Characteristics of 64 sarcoma patients referred to a sarcoma center after unplanned excision

Do Patients Treated With an Unplanned Resection for Small Superficial Soft Tissue Sarcomas Have Worse Long-term Survival Than Those Initially Treated With an Oncologic Resection?

BACKGROUND

Histologic grade, size, and depth are well-known prognostic factors in soft tissue sarcomas (STS). Small (< 5 cm) and superficial STS generally have an excellent prognosis when treated with appropriate surgery. However, they are often misdiagnosed and mistreated. We reported that in midterm follow-up (5 to 7 years), patients with unplanned resections of tumors with positive margins who immediately underwent a reoperation with margin-widening re-resection and postoperative radiotherapy had survival comparable to that of patients who were initially treated correctly. In that article, we included STS larger than 5 cm, deep STS, and individuals with local recurrence. However, we wanted to evaluate the impact of unplanned resection on the survival of patients who had STS with the best prognosis, small and superficial STS, with two groups that were as homogeneous as possible.

QUESTION/PURPOSE

Do patients with small and superficial STS who underwent an unplanned resection have worse prognosis in the long term than those who were initially treated correctly?

METHODS

We exclusively evaluated patients with small (< 5 cm) and superficial (to the deep fascia) STS. We systematically excluded deep STS. Among this subset, we identified 93 patients with superficial STS. We excluded patients with local relapse, metastatic disease, superficial STS of the head or neck, those with insufficient clinical or dosimetric information, and patients with follow-up of less than 2 years. Furthermore, our focus on investigating the most benign and homogeneous STS prompted us to exclude patients with superficial tumors greater than or equal to 5 cm. This selection was driven by the presumed better prognosis associated with smaller tumors, inevitably leading to a smaller pool of patients for direct comparison with patients who had unplanned resections. The initial expectation was to observe similar survival outcomes between cohorts. Between 1990 and 2019, a total of 17 patients underwent surgical treatment at our private, medium-size center. Of those, 29% (5 patients) were lost to follow-up before 2 years without meeting a study endpoint (relapse, metastasis or revision, reoperation, or death), leaving a total of 71% (12 patients) of the original group who had either follow-up of at least 2 years or who met a study endpoint before that minimum surveillance duration. They were treated with surgery alone. During that same period, another 51 patients were referred to us after undergoing an unplanned resection of a lesion that subsequently was determined to be a soft tissue malignancy. Of those, 18% (9 patients) were lost to follow-up before 2 years without meeting a study endpoint, leaving 82% (42 patients) of the original group who had either follow-up of at least 2 years or who met a study endpoint before that minimum surveillance duration. They were treated with re-excision and postoperative radiotherapy. Patients with unplanned resections had an older mean age (51± 5 versus 44 ± 7 years; p = 0.1) and a higher proportion of female patients (58% versus 38%; p = 0.07), but the groups did not differ in terms of largest diameter, histologic type, or tumor location. However, patients with planned resections had a higher proportion of high-grade STS (75% versus 55%; p = 0.07). No metastases were present in either group at diagnosis. We performed a univariate analysis of the groups. We could not perform a multivariate analysis because of the small sample. We compared the groups in terms of local recurrence and all-cause mortality using the Kaplan-Meier survivorship estimator.

RESULTS

According to the Kaplan-Meier survivorship estimator, survivorship free from local recurrence at a mean of 20 years of follow-up was better in the planned resection group than in the unplanned resection group (92% [95% CI 63% to 100%] versus 69% [95% CI 54% to 81%]; p = 0.04). Furthermore, overall survivorship at 5 years was higher in the planned resection group than in the unplanned resection group (100% [95% CI 72% to 100%] versus 70% [95% CI 54% to 81%]; p = 0.04). Similarly, the planned resection group exhibited superior survivorship at 20 years of follow-up (100% [95% CI 72% to 100%] versus 62% [95% CI 47% to 75%]; p = 0.01). Metastatic disease was absent in the planned resection group, while it occurred in 12 patients in the unplanned resection group (28% [95% CI 17% to 44%]).

CONCLUSION

Unplanned resection for patients with small and superficial STS was associated with a decrease in overall survival in the long term, despite the use of postoperative radiotherapy. An unplanned resection may be an important prognostic factor. Nevertheless, larger and prospective studies are needed to validate our findings. Although small and superficial lumps are usually benign, nonsarcoma surgeons should be aware that some masses may be malignant, and if in doubt, MR imaging, a biopsy before excision, or consultation with or referral to a sarcoma center should be considered before removing the mass.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The prognostic significance of surgical resection margins for local recurrence, distant metastasis, and overall survival in sarcoma

BACKGROUND AND OBJECTIVES

Surgical resection with microscopically negative margins constitutes one of the key elements of a curative therapeutic approach for localized sarcomas. However, the prognostic value of quantitative margin width remains controversial. We sought to determine the prognostic significance of margin status and margin width for local recurrence (LR), distant recurrence (DR), and overall survival.

METHODS

Retrospective analysis of 210 patients undergoing resection of localized sarcoma between 1997 and 2018 at a national sarcoma reference center.

RESULTS

Logistic regression did not reveal an effect of metric margin width as a prognostic factor for LR (odds ratio [OR] = 0.98, p = 0.574), DR (OR = 1, p = 0.908), or overall survival (hazard ratio = 0.98, 95% confidence interval = 0.73-1.20, p = 0.609). Subgroup analysis revealed no differences between complete first resections (R0) and re-resections (re-R0) following unplanned R1-resections for LR (p = 0.727) and overall survival (p = 0.125), but a significantly higher DR-rate in re-R0 cases (p = 0.022).

CONCLUSIONS

Achieving a negative margin is essential in sarcoma surgery, however, metric margin width was not associated with disease-specific outcomes. Re-resection of unplanned R1-resections should be performed to control for LR and overall survival rates. As re-R0 cases were at significantly higher risk of DR, these patients should be followed up closely in standardized surveillance protocols.

Issues of diagnostic search of soft tissue sarcoma

Relevance. Soft tissue sarcoma is a heterogeneous group of relatively rare types of tumors, which demonstrates a huge variety of anatomical localization and histopathological characteristics. The rarity of soft tissue sarcomas combined with a variety of subtypes, forms of growth, progression and frequency of relapses makes it difficult to study them, make a correct diagnosis and early referral of patients for specialized care.

The purpose of study. To analyze the problem of differential diagnosis of malignant and benign soft tissue neoplasms.

Materials and methods. In the course of the work, current literary sources of domestic and foreign authors on a given topic were analyzed.

Results. Since it is absolutely impossible to determine the clinical features of the presented sarcoma, soft tissue tumors showing any of the following signs are considered malignant until the opposite is proven: increasing in size, >5 cm, deeply located and/or painful. The greater the number of these clinical signs present, the higher the risk that the soft tissue tumor will turn out to be malignant; at the same time, an increase in size is the best individual indicator. It is worth noting that the absence of concomitant constitutional symptoms, such as fever, chills, night sweats or unintentional weight loss, should not reduce the doctor's suspicion of malignancy.

Conclusion. In order to avoid erroneous diagnoses, a standardized diagnostic approach should be followed, starting from the moment of collecting the patient's medical history, clinical examination and ending with the use of appropriate imaging methods and biopsy.

Issues of diagnostic search of soft tissue sarcoma

Relevance. Soft tissue sarcoma is a heterogeneous group of relatively rare types of tumors, which demonstrates a huge variety of anatomical localization and histopathological characteristics. The rarity of soft tissue sarcomas combined with a variety of subtypes, forms of growth, progression and frequency of relapses makes it difficult to study them, make a correct diagnosis and early referral of patients for specialized care.

The purpose of study. To analyze the problem of differential diagnosis of malignant and benign soft tissue neoplasms.

Materials and methods. In the course of the work, current literary sources of domestic and foreign authors on a given topic were analyzed.

Results. Since it is absolutely impossible to determine the clinical features of the presented sarcoma, soft tissue tumors showing any of the following signs are considered malignant until the opposite is proven: increasing in size, >5 cm, deeply located and/or painful. The greater the number of these clinical signs present, the higher the risk that the soft tissue tumor will turn out to be malignant; at the same time, an increase in size is the best individual indicator. It is worth noting that the absence of concomitant constitutional symptoms, such as fever, chills, night sweats or unintentional weight loss, should not reduce the doctor's suspicion of malignancy.

Conclusion. In order to avoid erroneous diagnoses, a standardized diagnostic approach should be followed, starting from the moment of collecting the patient's medical history, clinical examination and ending with the use of appropriate imaging methods and biopsy.

Shortening the Time Interval for the Referral of Patients With Soft Tissue Sarcoma to Expert Centers Using Mobile Health: Retrospective Study

BACKGROUND

According to guidelines, all patients with sarcoma must be managed from initial diagnosis at expert sarcoma centers. However, in everyday practice, the time interval to an expert center visit can be long, which delays presentation to an expert multidisciplinary tumor board and increases the risk of inappropriate management, negatively affecting local tumor control and prognosis. The advent of mobile health offers an easy way to facilitate communication and cooperation between general health care providers (eg, general practitioners and radiologists) and sarcomas experts. We developed a mobile app (Sar'Connect) based on the algorithm designed by radiologists from the French Sarcoma Group. Through a small number of easy-to-answer questions, Sar'Connect provides personalized advice for the management of patients and contact information for the closest expert center.

OBJECTIVE

This retrospective study is the first to assess this mobile app's potential benefits in reducing the time interval for patient referral to an expert center according to the initial clinical characteristics of the soft tissue tumor.

METHODS

From May to December 2021, we extracted tumor mass data for 78 patients discussed by the multidisciplinary tumor boards at 3 centers of the French Sarcoma Group. We applied the Sar'Connect algorithm to these data and estimated the time interval between the first medical description of the soft tissue mass and the referral to expert center. We then compared this estimated time interval with the observed time interval.

RESULTS

We found that the use of Sar'Connect could potentially shorten the time interval to an expert center by approximately 7.5 months (P<.001). Moreover, for half (31/60, 52%) of the patients with a malignant soft tissue tumor, Sar'Connect could have avoided inappropriate management outside of the reference center. We did not identify a significant determinant for shortening the time interval for referral.

CONCLUSIONS

Overall, promoting the use of a simple mobile app is an innovative and straightforward means to potentially accelerate both the referral and management of patients with soft tissue sarcoma at expert centers.

The incidence of unplanned excision in patients with soft tissue sarcoma: Reports from the Bone and Soft Tissue Tumor registry in Japan

BACKGROUND

Due to their rarity, soft tissue sarcomas (STS)s are often treated surgically as unplanned excisions (UE)s before referral to specialists. The Bone and Soft Tissue Tumor (BSTT) registry is a nationwide, organ-specific cancer registry for bone and soft-tissue tumors in Japan. The aim of this study was to elucidate the incidence and risk factors for UEs using data from the BSTT registry.

METHODS

Our study comprised 8761 patients with STS including 4826 males and 3935 females, with a mean age of 59 years (range, 0-105 years). Patients were classified into primary STS and UE groups.

RESULTS

Superficial and deep tumors were found in 2533 and 6120 patients, respectively. The mean STS size was 8.6 cm (range, 0.2-49 cm). We identified 6610 patients with high-grade, and 1758 patients with low-grade STS. Of the total 8761 patients, 7770 patients had primary STSs, whereas 991 patients were referred after undergoing UE. The UE mean incidence rate over 11 years was 11.3%. The UE incidence rates for leiomyosarcoma (LMS) (odds ratio [OR] = 1.75, p < 0.0001), fibrosarcoma (FS) (OR = 2.28, p < 0.0001), and epithelioid sarcoma (OR = 1.82, p = 0.01) were higher than the mean UE incidence rate (11.3%). Of 757 patients who underwent UE, 354 (47%) patients had superficial (≤5 cm) STSs, whereas 156 (20.6%) of patients had deep STSs (>5 cm) (p < 0.0001). Logistic regression analysis revealed that UE was frequently associated with males and small, superficial, and trunk STSs.

CONCLUSIONS

In the present study, the mean UE incidence rate (11.3%) was significantly different from the individual UE incidence rates of histological diagnoses suggesting that surgeons should consider STS, even with small tumors. Continuous education during training for medical students and surgeons is essential to ensure awareness and correct diagnostic procedures for STS.

Incidence of unplanned excisions of soft tissue sarcomas in the Netherlands: A population-based study

INTRODUCTION

Timely recognition of soft tissue sarcomas (STS) remains challenging, potentially leading to unplanned excisions (also known as 'whoops procedures'). This population-based study charted the occurrence of unplanned excisions and identified associated patient, tumour, and treatment-related characteristics. Furthermore, it presents an overview of the outcomes and clinical management following an unplanned excision.

METHODS

From the Netherlands Cancer Registry (NCR) database, information was obtained on 2187 adult patients diagnosed with STS in 2016-2019 who underwent surgery. Tumours located in the mediastinum, heart or retroperitoneum were excluded, as well as incidental findings. Differences between patients with planned and unplanned excisions were assessed with chi-square tests and a multivariable logistic regression model.

RESULTS

Overall, unplanned excisions comprise 18.2% of all first operations for STS, with a quarter of them occurring outside a hospital. Within hospitals, the unplanned excision rate was 14.4%. Unplanned excisions were more often performed on younger patients, and tumours unsuspected of being STS prior to surgery were generally smaller (≤5 cm) and superficially located. Preoperative imaging was omitted more frequently in these cases. An unplanned excision more often resulted in positive margins, requiring re-excision. Patients who had an unplanned excision outside of a sarcoma centre were more often discussed at or referred to a sarcoma centre, particularly in case of residual tumour.

DISCUSSION

Potential improvement in preventing unplanned excisions may be achieved by better compliance to preoperative imaging and referral guidelines, and stimulating continuous awareness of STS among general surgeons, general practitioners and private practices.

Unplanned excision of soft tissue sarcoma: does it impact the accuracy of intra-operative pathologic assessment at time of re-excision?

PURPOSE

An "unplanned excision" refers to soft tissue sarcomas excised without planning imaging studies and a diagnostic biopsy, resulting in the presence of residual disease and usually necessitating a re-excision procedure. We aimed to assess the impact of previous unplanned excisions on the intra-operative pathologic assessment at the time of re-excision, in terms of need to perform repeat assessments and the accuracy to predict margin status of the final pathologic specimen.

METHODS

Data was collected for all patients with extremity soft tissue sarcoma who had undergone wide local excision limb salvage surgery or amputation between 2012 and 2017. Intra-operative pathologic assessment with frozen sections was performed in all cases and was classified as negative, negative but close (< 1 mm), and positive.

RESULTS

A total of 173 patients with extremity soft tissue sarcoma were included, 54 in the unplanned excision group and 119 in the planned excision group. The accuracy of intra-operative pathologic assessment to predict the margin status on final pathology was similar between groups (87% unplanned vs. 90.7% planned excisions). However, the need for repeat intra-operative pathologic assessment and subsequent resection due to microscopically positive margins was found to be higher within the unplanned excision group ((p = 0.04), OR = 3.2 (95% CI: 1.1-9.1, p = 0.048)).

CONCLUSIONS

Intra-operative pathologic assessment of resection margins had a similar accuracy in planned and unplanned excisions; however, unplanned excisions showed a higher risk of re-resection during the same surgical setting.

Re-excision after unplanned excision of soft tissue sarcoma: A systematic review and metanalysis. The rationale of systematic re-excision

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.

Does Unplanned Soft Tissue Sarcoma Surgery Have a Negative Effect on Prognosis?

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.

Small indeterminate superficial soft tissue masses: relationship between depth and histological grade

OBJECTIVE

To determine whether the location of a small, indeterminate soft tissue mass within the subcutaneous compartment is related to its histological grade.

METHODS

All Sarcoma Service referrals over a 12 month period of small (<3 cm) superficial soft tissue masses, indeterminate by MRI evaluation which subsequently underwent primary excision biopsy were included. Lesions were categorised by their anatomical location in the subcutaneous compartment. Histopathological diagnoses were categorized according to12 WHO 2013. χ2 statistical analysis was performed to determine the relationship between lesion depth and histological grade.

RESULTS

The study included 43 patients, mean age 42 years (range 15-71 years). Within the subcutaneous compartment, 16 lesions were categorized as superficial, 9 lesions central and 18 lesions deep, of which 9 were non-neoplastic, 29 benign, 1 intermediate-grade and 4 malignant. Location in the deep aspect of the subcutaneous compartment was associated with a higher risk of intermediate or malignant histology (p = 0.02).

CONCLUSION

The location of a small, indeterminate soft tissue mass within the subcutaneous compartment may be an indicator of histological aggressiveness. Lesions in the deep subcutaneous compartment are more likely to be intermediate-grade/malignant lesions. Therefore, if considering excision biopsy as definitive treatment, a wider margin may be appropriate.

ADVANCES IN KNOWLEDGE

Small, indeterminate soft tissue masses can be aggressive and the anatomical depth within the subcutaneous tissue may be a potential indicator of histological aggressiveness.

The incidence and diagnostic relevance of chemical shift artefact in the magnetic resonance imaging characterisation of superficial soft tissue masses

OBJECTIVE

Chemical shift artefact (CSA) is often encountered during MRI evaluation of superficial soft tissue masses. The study aim was to determine the incidence and diagnostic relevance of CSA in a consecutive series of superficial soft tissue masses referred to a specialist musculoskeletal sarcoma service.

METHODS

All patients referred over a 6 month period with a non-lipomatous superficial soft tissue mass were prospectively analysed. Patients characteristics (age, gender), lesion features (anatomical location, size, relationship to the skin and deep fascia), presence of CSA and final histopathological diagnosis were collected. The presence of CSA was statistically analysed against these clinical, imaging and histopathological variables.

RESULTS

128 patients fulfilled the inclusion criteria [63 males, 65 females; mean age = 50.6 years (7-96 years)]. CSA was present in 50 cases (39.1%) overall, but in 39 (41.5%) of 94 cases with histological diagnosis. There was no statistically significant relationship to any assessed variable apart from relationship to the deep fascia, CSA being more frequent in lesions contacting the fascia compared to lesions contacting both skin and fascia (p-value 0.02). In particular, the presence of CSA did not allow differentiation between non-malignant and malignant lesions.

CONCLUSION

The presence of CSA is a not infrequent finding in the MRI assessment of superficial soft tissue masses but does not appear to be of any significance in differentiating between non-malignant and malignant lesions.

ADVANCES IN KNOWLEDGE

CSA is a relatively common finding in association with superficial soft tissue masses, but does not indicate a particular histological diagnosis or help in the differentiation of non-malignant from malignant lesions.

Synovial sarcoma mimicking a traumatic pseudoaneurysm in the upper extremity

Synovial sarcomas are a rare but aggressive malignancy that primarily affects young patients. Diagnosis is often difficult and delayed due to its insidious onset, heterogenous presentation and mimicry of other pathologies. We present the case of a patient with a history of a slow-growing left arm mass that arose after a traumatic fracture of the humerus. Multimodal imaging was undertaken and reported the mass as being consistent with a vascular malformation of the brachial artery. The patient underwent surgical repair of the artery and intraoperative biopsies confirmed a diagnosis of synovial sarcoma. This case highlights the importance of maintaining suspicion for soft-tissue sarcomas in young patients presenting with a mass, and demonstrates the way in which these tumours may mimic other pathologies both clinically and radiologically. Early referral to a specialist sarcoma centre is key for further investigative workup.

Small soft tissue masses indeterminate at imaging: histological diagnoses at a tertiary orthopedic oncology clinic

OBJECTIVE

To review histologic diagnoses of soft-tissue masses (STMs) ≤ 2 cm with indeterminate imaging features encountered in musculoskeletal oncology clinic at a tertiary referral center.

MATERIALS AND METHODS

This was an IRB-approved retrospective review of patients with STMs ≤ 2 cm, referred to our tertiary care orthopedic oncology clinic over 4.75 consecutive years. Maximum diameter was based on imaging measurement by a fellowship-trained musculoskeletal radiologist. Simple lipomas, synovial cysts, metastases, and cases without histologic confirmation were excluded. Patient demographics, tumor imaging features (location, depth, size, and tumor:muscle enhancement and T2 signal ratios), and histology were recorded and compared.

RESULTS

Mean maximum diameter for 42 trunk/extremity STMs was 1.5 cm (range, 0.7 to 2 cm). Mean age was 48 years (range, 18-83 years). Nine (21%) of the masses were malignant, while 33 (79%) were non-malignant. Thirty-nine (93%) of masses were superficial; 7/39 (18%) of these superficial tumors were malignant. Malignancy was not associated with underlying vessels, tendon, or fascia (p = 0.19). The non-malignant vs. malignant tumor:muscle enhancement ratio was 2.15 vs. 2.32 (p = 0.58) and enhancement coefficient of variation was 0.14 vs. 0.10 (p = 0.29). Most common malignant histologic subtypes were synovial sarcoma (n = 3), fibroblastic/myofibroblastic sarcoma (n = 2), leiomyosarcoma (n = 2), myxofibrosarcoma (n = 1), and angiomatoid fibrous histiocytoma (n = 1). The majority (67%) of non-malignant lesions were: leiomyoma (n = 6), angiomyoma (n = 5), schwannoma (n = 4), benign fibrous histiocytoma (n = 4), and hemangioma (n = 3).

CONCLUSIONS

At a tertiary musculoskeletal oncology referral clinic, primary STMs ≤ 2 cm with indeterminate imaging features should be managed cautiously despite their small size and/or superficial location.

Conformity to Clinical Practice Guidelines at Initial Management in Adult Soft Tissue and Visceral Tumors since the Implementation of the NetSarc Network in Eastern France

BACKGROUND

Soft tissue sarcomas are rare and heterogenous tumors that are hard to diagnose. The aim of this study was to evaluate local practices and conformity to clinical practice guidelines (CPGs) for their initial diagnostic management.

MATERIALS AND METHODS

Patients were carriers of a soft tissue or visceral tumor, presented at a sarcoma tumor board (STB) between 2010 and 2016. Conformity to CPGs was evaluated using ten criteria designed for this purpose. Associations between different factors and conformity to composite criteria, reflecting the three main diagnostic steps (imaging, biopsy and histological report) were analyzed.

RESULTS

A total of 643 patients were included. A preoperative tumor imaging assessment and a biopsy were performed according to CPGs in 80.8% and 36.8% of the cases, respectively. When done, the first surgical resection was R0 in 30.3% of cases, R1 in 28.6%, and R2 in 10.9%. The rest of the operated patients with sarcoma had a second surgical excision (11.4%), an intraoperative fragmentation (4.3%), or margins were unknown (14.4%). Six of the ten quality criteria presented a conformity rate higher than 70%. Two criteria with a conformity rate lower than 20% were the most controversial: presentation at a STB before biopsy and freezing of a tumor fragment. A multivariate analysis revealed that the common predictor of nonconformity to composite criteria was the initial management in a nonexpert center.

CONCLUSION

Initial diagnostic management requires improvement, especially outside of specialized centers.

IMPLICATIONS FOR PRACTICE

This article supports the essential need to refer patients with soft tissue tumors to specialized centers to improve the management of sarcomas beginning at the diagnostic phase. Indeed, the reported data were very similar to those already described at the national level of the NetSarc network and indicate the necessity to keep raising awareness about this simple issue: early referral to reference centers will save lives.

Limbs and trunk soft tissue sarcoma systematic local and remote monitoring by MRI and thoraco-abdomino-pelvic scanner: A single-centre retrospective study

INTRODUCTION

Soft tissue sarcomas (STS) are rare malignant tumors that require management by an expert center. Monitoring modalities are not consensual. The objective of our study is to report systematic radiological monitoring data obtained by local MRI and by thoracic-abdominal-pelvic computed tomography (TAP CT).

MATERIAL AND METHODS

113 consecutive patients managed at "Centre Georges François Leclerc, Dijon", between 2008 and 2016, for an initially localized STS were included. Patient follow-up consisted of a local MRI and a TAP CT. Follow-up exams schedule was initially every 4 months during 2 years, followed by every 6 months during 3 years and finally every year during 5 years.

RESULTS

Median follow-up time was 37.2 months [min = 2.4 - max = 111.6]. After 5 years of surveillance, local recurrence (LR) rate was 8.8% and diagnosed by imaging in 60% of cases. No deep LR was clinically found. Median LR diagnosis time was 23.9 months [min = 2.0 - max = 52.4]. 50% of patients locally treated for their LR were alive without recurrence. Metastatic recurrence (MR) rate was 31%. 42.8% had extra-pulmonary involvement and 17.1% had exclusive extrathoracic metastases. The median time to diagnosis of MR was 17.4 months [min = 2.7- max = 77.2]. High-grade tumors relapsed more (20.4%) and earlier (all before the 5th year) than low grade.

CONCLUSION

Local MRI seems particularly suitable for monitoring deep tumors. In addition, the systematic monitoring by TAP CT highlighted a limited number of cases of exclusive extrathoracic metastases. The schedule of local and remote monitoring should primarily be adjusted to tumor grade.

Symptom Signatures and Diagnostic Timeliness in Cancer Patients: A Review of Current Evidence

Early diagnosis is an important aspect of contemporary cancer prevention and control strategies, as the majority of patients are diagnosed following symptomatic presentation. The nature of presenting symptoms can critically influence the length of the diagnostic intervals from symptom onset to presentation (the patient interval), and from first presentation to specialist referral (the primary care interval). Understanding which symptoms are associated with longer diagnostic intervals to help the targeting of early diagnosis initiatives is an area of emerging research. In this Review, we consider the methodological challenges in studying the presenting symptoms and intervals to diagnosis of cancer patients, and summarize current evidence on presenting symptoms associated with a range of common and rarer cancer sites. We propose a taxonomy of cancer sites considering their symptom signature and the predictive value of common presenting symptoms. Finally, we consider evidence on associations between symptomatic presentations and intervals to diagnosis before discussing implications for the design, implementation, and evaluation of public health or health system interventions to achieve the earlier detection of cancer.

Soft-tissue Sarcomas

This article discusses the epidemiology, diagnosis, and management of primary soft-tissue sarcomas (STS). These musculoskeletal tumors are a rare and heterogeneous group of malignancies, which are best managed by multidisciplinary teams in specialist sarcoma referral centers. Historically, the standard for local control of these tumors has been amputation. Evolutions in multimodality treatment have seen a shift toward preservation of the limb. Advances in limb-sparing surgery have seen the quality of life in sarcoma patients to improve drastically; however, unplanned surgical excision of STS remains a major treatment dilemma in the control of local disease.

Small, superficial, indeterminate soft-tissue lesions as suspected sarcomas: is primary excision biopsy suitable?

OBJECTIVE

Suspected soft-tissue sarcomas are typically investigated using magnetic resonance imaging (MRI), with a view to planning image-guided core needle biopsy for confirmation of the histological diagnosis. Indeterminate superficial lesions may be small and therefore potentially difficult to biopsy safely, such lesions possibly being more amenable to primary excision biopsy. The aim of this study is to determine the suitability of this practice in the setting of a specialist sarcoma service.

MATERIALS AND METHODS

All patients referred over a 12-month period to the sarcoma service with a small (<3-cm), indeterminate, superficial soft-tissue mass according to MRI criteria, or a small lesion of the hand or foot deemed unsafe for percutaneous biopsy, and who underwent primary excision biopsy were included. The histology results were categorized into neoplastic and non-neoplastic lesions, and assessed for resection completeness.

RESULTS

Fifty-eight patients fulfilled the inclusion criteria from all patients referred to the sarcoma service in a 12-month period. Of these, 42 out of 58 (72.4%) had benign neoplasms, 4 out of 58 (6.9%) had malignant tumours, 2 out of 58 (3.4%) an intermediate grade lesion, while 10 out of 58 (17.2%) were non-neoplastic. All 4 malignant lesions were completely excised at the time of excision biopsy.

CONCLUSIONS

Primary excision biopsy of small, indeterminate soft-tissue masses within the setting of a specialist sarcoma service is a suitable management option. Only a small proportion of small superficial soft-tissue lesions with indeterminate MRI features are malignant tumours.

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

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.

The Danish Sarcoma Database

AIM

The aim of the database is to gather information about sarcomas treated in Denmark in order to continuously monitor and improve the quality of sarcoma treatment in a local, a national, and an international perspective.

STUDY POPULATION

Patients in Denmark diagnosed with a sarcoma, both skeletal and ekstraskeletal, are to be registered since 2009.

MAIN VARIABLES

The database contains information about appearance of symptoms; date of receiving referral to a sarcoma center; date of first visit; whether surgery has been performed elsewhere before referral, diagnosis, and treatment; tumor characteristics such as location, size, malignancy grade, and growth pattern; details on treatment (kind of surgery, amount of radiation therapy, type and duration of chemotherapy); complications of treatment; local recurrence and metastases; and comorbidity. In addition, several quality indicators are registered in order to measure the quality of care provided by the hospitals and make comparisons between hospitals and with international standards.

DESCRIPTIVE DATA

Demographic patient-specific data such as age, sex, region of living, comorbidity, World Health Organization's International Classification of Diseases - tenth edition codes and TNM Classification of Malignant Tumours, and date of death (after yearly coupling to the Danish Civil Registration System). Data quality and completeness are currently secured.

CONCLUSION

The Danish Sarcoma Database is population based and includes sarcomas occurring in Denmark since 2009. It is a valuable tool for monitoring sarcoma incidence and quality of treatment and its improvement, postoperative complications, and recurrence within 5 years follow-up. The database is also a valuable research tool to study the impact of technical and medical interventions on prognosis of sarcoma patients.