustment for AJCC tumor stage (HR 1.03; 95% CI 1.01-1.05; p = 0.013). Increasing levels of fibrinogen, a routinely available and inexpensive parameter, predicts the risk of mortality in patients with liposarcoma.
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Affiliation(s)
- L S Peschek
- Department of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Gerhard M Hobusch
- Department of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - P T Funovics
- Department of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - M Willegger
- Department of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - M P Schmid
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - G Amann
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - W Lamm
- Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Th Brodowicz
- Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - C Ay
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - R Windhager
- Department of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - J Panotopoulos
- Department of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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4
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Gouin F, Stoeckle E, Honoré C, Ropars M, Jafari M, Mattei JC, Rochwerger A, Carrere S, Waast D, Ferron G, Machiavello JC, Anract P, Marchal F, Sirveaux F, Marco O, Guiramand J, Paquette B, Di Marco A, Causeret S, Guilloit JM, Soibinet P, Tzanis D, Gimbergues P, Fiorenza F, Dujardin F, Le Nail LR, Ruzic JC, Chemin-Airiau C, Morelle M, Meeus P, Karanian M, Le Loarer F, Vaz G, Blay JY. Overall survival in patients with re-excision of positive microscopic margins of limb and trunk wall soft tissue sarcoma operated outside of a reference center: a nationwide cohort analysis. BMC Cancer 2022; 22:1034. [PMID: 36192725 PMCID: PMC9531489 DOI: 10.1186/s12885-022-10121-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background This French nationwide NETSARC exhaustive prospective cohort aims to explore the impact of systematic re-excision (RE) as adjuvant care on overall survival (OS), local recurrence free survival (LRFS), and local and distant control (RFS) in patients with soft tissue sarcoma (STS) with positive microscopic margins (R1) after initial resection performed outside of a reference center. Methods Eligible patients had experienced STS surgery outside a reference center from 2010 to 2017, and had R1 margins after initial surgery. Characteristics and treatment comparisons used chi-square for categorical variables and Kruskall-Wallis test for continuous data. Survival distributions were compared in patients reexcised (RE) or not (No-RE) using a log-rank test. A Cox proportional hazard model was used for subgroup analysis. Results A total of 1,284 patients had experienced initial STS surgery outside NETSARC with R1 margins, including 1,029 patients with second operation documented. Among the latter, 698 patients experienced re-excision, and 331 were not re-excised. Characteristics were significantly different regarding patient age, tumor site, tumor size, tumor depth, and histotype in the population of patients re-excised (RE) or not (No-RE). The study identified RE as an independent favorable factor for OS (HR 0.36, 95%CI 0.23–0.56, p<0.0001), for LRFS (HR 0.45, 95%CI 0.36–0.56, p<0.0001), and for RFS (HR 0.35, 95%CI 0.26–0.46, p<0.0001). Conclusion This large nationwide series shows that RE improved overall survival in patients with STS of extremities and trunk wall, with prior R1 resection performed outside of a reference center. RE as part of adjuvant care should be systematically considered. Level of evidence II Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10121-5.
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Affiliation(s)
| | | | - Charles Honoré
- Surgery department, Gustave Roussy Cancer Campus, Villejuif, France
| | - Mickael Ropars
- Orthopedic surgery department, CHU de Rennes, Rennes, France
| | - Mehrdad Jafari
- General and digestive oncologic surgery, Centre Oscar Lambret, Lille, France
| | - Jean Camille Mattei
- Ramsay Santé, Hôpital Privé Clairval, Marseille, France.,Aix Marseille University, Marseille, France.,INSERM, MMG, Marseille, France.,Orthopedic and traumatologic surgery department, Hôpital Nord, Marseille, France.,Hopital de la Conception, APHM, Marseille, France
| | - Alexandre Rochwerger
- INSERM, MMG, Marseille, France.,Hopital de la Conception, APHM, Marseille, France
| | - Sébastien Carrere
- Surgery department, Institut de recherche en cancérologie, Montpellier, France
| | - Denis Waast
- Orthopedic and traumatologic surgery clinic, CHU, Nantes, France
| | | | | | - Philippe Anract
- Orthopedic surgery department, Hôpital Cochin, AP-HP, Paris, France
| | - Frédéric Marchal
- Surgery department, Institut de Cancérologie de Lorraine, Université de Lorraine, CNRS, CRAN, UMR 7039, Vandoeuvre-les-Nancy, France
| | | | - Oren Marco
- Reconstructive et esthetic plastic surgery, Hôpital Saint Louis, Paris, France
| | | | - Brice Paquette
- Department of Digestive Surgery, Jean Minjoz University Hospital, Besançon, France
| | - Antonio Di Marco
- Orthopedic surgery department, CHU de Strasbourg, Strasbourg, France
| | - Sylvain Causeret
- Surgery department, Centre George-François Leclerc, Dijon, France
| | - Jean-Marc Guilloit
- Visceral et digestive surgery department, Centre François Baclesse, Caen, France
| | | | - Dimitri Tzanis
- Surgery department, Institut Curie, PSL university, Paris, France
| | | | - Fabrice Fiorenza
- Orthopedic and traumatology surgery department, CHU Limoges, Limoges, France
| | - Franck Dujardin
- Medical Oncology and Surgical Oncology department, Centre Henri Becquerel, Rouen, France
| | - Louis R Le Nail
- Onco-orthopedic surgery department, Hôpital Trousseau, CHRU de Tours, Tours, France
| | | | | | - Magali Morelle
- Clinical research and innovation department, Centre Léon Bérard, Lyon, France
| | - Pierre Meeus
- Surgery department, Centre Léon Bérard, Lyon, France
| | - Marie Karanian
- Department of Biopathology, Centre Léon Bérard, Lyon, France
| | - François Le Loarer
- Anatomo-pathology surgery department, Institut Bergonié, Bordeaux, France
| | - Gualter Vaz
- Surgery department, Centre Léon Bérard, Lyon, France
| | - Jean-Yves Blay
- Medical oncology Centre Léon Bérard, Lyon, France.,University Claude Bernard Lyon I, Lyon, France.,Headquarters, Unicancer, Paris, France
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Sacchetti F, Alsina AC, Morganti R, Innocenti M, Andreani L, Muratori F, Scoccianti G, Totti F, Campanacci DA, Capanna R. Re-excision after unplanned excision of soft tissue sarcoma: A systematic review and metanalysis. The rationale of systematic re-excision. J Orthop 2021; 25:244-251. [PMID: 34099954 PMCID: PMC8165293 DOI: 10.1016/j.jor.2021.05.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/09/2021] [Indexed: 01/14/2023] Open
Abstract
In Soft Tissue Sarcomas (STS) referral centre many patients have already had an incomplete tumour resection. In the majority of specimen, tumoral residual is detected and linked to a worsen prognosis. Systematic surgical re-resection of the scar tissue area is often performed. Some authors suggested to postpone re-resections until a clinically evident local recurrence is detected. A searching strategy was applied to Pubmed-Central and Ovid Medline. Odds ratio (OR) for local recurrence (LR), distant metastasis (MTS) or overall survival (OS) were calculated comparing patients who had tumour residual to people who hadn't. OR of local recurrences, distant metastasis and OS were calculated in planned vs unplanned-excisions groups. OR to develop a metastasis and OS after a local recurrences were calculated. Residual tumour led to an OR for LR of 3,56, OR of MTS was 3,42; OR of decreased OS was 3,42. Having a LR lead to a OR of 1,55 for MTS and to a OR of decreased OS of 2,32. Patients who underwent a re-excision compared to planned surgery did not have an increased OR of LR and had an OR to develop a MTS of 0,56. Our data confirm that there is a strong correlation between local recurrences, distant relapses and overall survival. Although there is a selection bias; this analysis highlights the optimal oncological outcome in patients who underwent re-resection. The rationale for systematic re-resection after unplanned excision of soft tissue sarcomas is very strong and this treatment remains the gold standard of care in these patients.
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Affiliation(s)
| | | | - Riccardo Morganti
- Department of Statistics for Clinical Study, University Hospital of Cisanello, Pisa, Italy
| | - Matteo Innocenti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Lorenzo Andreani
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Italy
| | - Francesco Muratori
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Guido Scoccianti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Francesca Totti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Domenico Andrea Campanacci
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Rodolfo Capanna
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Italy
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6
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Improta L, Valeri S, Alloni R, Pagnoni C, Mallozzi Santa Maria F, Brunetti B, Greco C, Aprile I, Maselli M, Vincenzi B, Gronchi A. Locally recurrent extraskeletal myxoid chondrosarcoma of the shoulder: a case of complete neoadjuvant radiotherapy response. Clin Sarcoma Res 2020; 10:27. [PMID: 33308312 PMCID: PMC7731621 DOI: 10.1186/s13569-020-00150-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 12/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue tumor that typically affects the lower limbs of men between the ages of 50 and 60. EMC of the shoulder is rare with a high risk of local recurrence and distant metastasis. A planned surgical excision in sarcoma referral centers (SRCs) is mandatory to obtain the best outcome. The role of chemotherapy (CHT) and Radiotherapy (RT) on soft tissue chondrosarcoma is still controversial. CASE PRESENTATION A 47-year-old man presented to our referral center with a history of EMC in the right shoulder excised with microscopic positive surgical margins in a non-referral center. Staging imaging exams did not reveal distant metastasis or residual disease, but during follow-up a local recurrence was detected. After a multidisciplinary discussion, preoperative radiotherapy was administered with a total dose of 50 Gy, and then the patient underwent wide surgical excision. Histological examination was negative for viable tumor cells. No relapse occurred in a 24-months post-operative follow up. CONCLUSIONS The case here described suggests the importance of patient's management in SRCs. A planned combined treatments with both surgery and RT seems to be the best choice to improve local control. RT seems to be promising within this specific histotype. Further studies are needed to confirm if the observed efficacy of combined treatments reflects in a consistent survival benefit for EMC patients.
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Affiliation(s)
- Luca Improta
- Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Roma, RM, Italy
| | - Sergio Valeri
- Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Roma, RM, Italy.
| | - Rossana Alloni
- Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Roma, RM, Italy
| | - Chiara Pagnoni
- Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Roma, RM, Italy
| | | | - Beniamino Brunetti
- Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Roma, RM, Italy
| | - Carlo Greco
- Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Roma, RM, Italy
| | - Irene Aprile
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
| | - Mirella Maselli
- Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Roma, RM, Italy
| | - Bruno Vincenzi
- Campus Bio-Medico University of Rome, Via Alvaro del Portillo, 200, 00128, Roma, RM, Italy
| | - Alessandro Gronchi
- Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Venezian, 1, 20133, Milan, MI, Italy
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Erol B, Baysal Ö. Does Unplanned Soft Tissue Sarcoma Surgery Have a Negative Effect on Prognosis? J INVEST SURG 2020; 35:38-43. [PMID: 32862737 DOI: 10.1080/08941939.2020.1813852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND We aimed to compare the oncological outcomes of patients who underwent re-excision following unplanned surgery and those who underwent planned surgery. METHODS Patients who were referred to our hospital after a mass was inappropriately resected and reported to have a malignant pathology with a positive surgical margin, as well as patients diagnosed with malignant soft tissue tumors, and operated on following a multidisciplinary assessment and staging between 2012 and 2018. All patients were followed up at least 6 months. RESULTS Our study included a total of 125 patients. Forty percent (n = 50) underwent unplanned excision and sixty percent (n = 75) underwent planned excision.There was no statistically significant difference in the survival curves between the two groups (p = 0.248). Tumor size was larger, and the rate of deep-localized tumors was higher in patients undergoing planned surgery than in the unplanned surgery group (p = 0.001). The rate of tumors localized in the upper extremities was significantly higher in the unplanned surgery group than in the planned surgery (p = 0.033). MRI examinations could detect residual tumors with an accuracy of 80%. Age (>48 years), tumor size (>8 cm), tumor grade (grade 3), and distant organ metastasis at follow-up, which were among risk factors found to have a significant effect on mortality. CONCLUSION Patients undergoing re-excision after an inappropriate resection and undergoing planned resection had a similar prognosis. Superficial, upper extremity-localized, and relatively small-size tumors are more prone to inadequate surgical resection. MRI can be used to detect residual tumors at a high rate in patients who have undergone unplanned surgery. Distant organ metastasis is the most important factor affecting survival.
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Affiliation(s)
- Bülent Erol
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Özgür Baysal
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
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8
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Scoccianti G, Innocenti M, Frenos F, Muratori F, Sacchetti F, Beltrami G, Capanna R, Campanacci DA. Re-excision after unplanned excision of soft tissue sarcomas: Long-term results. Surg Oncol 2020; 34:212-217. [PMID: 32891333 DOI: 10.1016/j.suronc.2020.04.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/12/2020] [Accepted: 04/25/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Unplanned excisions of soft tissue sarcomas are still not infrequent events with patients presenting to referral Centers after having received an inadequate surgical treatment. In literature, both the wait-and-see policy and the "aggressive" management with a re-excision have been advocated. The purposes of this study were to analyze the incidence of detectable residual tumor in surgical specimens following a re-excision and to verify the long-term results of patients treated with a re-excision after previous unplanned excision. METHODS We retrospectively evaluated 131 patients affected by localized soft tissue sarcoma (95 high grade; 36 low grade) of the limbs or the superficial trunk treated at our Institution, from 2000 to 2013, with a re-excision after a previous unplanned inadequate excision. Site, size, depth, histotype, grade, adjuvant therapies, time from unplanned surgery to re-excision were recorded and evaluated in association with clinical results. We specifically evaluated the disease-specific survival, local recurrence free survival, distant metastases free survival and the event free survival. RESULTS Mean follow-up for living patients was 10.9 years (median 11.2 years), with a follow-up ranging from 14 to 227 months. 34% of patients underwent a re-excision within the first 2 months after unplanned surgery, while 66% of patients at more than 2 months. Residual detectable tumor cells were found on histological examination in 54% of re-excisions. A wide margin was obtained in 123 cases, a persisting positive margin in 8 patients. Disease-specific survival was 93.5%, 91.6% and 89.6% at 5, 10 and 15 years for whole series and 90.9%, 88.2% and 85.7% for high grade tumors. Event-free survival in patients affected by high grade tumors rated 75.0% at 5 years, 72.4% at 10 years and 72.4% at 15 years. Local recurrence free survival in high grade tumors was 87.6%, 86.2% and 86.2% at 5, 10 and 15 years. The grade of the tumor (high grade) and the initial dimension of the tumor (≥5 cm) were associated with worst survival. High grade tumor impacted negatively also on local recurrence free survival and event free survival. Instead, the initial size of the tumor significantly affected the event free survival but not the local recurrence free survival. No significant differences of outcome were found analyzing tumor depth, time interval to re-excision, presence of residual tumor or margins. CONCLUSION Based on our results and literature findings, we believe that surgeons should offer a re-excision procedure in those patients presenting with an inadequate excision of a high grade soft-tissue tumor, in particular with tumors larger than 5 cm before excision. Indeed, if an adequate second treatment is performed with surgery ± radiotherapy, the long-term results of patients receiving a re-excision after unplanned excision of a high grade soft tissue sarcoma seem to be comparable to the results generally reported for wide primary excisions. More debatable is whether to perform a re-excision or not in patients with low-grade tumors. Perhaps, in this latter group a wait and see policy can eventually be offered as well as in high grade tumors when a re-excision procedure could involve major surgery or significantly affect postoperative function.
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Affiliation(s)
- Guido Scoccianti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy.
| | - Matteo Innocenti
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy.
| | - Filippo Frenos
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy.
| | - Francesco Muratori
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy.
| | - Federico Sacchetti
- Department of Orthopaedic and Trauma Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Giovanni Beltrami
- Department of Paediatric Orthopaedic Oncology, Meyer Children's Hospital, Azienda Ospedaliero-Universitaria Meyer, Firenze, Italy.
| | - Rodolfo Capanna
- Department of Orthopaedic and Trauma Surgery, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Domenico Andrea Campanacci
- Department of Orthopaedic Oncology and Reconstructive Surgery, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy.
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9
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Winkler D, Fritzsche H, Schaser KD, Hofbauer C. Biopsie muskuloskeletaler Tumoren. DER ORTHOPADE 2020; 49:88-97. [DOI: 10.1007/s00132-020-03875-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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10
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Rath B, Hardes J, Tingart M, Braunschweig T, Eschweiler J, Migliorini F. [Resection margins in soft tissue sarcomas]. DER ORTHOPADE 2019; 48:768-775. [PMID: 31463543 DOI: 10.1007/s00132-019-03795-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Soft tissue sarcomas (STS) are a rare and heterogeneous group of malignant tumors that arise from the mesenchymal tissue. STS can form anywhere in the human body, with the extremities being preferred sites of predilection. TREATMENT A fundamental pillar of treatment is the surgical resection of soft tissue sarcomas. The goal is always an R0 resection with a safety margin. There is no consensus in the literature about the desired tumor-free resection margin. The decisive factors for these resection margins are histopathology, presence of anatomical barriers (capsule, tendon, fascia, cartilage, periosteum) and possibilities of (neo-) adjuvant therapy. DISCUSSION References in the literature support the role of resection margins as a predictor of local recurrence. Regarding the role of resection margins in overall survival, available data is divergent. There are known prognostic factors that influence overall survival, such as histological subtype, tumor size, tumor grading, and presence of metastases. So far, several studies have attempted to quantify the margins of resection, but no consensus has been reached, and debates are ongoing. When analyzing all the results of the data in the literature, it seems appropriate to aim for a negative resection margin >1 mm including an anatomical border structure, if possible.
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Affiliation(s)
- B Rath
- Klinik für Orthopädie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland.
| | - J Hardes
- Abteilung für Tumororthopädie und Sarkomchirurgie, Westdeutsches Tumorzentrum, Universitätsklinikum Essen, Essen, Deutschland
| | - M Tingart
- Klinik für Orthopädie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - T Braunschweig
- Institut für Pathologie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - J Eschweiler
- Klinik für Orthopädie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
| | - F Migliorini
- Klinik für Orthopädie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
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Decanter G, Stoeckle E, Honore C, Meeus P, Mattei JC, Dubray-Longeras P, Ferron G, Carrere S, Causeret S, Guilloit JM, Fau M, Rosset P, Machiavello JC, Delhorme JB, Regenet N, Gouin F, Blay JY, Coindre JM, Penel N, Bonvalot S. Watch and Wait Approach for Re-excision After Unplanned Yet Macroscopically Complete Excision of Extremity and Superficial Truncal Soft Tissue Sarcoma is Safe and Does Not Affect Metastatic Risk or Amputation Rate. Ann Surg Oncol 2019; 26:3526-3534. [DOI: 10.1245/s10434-019-07494-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Indexed: 01/07/2023]
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12
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Lans J, Yue KLC, Castelein RM, Chen NC, Lozano-Calderon SA. Soft tissue sarcoma of the hand: Is unplanned excision a problem? Eur J Surg Oncol 2019; 45:1281-1287. [DOI: 10.1016/j.ejso.2019.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/11/2019] [Accepted: 03/16/2019] [Indexed: 11/16/2022] Open
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13
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Nessim C. When Is Watchful Waiting Warranted? Advances in Soft Tissue Sarcoma-An Editorial Commentary. Ann Surg Oncol 2019; 26:3420-3422. [PMID: 31209668 DOI: 10.1245/s10434-019-07496-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Carolyn Nessim
- Department of Surgery, The Ottawa Hospital Research Institute, 501 Smyth Rd, CCW 1617d, Ottawa, ON, K1H 8L6, Canada.
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14
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Abstract
Inadvertent excision of lumps which turn out to be sarcomas is not uncommon.Imaging has a limited role in detecting microscopic residual disease but can show the extent of the previous surgical field.Standard treatment is wide re-excision, usually combined with radiotherapy.Residual tumour is found in an average of 50% of reported cases.The presence of residual disease is an adverse prognostic factor.All lumps bigger than a golf ball should have a diagnosis prior to excision. Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180060.
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Kattepur A, Pareekutty N, Alapatt J, Satheesan B. Unplanned excision in soft-tissue sarcomas – Is it the unkindest cut of all? CANCER RESEARCH, STATISTICS, AND TREATMENT 2019. [DOI: 10.4103/crst.crst_72_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Traub F, Griffin AM, Wunder JS, Ferguson PC. Influence of unplanned excisions on the outcomes of patients with stage III extremity soft-tissue sarcoma. Cancer 2018; 124:3868-3875. [DOI: 10.1002/cncr.31648] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/07/2018] [Accepted: 05/24/2018] [Indexed: 12/24/2022]
Affiliation(s)
- Frank Traub
- University of Toronto Musculoskeletal Oncology Unit; Mount Sinai Hospital; Toronto Ontario Canada
- Department of Orthopaedic Surgery, Faculty of Medicine; Eberhard Karls University of Tübingen; Tübingen Germany
| | - Anthony M. Griffin
- University of Toronto Musculoskeletal Oncology Unit; Mount Sinai Hospital; Toronto Ontario Canada
| | - Jay S. Wunder
- University of Toronto Musculoskeletal Oncology Unit; Mount Sinai Hospital; Toronto Ontario Canada
- Division of Orthopaedic Surgery, Department of Surgery; University of Toronto; Toronto Ontario Canada
- Sarcoma Site Group, Princess Margaret Cancer Center; Toronto Ontario Canada
| | - Peter C. Ferguson
- University of Toronto Musculoskeletal Oncology Unit; Mount Sinai Hospital; Toronto Ontario Canada
- Division of Orthopaedic Surgery, Department of Surgery; University of Toronto; Toronto Ontario Canada
- Sarcoma Site Group, Princess Margaret Cancer Center; Toronto Ontario Canada
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17
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Willegger M, Posch F, Schieder S, Funovics PT, Scharrer A, Brodowicz T, Ay C, Windhager R, Panotopoulos J. Serum creatinine and albumin predict sarcoma-specific survival in patients with myofibroblastic and fibroblastic sarcomas. J Orthop Res 2017; 35:2815-2824. [PMID: 28485477 DOI: 10.1002/jor.23598] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/03/2017] [Indexed: 02/04/2023]
Abstract
Recent evidence suggests that common prognostic factors predicting disease progression and survival in soft tissue sarcomas (STS) are not applicable to all STS entities, indicating the need for histotype specific evaluation of new prognosticators. This study aimed at evaluating preoperative serum creatinine, albumin, and the albumin-creatinine ratio (ACR) as markers for survival in patients with malignant fibroblastic and myofibroblastic sarcomas. One hundred and thirty-two patients who underwent sarcoma resection have been included. Statistical analysis comprised uni- and multivariable Cox proportional hazard models, competing risk analysis and Kaplan-Meier estimates. The 5-year overall survival (OS) was estimated at 64.1% (95%CI: 53.7-72.8) and the 5-year sarcoma-specific mortality was 19.9% (95%CI: 12.8-28.1). Elevated serum creatinine levels were significantly associated with an impaired sarcoma-specific survival (SSS) adjusted for tumor stage (subdistribution hazard ratio (SHR) per 1 mg/dl increase: 3.27; 95%CI: 1.87-5.73; p < 0.0001). Low serum albumin levels were associated with a shorter recurrence-free survival (RFS) experience (HR per 10 g/L increase: 0.62; 95%CI: 0.41-0.94; p = 0.024). The ACR emerged as an AJCC-stage-independent prognosticator of SSS (SHR per 1 unit increase: 0.94; 95%CI: 0.90-0.98; p = 0.003). In conclusion, serum albumin and creatinine have been confirmed as predictive biomarkers for disease-specific outcomes in myofibroblastic and fibroblastic sarcomas. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2815-2824, 2017.
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Affiliation(s)
- Madeleine Willegger
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Florian Posch
- Clinical Division of Medical Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.,Clinical Division of Haematology & Haemostaseology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sophie Schieder
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Philipp Theodor Funovics
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Anke Scharrer
- Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Thomas Brodowicz
- Clinical Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology & Haemostaseology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Joannis Panotopoulos
- Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
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Smolle MA, Andreou D, Tunn PU, Szkandera J, Liegl-Atzwanger B, Leithner A. Diagnosis and treatment of soft-tissue sarcomas of the extremities and trunk. EFORT Open Rev 2017; 2:421-431. [PMID: 29209518 PMCID: PMC5702952 DOI: 10.1302/2058-5241.2.170005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The relatively low incidence and often atypical clinical presentation of soft-tissue sarcomas (STS) impedes early and adequate diagnosis. Patients may report on recently enlarged soft-tissue swellings, infrequently complain of painful lesions, or even have no symptoms at all. A thorough diagnostic work-up is essential in order to distinguish between benign soft-tissue tumours and STSs. Patient history, clinical features and radiological findings all help in assessing the underlying pathology. ‘Worrying’ features such as recent increase in size, deep location relative to the fascia, a tumour exceeding 4 cm in size, and invasive growth patterns seen on imaging should prompt verification by biopsy. Even though acquisition of biopsy material may be incomplete, one should bear in mind some essential rules. Regardless of the biopsy technique applied, the most direct route to the lump in question should be identified, contamination of adjacent structures should be avoided and a sufficient amount of tissue acquired. Treatment of STS is best planned by a multidisciplinary team, involving experts from various medical specialities. The benchmark therapy consists of en bloc resection of the tumour, covered by a safety margin of healthy tissue. Depending on tumour histology, grade, local extent and anatomical stage, radiotherapy, chemotherapy and isolated hyperthermic limb perfusion may be employed. Due to the complexity of treatment, any soft-tissue swelling suspected of malignancy is best referred directly to a sarcoma centre, where therapeutic management is carefully planned by an experienced multidisciplinary team.
Cite this article: EFORT Open Rev 2017;2:421-431. DOI: 10.1302/2058-5241.2.170005
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Affiliation(s)
| | | | - Per-Ulf Tunn
- Sarcoma Center Berlin-Brandenburg, HELIOS Klinikum Berlin-Buch, Germany
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19
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20
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Surgery alone is sufficient therapy for children and adolescents with low-risk synovial sarcoma: A joint analysis from the European paediatric soft tissue sarcoma Study Group and the Children's Oncology Group. Eur J Cancer 2017; 78:1-6. [PMID: 28391003 DOI: 10.1016/j.ejca.2017.03.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/07/2017] [Accepted: 03/09/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Multimodal risk-adapted treatment is used in paediatric protocols for synovial sarcoma (SS). Retrospective analyses suggest that low-risk SS patients can be safely treated with surgery alone, but no prospective studies have confirmed the safety of this approach. This analysis pooled data from the two prospective clinical trials to assess outcomes in SS patients treated with a surgery-only approach and to identify predictors of treatment failure. METHODS Patients with localised SS enrolled on the European paediatric Soft tissue sarcoma Study Group (EpSSG) NRSTS2005 and on the Children Oncology Group (COG) ARST0332 trials, treated with surgery alone were eligible for this analysis. Patients must have undergone initial complete resection with histologically free margins, with a grade 2 tumour of any size or a grade 3 tumour ≤5 cm. RESULTS Sixty patients under 21 years of age were eligible for the analysis; 36 enrolled in the COG (from 2007 to 2012) and 24 in the EpSSG study (from 2005 to 2012). The 3-year event-free survival was 90% (median follow-up 5.2 years, range 1.9-9.1). All eight events were local tumour recurrence, whereas no metastatic recurrences were seen. All patients with recurrence were effectively salvaged, resulting in 100% overall survival. CONCLUSION This joint prospective analysis showed that patients with adequately resected ≤5 cm SS, regardless of grade, can be safely treated with a surgery-only approach. Avoiding the use of adjuvant chemotherapy and radiotherapy in this low-risk patient population may decrease both short- and long-term morbidity and mortality.
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21
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Smolle MA, Tunn PU, Goldenitsch E, Posch F, Szkandera J, Bergovec M, Liegl-Atzwanger B, Leithner A. The Prognostic Impact of Unplanned Excisions in a Cohort of 728 Soft Tissue Sarcoma Patients: A Multicentre Study. Ann Surg Oncol 2017; 24:1596-1605. [PMID: 28108827 PMCID: PMC5413518 DOI: 10.1245/s10434-017-5776-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Indexed: 12/17/2022]
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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Affiliation(s)
- Maria Anna Smolle
- Department of Orthopaedic Surgery, Medical University of Graz, Graz, Austria.
| | - Per-Ulf Tunn
- Sarcoma Centre HELIOS Klinikum Berlin-Buch, Berlin, Germany
| | | | - Florian Posch
- Division of Clinical Oncology, Medical University of Graz, Graz, Austria
| | - Joanna Szkandera
- Division of Clinical Oncology, Medical University of Graz, Graz, Austria
| | - Marko Bergovec
- Department of Orthopaedic Surgery, Medical University of Graz, Graz, Austria
| | | | - Andreas Leithner
- Department of Orthopaedic Surgery, Medical University of Graz, Graz, Austria
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22
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Gingrich AA, Elias A, Michael Lee CY, Nakache YPN, Li CS, Shah DR, Boutin RD, Canter RJ. Predictors of residual disease after unplanned excision of soft tissue sarcomas. J Surg Res 2016; 208:26-32. [PMID: 27993214 DOI: 10.1016/j.jss.2016.08.096] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/19/2016] [Accepted: 08/31/2016] [Indexed: 10/21/2022]
Abstract
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 reexcision, we sought to determine predictors of residual STS following unplanned excision. METHODS We identified 76 patients from a prospective database (January 1, 2008-September 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 reexcision. RESULTS Mean age was 52 y, and 63.2% were male. 50% had fragmented unplanned excision. Among patients undergoing reexcision, residual STS was identified in 70%. On univariable analysis, MRI showing gross disease and fragmented excision were significant predictors of residual STS (odds ratio, 10.59; 95% CI, 2.14-52.49; P = 0.004 and odds ratio, 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 About 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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Affiliation(s)
- Alicia A Gingrich
- Division of Surgical Oncology, Department of Surgery, UC Davis School of Medicine, Sacramento, California
| | - Alexandra Elias
- Division of Surgical Oncology, Department of Surgery, UC Davis School of Medicine, Sacramento, California
| | - Chia-Yuan Michael Lee
- Division of Biostatistics, Department of Public Health Sciences, Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona
| | - Yves-Paul N Nakache
- Division of Surgical Oncology, Department of Surgery, UC Davis School of Medicine, Sacramento, California
| | - Chin-Shang Li
- Division of Biostatistics, Department of Public Health Sciences, UC Davis, Davis, California
| | - Dhruvil R Shah
- Division of Surgical Oncology, Department of Surgery, UC Davis School of Medicine, Sacramento, California
| | - Robert D Boutin
- Department of Radiology, UC Davis School of Medicine, Sacramento, California
| | - Robert J Canter
- Division of Surgical Oncology, Department of Surgery, UC Davis School of Medicine, Sacramento, California.
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Panotopoulos J, Posch F, Funovics PT, Willegger M, Scharrer A, Lamm W, Brodowicz T, Windhager R, Ay C. Elevated serum creatinine and low albumin are associated with poor outcomes in patients with liposarcoma. J Orthop Res 2016. [PMID: 26222652 DOI: 10.1002/jor.23002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Low serum albumin levels and impaired kidney function have been associated with decreased survival in patients with a variety of cancer types. In a retrospective cohort study, we analyzed 84 patients with liposarcoma treated at from May 1994 to October 2011. Uni- and multivariable Cox proportional hazard models and competing risk analyses were performed to evaluate the association between putative biomarkers with disease-specific and overall survival. The median age of the study population was 51.7 (range 19.6-83.8) years. In multivariable analysis adjusted for AJCC tumor stage, serum creatinine was highly associated with disease-specific survival (Subdistribution Hazard ratio (SHR) per 1 mg/dl increase = 2.94; 95%CI 1.39-6.23; p = 0.005). High albumin was associated with improved overall and disease-specific survival (Hazard Ratio (HR) per 10 units increase = 0.50; 95%CI 0.26-0.95; p = 0.033 and SHR = 0.64; 95%CI 0.42-1.00; p = 0.049). The serum albumin-creatinine-ratio emerged to be associated with both overall and disease-specific survival after adjusting for AJCC tumor stage (HR = 0.95; 95%CI 0.92-0.99; p = 0.011 and SHR = 0.96; 95%CI 0.93-0.99; p = 0.08). Our study provides evidence for a tumor-stage-independent association between higher creatinine and lower albumin with worse disease-specific survival. Low albumin and a high albumin-creatinine-ratio independently predict poor overall survival. Our work identified novel prognostic biomarkers for prognosis of patients with liposarcoma.
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Affiliation(s)
| | - Florian Posch
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Philipp T Funovics
- Department of Orthopaedics, Medical University of Vienna, Vienna, Austria
| | | | - Anke Scharrer
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Lamm
- Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Thomas Brodowicz
- Department of Medicine I, Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
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Panotopoulos J, Posch F, Alici B, Funovics P, Stihsen C, Amann G, Brodowicz T, Windhager R, Ay C. Hemoglobin, alkalic phosphatase, and C-reactive protein predict the outcome in patients with liposarcoma. J Orthop Res 2015; 33:765-70. [PMID: 25641201 DOI: 10.1002/jor.22827] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 01/07/2015] [Indexed: 02/04/2023]
Abstract
Data on prognostic biomarkers in soft tissue sarcomas are scarce. The aim of the study was to define prognostic markers in patients with a liposarcoma, a subtype of sarcoma derived from adipose tissue. We restrospectively reviewed 85 patients with liposarcoma treated at our department from May 1994 to October 2011. Kaplan-Meier curves, uni-, and multivariable Cox proportional hazard models and competing risk analysis were performed to evaluate the association between putative biomarkers with disease-specific and overall survival. We observed a significant association between both alkalic phosphatase (ALP; subhazard ratio [SHR] per 1 unit increase: 1.35; 95%CI 1.10-1.65; p = 0.005) and C-reactive protein (CRP; SHR per 1 mg/dl increase: 2,57; 95%CI 1.36-4,86; p = 0.004) with disease-specific survival. Hemoglobin (Hb) (HR per 1 g/dl increase: 065; 95%CI 0.48-0.87; p = 0.003) was associated with overall survival. These associations prevailed after multivariable adjustment for AJCC tumor stage. This study identifies CRP and ALP as novel independent predictors of disease-specific survival in patients with liposarcoma.
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Abstract
Soft tissue sarcomas are a rare and heterogeneous group of tumors. Surgery clearly remains the standard therapy of non-metastatic soft tissue sarcoma. A pretreatment biopsy is necessary to determine the histology and grade of soft tissue sarcomas and to diagnose entities that can be treated by targeted therapies, such as dermatofibrosarcoma protuberans or alveolar soft tissue sarcoma once they are in a metastatic stage. Nevertheless, locally advanced disease requires multimodal treatment and interdisciplinary treatment decisions. Limb sarcoma of borderline resectability (encasement of vessels, invasion of joints or close proximity to motor nerves) may profit from isolated limb perfusion with recombinant tumor necrosis factor and melphalan. Preoperative chemotherapy may be applied in locally advanced high grade tumors when clear resection margins are difficult to achieve. Deep wave hyperthermia has proven to be a useful addition to systemic chemotherapy in such a neoadjuvant setting. Also preoperative radiation therapy has proven to be effective in controlling locally advanced sarcoma despite higher perioperative morbidity which pays off in the long run by better limb function. Postoperative adjuvant external beam irradiation therapy with the best available technique is recommended for any tumor larger than 5 cm with (FNLCC) grades 2 and 3 (American Joint Committee on Cancer stage IIb/III). Given all these therapeutic options, it is absolutely crucial that interdisciplinary decision-making starts early in the therapeutic process. Patients are often seen first by the surgeon. For an optimal treatment surgeons need to know the efficacy and toxicity of the multimodal treatment options described.
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Modesto A, Filleron T, Chevreau C, Le Pechoux C, Rochaix P, Le Guellec S, Ducassou A, Gangloff D, Ferron G, Delannes M. Role of radiation therapy in the conservative management of sarcoma within an irradiated field. Eur J Surg Oncol 2013; 40:187-92. [PMID: 24074728 DOI: 10.1016/j.ejso.2013.07.088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Revised: 07/16/2013] [Accepted: 07/22/2013] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To report on clinical outcome and toxicity profile after combined treatment that included radiation therapy (RT) in patients with localized sarcoma within an irradiated field. PATIENTS AND METHODS Individual clinical data from all consecutive patients diagnosed and treated for a localized SIF between January 2000 and October 2011 at the Institut Claudius Regaud, Toulouse, France, were retrospectively reviewed. Outcomes of patients with SIF who underwent adjuvant or definitive radiotherapy were compared with patients who did not receive further RT. RESULTS Of the 27 patients eligible for this study: surgery alone (S), surgery followed by RT (S + RT) or definitive RT (RT) was performed in 16, 8 and 2 cases respectively. The rate of unresectable, gross or microscopically positive margin disease among the 10 re-irradiated patients was significantly higher than the non re-irradiated group (90% vs. 12% p < 0.001). After a median follow-up of 3.8 years, there was a trend toward longer survival and better local control in the subgroup of patients who received adjuvant or definitive RT compared to the rest of the cohort with an acceptable toxicity profile. The 4-year relapse free survival rates of patients treated with and without RT were 53% and 27% respectively (p = 0.09). CONCLUSION SIF complete surgical resection is often difficult to achieve, enhancing the risk of relapse. RT should be discussed in case of unresectable tumor or after suboptimal surgery as part of intensified local management that has a curative intent.
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Affiliation(s)
- A Modesto
- Institut Claudius Regaud, Department of Radiation Oncology, 20-24, rue du Pont Saint-Pierre, 31000 Toulouse, France.
| | - T Filleron
- Institut Claudius Regaud, Department of Biostatistics, 20-24, rue du Pont Saint-Pierre, 31000 Toulouse, France
| | - C Chevreau
- Institut Claudius Regaud, Department of Medical Oncology, 20-24, rue du Pont Saint-Pierre, 31000 Toulouse, France
| | - C Le Pechoux
- Institut Gustave Roussy, Department of Radiation Oncology, 114 rue Édouard-Vaillant, 94805 Villejuif, France
| | - P Rochaix
- Institut Claudius Regaud, Department of Pathology, 20-24, rue du Pont Saint-Pierre, 31000 Toulouse, France
| | - S Le Guellec
- Institut Claudius Regaud, Department of Pathology, 20-24, rue du Pont Saint-Pierre, 31000 Toulouse, France
| | - A Ducassou
- Institut Claudius Regaud, Department of Radiation Oncology, 20-24, rue du Pont Saint-Pierre, 31000 Toulouse, France
| | - D Gangloff
- Institut Claudius Regaud, Department of Surgery, 20-24, rue du Pont Saint-Pierre, 31000 Toulouse, France
| | - G Ferron
- Institut Claudius Regaud, Department of Surgery, 20-24, rue du Pont Saint-Pierre, 31000 Toulouse, France
| | - M Delannes
- Institut Claudius Regaud, Department of Radiation Oncology, 20-24, rue du Pont Saint-Pierre, 31000 Toulouse, France
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Canter RJ, Smith CA, Martinez SR, Goodnight JE, Bold RJ, Wisner DH. Extremity soft tissue tumor surgery by surgical specialty: A comparison of case volume among oncology and non-oncology-designated surgeons. J Surg Oncol 2013; 108:142-7. [DOI: 10.1002/jso.23372] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 06/10/2013] [Indexed: 11/12/2022]
Affiliation(s)
- Robert J. Canter
- Division of Surgical Oncology; Department of Surgery; University of California Davis Medical Center; Sacramento California
| | - Caitlin A. Smith
- Department of Surgery; University of California Davis Medical Center; Sacramento California
| | - Steve R. Martinez
- Division of Surgical Oncology; Department of Surgery; University of California Davis Medical Center; Sacramento California
| | | | - Richard J. Bold
- Division of Surgical Oncology; Department of Surgery; University of California Davis Medical Center; Sacramento California
| | - David H. Wisner
- Department of Surgery; University of California Davis Medical Center; Sacramento California
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28
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Zacherl M, Kastner N, Glehr M, Scheipl S, Schwantzer G, Koch H, Leithner A, Windhager R. Influence of prereferral surgery in soft tissue sarcoma: 10 years' experience in a single institution. Orthopedics 2012; 35:e1214-20. [PMID: 22868608 DOI: 10.3928/01477447-20120725-22] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Soft tissue sarcomas are a group of rare mesenchymal neoplasms comprising 0.8% of all malignant tumors. Workup should include medical history, physical examination, magnetic resonance imaging, biopsy, and thoracoabdominal computed tomography scan, in that order. Centralized multimodality treatment in a cross-disciplinary setting is mandatory. Treatment not according to current clinical practice guidelines is a common problem before referral to a specialized institution. The purpose of this 10-year, single-institution review was to investigate the influence of curative surgery on outcome, with a special emphasis on surgery before referral. A cohort of 266 patients who underwent curative surgery for soft tissue sarcoma between 1998 and 2008 was analyzed. One hundred thirty-one (49%) patients underwent surgery contrary to current clinical guidelines before referral, most (73%) at primary care units. One hundred thirteen (86%) of these patients underwent surgery without previous biopsy with a higher rate of intralesional margins (P<.001), a smaller mean diameter of primary lesion (P<.001), a higher rate of subcutaneous situs (P<.001), a lower mean American Joint Committee on Cancer score (P=.008), a higher rate of additional plastic surgery after re-resection (eg, flap surgery) (P<.001), and a longer period before referral (P<.001). No influence on survival, local recurrence, or metastasis existed. Prereferral surgery necessitating re-resection has no influence on survival but leads to an unfavorable clinical course. More effort should be made to improve awareness and referral modalities for general practitioners and physicians at community hospitals.
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Affiliation(s)
- Maximilian Zacherl
- Department of Orthopaedic Surgery, Medical University of Graz, Graz, Austria.
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29
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Brodowicz T, Amann G, Leithner A, Sztankay A, Kainberger F, Eisterer W, Liegl-Atzwanger B, Rachbauer F, Rath T, Bergmann M, Funovics PT, Ploner F, Windhager R. [Consensus diagnosis and therapy of soft tissue sarcoma]. Wien Klin Wochenschr 2011; 124:85-99. [PMID: 22038378 DOI: 10.1007/s00508-011-0079-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 09/13/2011] [Indexed: 02/07/2023]
Abstract
Soft tissue sarcomas are heterogeneous tumours and relatively uncommon. There have been advances over the past years concerning pathology, clinical behaviour, diagnosis strategies and the treatment. To summarize these advances as well as making it public is one of the goals of the following consensus guidelines. But why do we need special guidelines for Austria? There are international guidelines published by the European Society of Medical Oncology (ESMO) and the National Comprehensive Cancer Network (NCCN). The cause is that we need an explanation of the matrix the ESMO and the NCCN gave according to our clinical practice, the local requirements and facilities in Austria. The following recommendations were drawn up following a consensus meeting of sarcoma specialists from the three high volume centres located at the medical universities in Austria. All fields of involved physicians from diagnosis to therapy worked together to know that soft tissue sarcomas are an interdisciplinary challenge and multimodal treatment is essential. For this reason, these guidelines not only explain but also give the state of the art and clear recommendations. One of the most important guidelines is that any patient with a suspected soft tissue sarcoma should be referred to one of the three university centres and managed by a specialist sarcoma multidisciplinary team. We hope that the consensus is helpful for the clinical practice and improves the quality of care for patients with soft tissue sarcomas in Austria.
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Affiliation(s)
- Thomas Brodowicz
- Klinische Abteilung für Onkologie, Universitätsklinik für Innere Medizin, Wien, Austria.
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