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Broida SE, Arguello AM, Sullivan MH, Robinson SI, Okuno SH, Siontis BL, Ho TP, Rose PS, Xu-Welliver M, Houdek MT. Unplanned Excision of Synovial Sarcoma: Factors Associated with Recurrence and Survival. Cancers (Basel) 2024; 16:3157. [PMID: 39335129 PMCID: PMC11429553 DOI: 10.3390/cancers16183157] [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: 08/12/2024] [Revised: 09/05/2024] [Accepted: 09/12/2024] [Indexed: 09/30/2024] Open
Abstract
Background: Synovial sarcoma is rare and may present as a small, slow-growing mass. These tumors are often mistaken as benign and are therefore prone to unplanned and/or non-oncologic excision. We sought to identify the rate of unplanned excision of synovial sarcoma and risk factors for recurrence and survival among this cohort. Methods: The medical records of 246 patients evaluated at a single institution for synovial sarcoma between 1997 and 2022 were retrospectively reviewed. Of these, 87 (35%) underwent unplanned, non-oncologic excision. The mean age of the cohort was 49 years. Primary tumors were located in the extremity (n = 63), abdomen (n = 6), thorax (n = 7), head/neck (n = 8), and paraspinal region (n = 3). The median maximum pre-treatment dimension of the primary tumor was 4.8 cm (IQR 7-2.4). Seventy-seven (86%) patients underwent re-excision of the tumor bed, 39 (45%) received chemotherapy, and 63 (72%) received radiation therapy. Results: Among patients who underwent unplanned excision, local recurrence-free survival (LRFS) was 98% at 1 year and 82% at 5 years. Metastasis-free survival (MFS) was 91% at 1 year and 72% at 5 years. Disease-specific survival (DSS) was 98% at 1 year and 72% at 5 years. When adjusting for tumor size, tumors which underwent unplanned excision did not have worse recurrence or survival compared to those which had planned excision (p > 0.10). Size > 5 cm, monophasic subtype, and axial location were associated with increased risk of disease recurrence. Forty-six patients had residual tumor following re-excision, which was associated with worse MFS (HR 8.17, 95% CI [1.89, 35.2], p < 0.01) and DSS (HR 7.66, 95% CI [1.76, 33.4], p < 0.01). Patients who received radiotherapy had improved MFS (HR 6.4, 95% CI [1.42, 29.0], p = 0.02) and DSS (HR 5.86, 95% CI [1.27, 26.9], p = 0.02). Conclusions: One-third of patients presenting with synovial sarcoma were diagnosed after unplanned, non-oncologic excision. Patients with large, axial tumors had worse survival. Approximately half of patients who underwent unplanned excision had no residual tumor after pre-operative radiation. The use of radiation was associated with decreased rates of recurrence and improved disease-specific survival. Our results suggest that margin-negative re-resection and radiotherapy should be considered when feasible following unplanned excision of synovial sarcoma.
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Affiliation(s)
- Samuel E Broida
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | - Steven I Robinson
- Department of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Scott H Okuno
- Department of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Thanh P Ho
- Department of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Meng Xu-Welliver
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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2
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Elmorsi R, Camacho L, Krijgh DD, Tilney GS, Lyu H, Traweek RS, Witt RG, Roubaud MS, Roland CL, Mericli AF. Optimizing Morbidity in Unplanned Soft Tissue Sarcoma Excisions: Should We Skip the Reconstructive Ladder? Ann Plast Surg 2024; 93:361-368. [PMID: 38920187 DOI: 10.1097/sap.0000000000004013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
INTRODUCTION Soft tissue sarcomas (STSs) are rare and diverse primary malignant tumors that comprise approximately 1% of all malignancies. Misdiagnoses and unplanned excisions of STSs are common due to the tumor's rarity, leading to secondary tumor bed excisions (TBEs). Reconstructive outcomes for TBEs remain poorly understood, prompting this study to address the knowledge gap and inform preoperative discussions. METHODS This was a retrospective cohort study of patients who underwent STS excisions at a quaternary cancer center. Patients were categorized into mass excision (ME) and TBE groups. Reconstructive approaches were divided into simple (primary closure, complex repair, skin grafts, local flaps) and advanced (pedicled or free flaps). The groups were compared for postoperative outcomes, including complications, recurrence, and death. RESULTS When simple reconstructive techniques were used, TBEs exhibited higher rates of overall and major complications, whereas MEs had higher rates of overall and minor complications. Intergroup analysis revealed that with simple reconstruction, rates of overall and major complications were higher in TBEs than in MEs, and rates of minor complications were higher in MEs than in TBEs. Regression analyses revealed that simple reconstruction of TBEs had 90% and 180% higher odds of major complications and reoperation compared to simple reconstruction of MEs ( P < 0.05). CONCLUSION TBEs, despite their smaller size, exhibited a heightened susceptibility to overall and major complications, challenging the notion that simpler techniques suffice in these cases. Our findings encourage the consideration of advanced reconstructive techniques for TBEs that may seem amenable to simple reconstructive techniques.
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Affiliation(s)
- Rami Elmorsi
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Luis Camacho
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David D Krijgh
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gordon S Tilney
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Heather Lyu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Raymond S Traweek
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Russell G Witt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Margaret S Roubaud
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexander F Mericli
- From the Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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3
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Ahlquist S, Chen KY, Chang E, Nelson SD, Bernthal NM, Wessel LE. Early Complications of Planned Resection Versus Unplanned Excision of Sarcomas in the Distal Upper Extremity. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:558-562. [PMID: 39166192 PMCID: PMC11331227 DOI: 10.1016/j.jhsg.2024.04.010] [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: 03/17/2024] [Accepted: 04/08/2024] [Indexed: 08/22/2024] Open
Abstract
Purpose Unplanned excisions are defined as excisions of malignant tumors performed without preoperative cross-sectional imaging or diagnostic biopsy, frequently resulting in residual disease and re-excision secondary to positive surgical margins. The purpose of this study was to compare the relative morbidity of planned versus unplanned upper-extremity sarcoma excisions. Methods A single tertiary referral hospital pathology database was queried from January 2015 through 2022 for primary upper-extremity sarcomas (forearm, wrist, hand, and finger). Demographics, tumor features, survival characteristics, and outcomes were retrospectively reviewed. Results Forty-two upper-extremity sarcoma patients were identified, two-thirds of whom had unplanned excisions. Those with unplanned excisions were more likely to be female (relative risk [RR]: 1.9; P = .002), undergo initial excision at a nonsarcoma center (RR: 14.0; P < .001), have masses distal to the forearm (RR: 1.6; P = .02), and have smaller masses (4.8 vs 7.4 cm, P = .03). 71.4% of tumors were high grade, and 60.7% less than 5 cm in size.Unplanned excisions had positive margins in 96.4% of cases and were more likely to undergo re-excision (odds ratio [OR]: 20.0; P = .001), more total resections (2.7 vs 1.4, P = .009), sacrifice of neurovascular structures (OR: 6.1; P = .04), adjuvant radiation therapy (OR: 4.5; P = .05), adjuvant systemic therapy (OR: 10.9; P = .03), or experience a complication (OR: 17.6; P = .002) at an average of 38.0 months of follow-up.Nearly half of all unplanned excision patients developed a local recurrence or metastatic disease. Six patients required an amputation versus one in the planned cohort (P = .17), and 26.5% of patients died at an average of 32.5 months from presentation. Conclusions Distal upper-extremity sarcoma excisions are frequently unplanned, with high rates of morbidity compared with planned excisions. Surgeons should have a low threshold for cross-sectional imaging and core needle biopsy of atypical lesions, irrespective of size, with referral to a sarcoma center. Type of study/level of evidence Prognostic IV.
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Affiliation(s)
- Seth Ahlquist
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Kevin Y. Chen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Eric Chang
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Scott D. Nelson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Nicholas M. Bernthal
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Lauren E. Wessel
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
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4
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Miura J, Sabharwal S, Ghert M, Karakousis G, Roland CL. Great Debate: Systematic Re-Resection After Macroscopic Complete Unplanned Excision of Soft Tissue Sarcoma. Ann Surg Oncol 2024; 31:2047-2050. [PMID: 38112886 DOI: 10.1245/s10434-023-14780-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Affiliation(s)
- John Miura
- Hospital of the University of Pennsylvania, Pennsylvania, PA, USA
| | | | - Michelle Ghert
- McMaster University, Hamilton, ON, Canada
- The University of Maryland, College Park, MD, USA
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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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Belzarena AC, Binitie O, Letson GD, Joyce DM. Unplanned Sarcoma Excisions: Understanding How They Happen. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202401000-00008. [PMID: 38252542 PMCID: PMC10805420 DOI: 10.5435/jaaosglobal-d-23-00176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/03/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Soft-tissue sarcomas present as a mass with nonspecific symptoms, and unplanned excisions commonly occur. The purpose of this study was to analyze the incidence of unplanned excisions performed by orthopaedic surgeons and to conduct a root cause analysis (RCA) of the steps that led to unplanned excisions in all the cases. METHODS A retrospective case-control study was conducted. Two cohorts were identified, one including patients who underwent an unplanned excision of a soft-tissue sarcoma (n = 107) and a second cohort with patients whose entire care was performed at our sarcoma center (n = 102). A RCA was conducted with the whole sample to identify the preventable causes that led to sarcoma unplanned excisions. RESULTS Orthopedic surgeons were the second group of physicians to perform the most unplanned excisions, only behind general surgeons. Inadequate imaging was encountered in 76.6% of the patients (n = 82, 95% confidence interval, 67.8 to 83.6). Forty-five patients (42.1%) had no imaging studies before the unplanned procedure. In the RCA, the most notable obstacles found were (1) incorrect assumption of a benign diagnosis, (2) failure to obtain the appropriate imaging study, (3) incorrectly reported imaging studies, (4) failure to order a biopsy, and (5) incorrect reporting of the biopsy. CONCLUSIONS Despite educational efforts, unplanned excisions and the devastating consequences that sometimes follow continue to occur. Orthopaedic surgeons persist in playing a role in the unplanned procedure burden.
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Affiliation(s)
- Ana Cecilia Belzarena
- From the Department of Orthopedic Surgery, University of Missouri, Columbia, MO (Dr. Belzarena), and the Sarcoma Department, Moffitt Cancer Center, Tampa, FL (Dr. Binitie, Dr. Letson, and Dr. Joyce)
| | - Odion Binitie
- From the Department of Orthopedic Surgery, University of Missouri, Columbia, MO (Dr. Belzarena), and the Sarcoma Department, Moffitt Cancer Center, Tampa, FL (Dr. Binitie, Dr. Letson, and Dr. Joyce)
| | - George Douglas Letson
- From the Department of Orthopedic Surgery, University of Missouri, Columbia, MO (Dr. Belzarena), and the Sarcoma Department, Moffitt Cancer Center, Tampa, FL (Dr. Binitie, Dr. Letson, and Dr. Joyce)
| | - David Michael Joyce
- From the Department of Orthopedic Surgery, University of Missouri, Columbia, MO (Dr. Belzarena), and the Sarcoma Department, Moffitt Cancer Center, Tampa, FL (Dr. Binitie, Dr. Letson, and Dr. Joyce)
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7
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Stauss R, Aigner A, Richter A, Suero E, Altemeier A, Savov P, Ettinger M, Omar M. The prognostic significance of surgical resection margins for local recurrence, distant metastasis, and overall survival in sarcoma. J Surg Oncol 2023; 128:1160-1170. [PMID: 37530536 DOI: 10.1002/jso.27411] [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: 07/09/2023] [Accepted: 07/16/2023] [Indexed: 08/03/2023]
Abstract
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.
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Affiliation(s)
- Ricarda Stauss
- Hannover Medical School, Department of Trauma Surgery, Hannover, Germany
- University of Oldenburg, Department of Orthopaedic and Trauma Surgery, Pius Hospital, Oldenburg, Germany
| | - Alexander Aigner
- Hannover Medical School, Department of Trauma Surgery, Hannover, Germany
| | - Alena Richter
- Hannover Medical School, Department of Orthopaedic Surgery, Hannover, Germany
| | - Eduardo Suero
- Ludwig-Maximilians-University, Department of General Trauma and Reconstructive Surgery, Munich, Germany
| | - Anna Altemeier
- University of Oldenburg, Department of Orthopaedic and Trauma Surgery, Pius Hospital, Oldenburg, Germany
| | - Peter Savov
- University of Oldenburg, Department of Orthopaedic and Trauma Surgery, Pius Hospital, Oldenburg, Germany
| | - Max Ettinger
- University of Oldenburg, Department of Orthopaedic and Trauma Surgery, Pius Hospital, Oldenburg, Germany
| | - Mohamed Omar
- Hannover Medical School, Department of Trauma Surgery, Hannover, Germany
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Wang J, Wen C, Zhang Y. Comment on Mihara et al.: Oncological and functional outcomes of planned and unplanned excision of soft tissue sarcoma: a retrospective study. J Orthop Sci 2023; 28:1620. [PMID: 37541919 DOI: 10.1016/j.jos.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/28/2023] [Indexed: 08/06/2023]
Affiliation(s)
- Jingzhi Wang
- School of Clinical Medicine, Jining Medical University, Jining, Shandong 272067, China
| | - Caining Wen
- Department of Joint Surgery and Sports Medicine, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong 272029, China
| | - Yuanmin Zhang
- Department of Joint Surgery and Sports Medicine, Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, Shandong 272029, China.
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9
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Mihara A, Iwanaga R, Muramatsu K, Ihara K, Sakai T. Oncological and functional outcomes of planned and unplanned excision of soft tissue sarcoma: A retrospective study. J Orthop Sci 2023; 28:867-873. [PMID: 35491297 DOI: 10.1016/j.jos.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/25/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND In soft tissue sarcomas, the oncological and functional outcomes between planned excision and unplanned excision with additional wide resection remains controversial. The purpose of this study is to determine the impact of unplanned excision on oncological and functional outcomes. METHODS A retrospective single-center study was performed. Patients with soft tissue sarcoma surgically treated in 2005-2019 were included in this study. A total of 120 patients consisting of planned excision (PE) group (n = 88), and unplanned excision (UE) group (n = 32) were included. Overall-survival (OS), local recurrence-free survival (LRFS), metastasis-free survival (MFS), disease-free survival (DFS), incidence rate of reconstructive surgery and musculoskeletal tumor society (MSTS) score were assessed. Propensity score matching method was used in statistical analysis. RESULTS The 5-year survival rate of OS, LRFS, MFS, and DFS did not differ between the PE and UE groups, however, rates of reconstructive surgery were higher in the UE group (PE: 48% vs. UE: 84%, p < 0.001). These results did not differ (PE: 41% vs. UE: 82%, p = 0.012) after propensity score matching was performed to align the backgrounds with difference in tumor size and depth. For MSTS score, the total score and "pain" and "emotional acceptance" scores were higher in the PE group before propensity score matching. The "pain" and "emotional acceptance" scores were higher in the PE group after propensity score matching also. CONCLUSIONS Unplanned excision did not deteriorate oncological outcomes, however unplanned excision lead to unnecessary reconstructive surgery. Unplanned excision adversely affected patient-reported outcomes without worsening pure functional outcomes.
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Affiliation(s)
- Atsushi Mihara
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505, Japan.
| | - Ryuta Iwanaga
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505, Japan
| | - Keiichi Muramatsu
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505, Japan
| | - Koichiro Ihara
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505, Japan
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505, Japan
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10
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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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11
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Yanar F, Öner G, Yüksel S, Salduz A, Azamat İF, Özçınar B, Bilgic B, Günöz Cömert R, Kozanoğlu E, Kurtoğlu M. Femoral artery aneurysm developed on intimal sarcoma: Case report. Turk J Surg 2022; 38:306-311. [PMID: 36846070 PMCID: PMC9948668 DOI: 10.47717/turkjsurg.2022.4381] [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: 10/11/2020] [Accepted: 05/05/2020] [Indexed: 12/24/2022]
Abstract
Intimal angiosarcoma is a rare vascular malignancy, and diagnosis is very difficult due to nonspecific symptoms. There are controversial points regarding the diagnosis, treatment and follow-up of intimal angiosarcomas. The purpose of this case report was to evaluate the diagnosis and treatment process of a patient diagnosed with femoral artery intimal angiosarcoma. Furthermore, in line with previous studies, it was aimed to illuminate controversial points. A 33-year-old male patient, who had been operated on due to ruptured femoral artery aneurysm, was diagnosed with intimal angiosarcoma with the pathology result. Recurrence was observed during clinical follow-up, and the patient was treated with chemotherapy and radiotherapy. Since there was no response to treatment, the patient underwent aggressive surgery including the surrounding tissues. No recurrence or metastasis was observed in the patient's 10th month follow-up. Although intimal angiosarcoma is rare, it should be considered in differential diagnosis when femoral artery aneurysm is detected. The most important step in treatment is aggressive surgery, but adding chemo-radiotherapy to the treatment should be considered.
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Affiliation(s)
- Fatih Yanar
- Department of General Surgery, İstanbul University Faculty of Medicine, İstanbul, Türkiye
| | - Gizem Öner
- Multidisciplinary Oncologic Centre (MOCA), Antwerpen University Hospital, Antwerpen, Belgium
| | - Sercan Yüksel
- Department of General Surgery, İstanbul University Faculty of Medicine, İstanbul, Türkiye
| | - Ahmet Salduz
- Department of Orthopaedic Surgery and Traumatology, İstanbul University Faculty of Medicine, İstanbul, Türkiye
| | - İbrahim Fethi Azamat
- Department of General Surgery, İstanbul University Faculty of Medicine, İstanbul, Türkiye
| | - Beyza Özçınar
- Department of General Surgery, İstanbul University Faculty of Medicine, İstanbul, Türkiye
| | - Bilge Bilgic
- Department of Pathology, İstanbul University Faculty of Medicine, İstanbul, Türkiye
| | - Rana Günöz Cömert
- Department of Radiology, İstanbul University Faculty of Medicine, İstanbul, Türkiye
| | - Erol Kozanoğlu
- Department of Plastic and Reconstructive Surgery, İstanbul University Faculty of Medicine, İstanbul, Türkiye
| | - Mehmet Kurtoğlu
- Department of General Surgery, İstanbul University Faculty of Medicine, İstanbul, Türkiye
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12
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Morinaga S, Miwa S, Yamamoto N, Hayashi K, Takeuchi A, Igarashi K, Tada K, Langit MB, Yonezawa H, Araki Y, Asano Y, Tsuchiya H. Clinical characteristics of patients with undergoing unplanned excisions of malignant soft tissue tumors. J Orthop Surg (Hong Kong) 2022; 29:23094990211057597. [PMID: 34893007 DOI: 10.1177/23094990211057597] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Malignant soft tissue tumors are rare tumors representing <1% of all malignancies. As these tumors are rare, it is not uncommon that malignant soft tissue tumor excision is performed without the required preoperative imaging, staging, or wide resection margins for sarcomas. The purpose of this study was to investigate the characteristics of patients with undergoing unplanned excisions. Risk factors for tumor recurrence and mortality in patients treated with unplanned excisions were also analyzed. METHODS Forty-nine patients who underwent unplanned excision at other hospitals and additional wide excision at our hospital between January 2002 and December 2018 were identified. Among them, 42 patients with follow-up for more than 1 year were included in this retrospective study. The relationships between sex, age, tumor depth, histological grade, location, size, surgical margin at additional wide excision, residual tumor, reconstruction, kind of hospital where the primary excision was done (sarcoma vs non-sarcoma center), preoperative examination, chemotherapy, radiation therapy, and oncological outcomes were statistically analyzed. RESULTS Mean patient age was 57.3 years (15-85 years) and the mean observation period was 72.5 months (14-181 months). This analysis showed 53.8% tumors that underwent unplanned excisions were small (<5 cm) and 70.7% tumors were superficial. Multivariate analysis revealed that a positive margin during additional wide excision was significantly associated with a lower 5-year LRFS (p < 0.01). CONCLUSION Most of the tumors underwent unplanned excisions were small (<5 cm) and superficial. Surgeons should be aware that a positive margin during additional wide excision is an independent risk factor for local recurrence.
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Affiliation(s)
- Sei Morinaga
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Shinji Miwa
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Norio Yamamoto
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Katsuhiro Hayashi
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Akihiko Takeuchi
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Kentaro Igarashi
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Kaoru Tada
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Mickhael B Langit
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan.,Department of Orthopedic Surgery, Philippine Orthopedic Center, Manilla, Philippines
| | - Hirotaka Yonezawa
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Yoshihiro Araki
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Yohei Asano
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Kanazawa University School of Medicine, Kanazawa, Japan
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13
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Wang L, Yan X, Zhao J, Chen C, Chen C, Chen J, Chen KN, Cao T, Chen MW, Duan H, Fan J, Fu J, Gao S, Guo H, Guo S, Guo W, Han Y, Jiang GN, Jiang H, Jiao WJ, Kang M, Leng X, Li HC, Li J, Li J, Li SM, Li S, Li Z, Li Z, Liang C, Mao NQ, Mei H, Sun D, Wang D, Wang L, Wang Q, Wang S, Wang T, Liu L, Xiao G, Xu S, Yang J, Ye T, Zhang G, Zhang L, Zhao G, Zhao J, Zhong WZ, Zhu Y, Hulsewé KWE, Vissers YLJ, de Loos ER, Jeong JY, Marulli G, Sandri A, Sziklavari Z, Vannucci J, Ampollini L, Ueda Y, Liu C, Bille A, Hamaji M, Aramini B, Inci I, Pompili C, Van Veer H, Fiorelli A, Sara R, Sarkaria IS, Davoli F, Kuroda H, Bölükbas S, Li XF, Huang L, Jiang T. Expert consensus on resection of chest wall tumors and chest wall reconstruction. Transl Lung Cancer Res 2022; 10:4057-4083. [PMID: 35004239 PMCID: PMC8674598 DOI: 10.21037/tlcr-21-935] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/26/2021] [Indexed: 02/05/2023]
Abstract
Chest wall tumors are a relatively uncommon disease in clinical practice. Most of the published studies about chest wall tumors are usually single-center retrospective studies, involving few patients. Therefore, evidences regarding clinical conclusions about chest wall tumors are lacking, and some controversial issues have still to be agreed upon. In January 2019, 73 experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese Expert Consensus on Chest Wall Tumor Resection and Chest Wall Reconstruction (2018 edition). After that, numerous experts put forward new perspectives on some academic issues in this version of the consensus, pointing out the necessity to further discuss the points of contention. Thus, we conducted a survey through the administration of a questionnaire among 85 experts in the world. Consensus has been reached on some major points as follows. (I) Wide excision should be performed for desmoid tumor (DT) of chest wall. After excluding the distant metastasis by multi-disciplinary team, solitary sternal plasmacytoma can be treated with extensive resection and adjuvant radiotherapy. (II) Wide excision with above 2 cm margin distance should be attempted to obtain R0 resection margin for chest wall tumor unless the tumor involves vital organs or structures, including the great vessels, heart, trachea, joints, and spine. (III) For patients with chest wall tumors undergoing unplanned excision (UE) for the first time, it is necessary to carry out wide excision as soon as possible within 1–3 months following the previous surgery. (IV) Current Tumor Node Metastasis staging criteria (American Joint Committee on Cancer) of bone tumor and soft tissue sarcoma are not suitable for chest wall sarcomas. (V) It is necessary to use rigid implants for chest wall reconstruction once the maximum diameter of the chest wall defect exceeds 5 cm in adults and adolescents. (VI) For non-small cell lung cancer (NSCLC) invading the chest wall, wide excision with neoadjuvant and/or adjuvant therapy are recommended for patients with stage T3-4N0-1M0. As clear guidelines are lacking, these consensus statements on controversial issues on chest wall tumors and resection could possibly serve as further guidance in clinical practice during the upcoming years.
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Affiliation(s)
- Lei Wang
- Department of Thoracic Surgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Xiaolong Yan
- Department of Thoracic Surgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jinbo Zhao
- Department of Thoracic Surgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jun Chen
- Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Lung Cancer Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Ke-Neng Chen
- Department of Thoracic Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing, China
| | - Tiesheng Cao
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Ming-Wu Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hongbin Duan
- Department of Thoracic Surgery, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Junqiang Fan
- Department of Thoracic Surgery, Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Junke Fu
- Department of Thoracic Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | | | - Wei Guo
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, Chongqing, China
| | - Yongtao Han
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Research Institute, School of Medicine, University of Electronic Science and Technology of China (UESTC), Chengdu, China
| | - Ge-Ning Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hongjing Jiang
- Department of Minimally Invasive Esophageal Surgery, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Wen-Jie Jiao
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Mingqiang Kang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xuefeng Leng
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Research Institute, School of Medicine, University of Electronic Science and Technology of China (UESTC), Chengdu, China
| | - He-Cheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Li
- Department of Plastic and Burn Surgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jian Li
- Department of Thoracic Surgery, Peking University Third Hospital, Beijing, China
| | - Shao-Min Li
- Department of Thoracic Surgery, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shuben Li
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhigang Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhongcheng Li
- Department of Thoracic and Cadiovascular Surgery, Affiliated Hospital of Qinghai University, Xining, China
| | - Chaoyang Liang
- Department of Thoracic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Nai-Quan Mao
- Department of Thoracic Surgery, Tumor Hospital Affiliated to Guangxi Medical University, Nanning, China
| | - Hong Mei
- Department of Thoracic Surgery, Guizhou Provincial People's Hospital, Guiyang, China
| | - Daqiang Sun
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Dong Wang
- Department of Cardiothoracic Surgery, Affiliated Taikang Xianlin Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Luming Wang
- Department of Thoracic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qun Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shumin Wang
- Department of Thoracic Surgery, General Hospital of Shenyang Military Area, Shenyang, China
| | - Tianhu Wang
- Department of Thoracic Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Gaoming Xiao
- Department of Thoracic Surgery, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Shidong Xu
- Department of Thoracic Surgery and Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jinliang Yang
- Department of Thoracic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ting Ye
- Department of Thoracic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Guangjian Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Linyou Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guofang Zhao
- Department of Cardiothoracic Surgery, Hwa Mei Hospital (Ningbo No. 2 Hospital), University of Chinese Academy of Sciences, Ningbo, China
| | - Jun Zhao
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-Zhao Zhong
- Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuming Zhu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Karel W E Hulsewé
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Yvonne L J Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Erik R de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jin Yong Jeong
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Giuseppe Marulli
- Department of Emergency and Organ Transplantation, Thoracic Surgery Unit, University Hospital of Bari, Bari, Italy
| | - Alberto Sandri
- Thoracic Surgery Division, Department of Oncology, San Luigi Gonzaga Hospital, Orbassano (To), Italy
| | - Zsolt Sziklavari
- Department of Thoracic Surgery, Klinikum Coburg, Coburg, Germany.,Department of Thoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Jacopo Vannucci
- Department of Thoracic Surgery, University of Rome Sapienza, Policlinico Umberto I, Rome, Italy
| | - Luca Ampollini
- Thoracic Surgery, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Yuichiro Ueda
- Department of General Thoracic, Breast and Pediatric Surgery, School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Chaozong Liu
- Institute of Orthopaedic & Musculoskeletal Science, Division of Surgery & Interventional Science, University College London, Royal National Orthopaedic Hospital, London, UK
| | - Andrea Bille
- Department of Thoracic Surgery, Guy's Hospital, London, UK
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Beatrice Aramini
- Division of Thoracic Surgery, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital, Raemistrasse, Zurich, Switzerland
| | | | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Alfonso Fiorelli
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Ricciardi Sara
- Division of Thoracic Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | - Inderpal S Sarkaria
- Department of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Fabio Davoli
- Department of Thoracic Surgery, AUSL Romagna, S. Maria delle Croci Teaching Hospital, Ravenna, Italy
| | - Hiroaki Kuroda
- Department of Thoracic Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Servet Bölükbas
- Department of Thoracic Surgery, Evang. Kliniken Essen-Mitte, Essen, Germany
| | - Xiao-Fei Li
- Department of Thoracic Surgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Lijun Huang
- Department of Thoracic Surgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Tao Jiang
- Department of Thoracic Surgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
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14
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Tirotta F, Sayyed R, Jones RL, Hayes AJ. Risk factors for the development of local recurrence in extremity soft-tissue sarcoma. Expert Rev Anticancer Ther 2021; 22:83-95. [PMID: 34822313 DOI: 10.1080/14737140.2022.2011723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Local recurrence (LR) is one of the main pitfalls in surgery for extremities soft tissue sarcoma (eSTS). Achieving clear histopathological margins is the most important factor to reduce the risk of LR, but the ability to do so depends on not only surgical technique but also the interplay between tumor biology, anatomical location and surgical approach. The balance between postoperative morbidity and oncological benefits in reducing the risk of LR needs to be considered. AREAS COVERED This review will cover which etiological factors for the development of eSTS lead to an increased risk of LR and discuss histological subtypes that have a high risk of LR and which surgical and neoadjuvant therapeutic strategies can minimize the risk of LR. EXPERT OPINION The traditional view that surgical radicality always results in low rates of LR, while marginality alone always leads to high rates of relapse, is outdated. In the modern era of surgical oncology, limb salvage and high-level function after resectional surgery are the key surgical goals. The best results are achieved by combining effective neoadjuvant treatments with planned bespoke oncological operations that consider the biological and anatomical factors of each individual sarcoma.
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Affiliation(s)
- Fabio Tirotta
- Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Raza Sayyed
- Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Robin L Jones
- Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Andrew J Hayes
- Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
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15
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Nakamura T, Kawai A, Hagi T, Asanuma K, Sudo A. A comparison of clinical outcomes between additional excision after unplanned and planned excisions in patients with soft-tissue sarcoma of the limb : a propensity matching cohort study. Bone Joint J 2021; 103-B:1809-1814. [PMID: 34847719 DOI: 10.1302/0301-620x.103b12.bjj-2021-0037.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
AIMS Patients with soft-tissue sarcoma (STS) who undergo unplanned excision (UE) are reported to have worse outcomes than those who undergo planned excision (PE). However, others have reported that patients who undergo UE may have similar or improved outcomes. These discrepancies are likely to be due to differences in characteristics between the two groups of patients. The aim of the study is to compare patients who underwent UE and PE using propensity score matching, by analyzing data from the Japanese Bone and Soft Tissue Tumor (BSTT) registry. METHODS Data from 2006 to 2016 was obtained from the BSTT registry. Only patients with STS of the limb were included in the study. Patients with distant metastasis at the initial presentation and patients with dermatofibrosarcoma protuberans and well-differentiated liposarcoma were excluded from the study. RESULTS A total of 4,483 patients with STS of the limb were identified before propensity score matching. There were 355 patients who underwent UE and 4,128 patients who underwent PE. The five-year disease-specific survival (DSS) rate was significantly better in the patients who received additional excision after UE than in those who underwent PE. There was no significant difference in local recurrence-free survival (LRFS) between the two groups. After propensity score matching, a new cohort of 355 patients was created for both PE and UE groups, in which baseline covariates were appropriately balanced. Reconstruction after tumour excision was frequently performed in patients who underwent additional excision after UE. There were no significant differences in DSS and LRFS between the patients who underwent PE and those who had an additional excision after UE. CONCLUSION Using propensity score matching, patients with STS of the limb who underwent additional excision after UE did not experience higher mortality and local failure than those who underwent PE. Reconstruction may be necessary when additional excision is performed. Cite this article: Bone Joint J 2021;103-B(12):1809-1814.
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Affiliation(s)
- Tomoki Nakamura
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine Faculty of Medicine, Tsu, Japan
| | - Akira Kawai
- Department of Musculoskeletal Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomohito Hagi
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine Faculty of Medicine, Tsu, Japan
| | - Kunihiro Asanuma
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine Faculty of Medicine, Tsu, Japan
| | - Akihiro Sudo
- Department of Orthopedic Surgery, Mie University Graduate School of Medicine Faculty of Medicine, Tsu, Japan
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16
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Shemesh SS, Garbrecht EL, Rutenberg TF, Conway SA, Rosenberg AE, Pretell-Mazzini J. Unplanned excision of soft tissue sarcoma: does it impact the accuracy of intra-operative pathologic assessment at time of re-excision? INTERNATIONAL ORTHOPAEDICS 2021; 45:2983-2991. [PMID: 34415419 DOI: 10.1007/s00264-021-05187-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Shai S Shemesh
- Department of Orthopedic Surgery, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Erika L Garbrecht
- Musculoskeletal Oncology Division, Department of Orthopedic Surgery, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA
| | - Tal Frenkel Rutenberg
- Department of Orthopedic Surgery, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sheila A Conway
- Musculoskeletal Oncology Division, Department of Orthopedic Surgery, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA
| | - Andrew E Rosenberg
- Department of Pathology, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA
| | - Juan Pretell-Mazzini
- Musculoskeletal Oncology Division, Department of Orthopedic Surgery, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA.
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17
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Nakamura T, Kawai A, Asanuma K, Hagi T, Sudo A. Clinical Outcome of Dermatofibrosarcoma Protuberance. Report From the Bone and Soft Tissue Tumor (BSTT) Registry in Japan. In Vivo 2021; 35:611-615. [PMID: 33402516 DOI: 10.21873/invivo.12298] [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: 11/02/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Owing to its rarity, dermatofibrosarcoma protuberance (DFSP) is often inappropriately excised. After unplanned excision (UE), additional excision is commonly performed. We aimed to elucidate the effect of additional excision after UE. PATIENTS AND METHODS We examined 306 patients with primary DFSP. We analyzed surgical outcomes in 291 patients who received planned excision (PE) or additional excision after UE. RESULTS Of 306 patients, 194 received PE and the remaining 112 received UE. Of 112 patients, 97 received additional excision after UE. Additional surgery due to complications was more frequent in patients with UE than in those with PE. The 5-year local recurrence-free rate in patients without additional excision after UE was significantly worse than that in those with additional excision after UE. CONCLUSION If UE is performed, we recommend additional excision for preventing local recurrence; however, the surgical wound should be carefully observed.
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Affiliation(s)
- Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan;
| | - Akira Kawai
- Department of Musculoskeletal Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kunihiro Asanuma
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Tomohito Hagi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
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18
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Adjuvant high-dose-rate interstitial brachytherapy for malignant peripheral nerve sheath tumor of the foot: a case report. J Contemp Brachytherapy 2021; 13:338-346. [PMID: 34122575 PMCID: PMC8170520 DOI: 10.5114/jcb.2021.106204] [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: 07/03/2020] [Accepted: 03/20/2021] [Indexed: 11/17/2022] Open
Abstract
Soft tissue sarcomas of the foot are extremely rare and can therefore be misdiagnosed as benign diseases, and be prematurely removed with an unplanned excision. The standard treatment is a wide local excision with an addition of radiotherapy as an alternative to a radical resection (e.g., below-knee or foot amputation). We report on a patient with primary malignant peripheral nerve sheath tumor in the foot plantar soft tissue, who had no evidence of the disease and no severe late toxicity higher than grade 2, 40 months after receiving amputation of toes and adjuvant interstitial high-dose-rate brachytherapy (HDR-BT). To the best of our knowledge, only a few cases were treated with HDR-BT with this scenario. From our findings, HDR-BT could be a safe and quick treatment option for these types of lesions.
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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: 18] [Impact Index Per Article: 6.0] [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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Ohshika S, Saruga T, Ogawa T, Ono H, Ishibashi Y. Distinction between benign and malignant soft tissue tumors based on an ultrasonographic evaluation of vascularity and elasticity. Oncol Lett 2021; 21:281. [PMID: 33732357 PMCID: PMC7905527 DOI: 10.3892/ol.2021.12542] [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: 05/01/2020] [Accepted: 12/30/2020] [Indexed: 11/30/2022] Open
Abstract
The initial diagnostic distinction between benign and malignant soft tissue tumors is critical for decisions regarding the appropriate course of treatment. The current study aimed to evaluate the vascularity and elasticity of soft tissue tumors by superb microvascular imaging and shear wave elastography using ultrasonography (US), to determine their usefulness in distinguishing malignant soft tissue tumors, and to further establish the diagnostic accuracy and usefulness of a scoring system (SS) based on these evaluations. The present study used 167 lesions of soft tissue tumors examined by US prior to biopsy, surgery and pathological tissue diagnosis. The vascularity index (VI) and the maximal shear velocity (MSV), as indices of vascularity and elasticity respectively, were evaluated using US. The tumor size and depth were also evaluated via magnetic resonance imaging (MRI). Based on the odds ratio of these parameters determined by multivariate logistic regression analysis, an original SS was established to identify the malignancy of soft tissue tumors. VI and MSV exhibited significantly high values for malignant tumors. Tumor size was also significantly larger for malignant than benign tumors. The areas under the curves (AUCs) of the receiver operating characteristic analysis for VI, MSV and tumor size were 0.75, 0.84 and 0.69, respectively, indicating that these methods were effective for the diagnosis of malignancy. An original SS consisting of VI, MSV and tumor size, excluding tumor depth, was established, and revealed an AUC value of 0.90, with 93.6% sensitivity and 79.2% specificity for malignancy distinction. US evaluation of vascularity and elasticity was an effective technique to distinguish malignant soft tissue tumors, and the current SS based on US evaluations including tumor size via MRI demonstrated a high diagnostic accuracy for malignant soft tissue tumors.
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Affiliation(s)
- Shusa Ohshika
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Tatsuro Saruga
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Tetsuya Ogawa
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Hiroya Ono
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori 036-8562, Japan
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Inadvertent Inguinal Sarcoma Excision during Hernia Surgery: Outcomes, Gender Analysis, and Prevention. Int J Surg Oncol 2020; 2020:8374790. [PMID: 33489372 PMCID: PMC7787872 DOI: 10.1155/2020/8374790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 11/17/2020] [Accepted: 11/24/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Inadvertent excision of a soft tissue sarcoma during hernia surgery is a preventable clinical scenario that leads to unnecessary patient morbidity. Prior series are few, which only include male patients with little focus on prevention. The purpose of this study is to report the presenting features and outcomes of both male and female patients who underwent inadvertent inguinal sarcoma excision during hernia surgery. Methods A retrospective analysis of a single sarcoma referral center identified 33 patients who were referred for definitive treatment. Patients were divided into three clinically relevant groups based on intraoperative diagnosis, sex, and location of the mass relative to the inguinal ligament. T-tests and Fisher's exact tests were performed to compare continuous and categorical variables, respectively. Kaplan–Meier modeling was performed to assess sarcoma-specific survival. Results Females were younger (47 years vs. 61 years, p=0.003) and had smaller sarcomas (6.7 cm vs. 11 cm, p=0.012) compared to males. Only two sarcomas (2/33, 6%) were <4 cm in size. The majority of sarcomas in females were above the inguinal ligament (12/14, 86%). Twenty-nine (88%) underwent definitive R0 excision. The mean number of surgeries per patient was three (range 1–13), with nineteen (58%) patients requiring flap reconstruction and six (18%) requiring vascular bypass. Five patients locally recurred (15%) at a mean of 38 months after definitive excision (range 5–128 months). Overall sarcoma-specific disease-free survival was 64%, with no difference between males (80 ± 11%) and females (59 ± 17%) (p=0.885). Mean follow-up was 75 months (range 5–212). Conclusion This is the second largest study regarding inadvertent inguinal sarcoma excision and the first to include females. When a suspected hernia is >4 cm, irreducible, firm, and is growing, especially in females, consider obtaining preoperative advanced three-dimensional imaging (CT or MRI) that can differentiate a neoplasm from a hernia.
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Nakamura T, Sugaya J, Naka N, Kobayashi H, Okuma T, Kunisada T, Asanuma K, Outani H, Nishimura S, Kawashima H, Akiyama T, Yasuda T, Miwa S, Sudo A, Ueda T. Standard Treatment Remains the Recommended Approach for Patients with Bone Sarcoma Who Underwent Unplanned Surgery: Report from the Japanese Musculoskeletal Oncology Group. Cancer Manag Res 2020; 12:10017-10022. [PMID: 33116858 PMCID: PMC7567545 DOI: 10.2147/cmar.s270178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/05/2020] [Indexed: 11/23/2022] Open
Abstract
Background The outcomes of unplanned surgery for bone sarcomas have not been frequently discussed. However, it is important to recognize patterns, treatment, and clinical outcomes of unplanned surgeries for patients with bone sarcomas. This multicenter study aimed to characterize the clinical outcomes of patients with bone sarcomas who underwent unplanned surgeries. Patients and Methods Data of 43 patients with bone sarcomas who underwent unplanned surgery between 2006 and 2017 were obtained from 23 hospitals in Japan. These included 18 cases of osteosarcoma, 9 of Ewing sarcoma, 8 of chondrosarcoma, and 6 of undifferentiated pleomorphic sarcoma. The study included 28 men and 15 women, with a mean age of 46 years. The mean follow-up duration was 59 months. Results The main primary tumor sites were the femur (n = 19), spine (n = 6), pelvis (n = 5), tibia (n = 3), and humerus (n = 3). The primary diagnoses were benign bone tumor (n = 24), trauma (n = 7), bone metastasis (n = 5), osteomyelitis (n = 4), degeneration (n=2), and unknown (n = 1). As unplanned surgeries, curettage, with or without bone graft, was performed in 26 patients; internal fixation was performed in 7; spinal surgery in 5; arthroplasty in 4; and arthroscopy in one. Thirty-eight patients received additional standard treatments. Thirty-four of these patients underwent surgical tumor resections, including amputation (n = 10), and the remaining 4 received radiotherapy or carbon ion radiotherapy as additional standard treatments. The 5-year disease-specific survival (DSS) rates in patients with osteosarcoma, Ewing sarcoma, and chondrosarcoma were 65.5%, 58.3%, and 72.9%, respectively. Twelve (27.9%) patients developed local recurrences (LR); among the total 43 patients studied, the 5-year DSS rates were significantly worse for those who developed LR compared to those who did not (p = 0.03). The 5-year DSS rates in patients with and without LR were 44% and 73.8%, respectively. Conclusion We recommend that patients who have undergone unplanned surgery be administered standard treatment, including the option of amputation because herein, LR was shown to be a risk factor for decreased DSS.
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Affiliation(s)
- Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| | - Jun Sugaya
- Department of Musculoskeletal Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo 104-0045, Japan
| | - Norifumi Naka
- Musculoskeletal Oncology Service, Osaka International Cancer Institute, Chuo-ku, Osaka 541-8567, Japan
| | - Hiroshi Kobayashi
- Department of Orthopaedic Surgery, The University of Tokyo Hospital, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Tomotake Okuma
- Department of Musculoskeletal Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Toshiyuki Kunisada
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Kunihiro Asanuma
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| | - Hedetatsu Outani
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Shunji Nishimura
- Department of Orthopaedic Surgery, Kindai University Hospital, Osaka-Sayama, Osaka 589-8511, Japan
| | - Hiroyuki Kawashima
- Division of Orthopaedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata 951-8510, Japan
| | - Toru Akiyama
- Department of Orthopaedic Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Saitama 330-8503, Japan
| | - Taketoshi Yasuda
- Department of Orthopaedic Surgery, University of Toyama, Toyama 930-0194, Japan
| | - Shinji Miwa
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa 920-8641, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| | - Takafumi Ueda
- Department of Orthopaedic Surgery, Osaka National Hospital, Chuo-ku, Osaka 540-0006, Japan
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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: 7] [Impact Index Per Article: 1.8] [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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Tokumoto H, Akita S, Kubota Y, Mitsukawa N. Effect of unplanned excision of soft tissue sarcomas on skin defects and reconstructive procedures. J Plast Surg Hand Surg 2020; 54:372-376. [PMID: 32734802 DOI: 10.1080/2000656x.2020.1799817] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Unplanned excision (UE) is defined as a procedure wherein a surgeon operates a tumor resection without appropriate preoperative diagnostic modalities and without the intent to achieve tumor-free margins. Generally, the reconstruction rate after UE is higher than that after planned excision (PE). The present study aimed to investigate how the reconstructive procedure and size of skin defect could be influenced. We reviewed the cases of 442 patients who underwent the resection of soft tissue sarcoma. Patients were stratified into two groups (UE vs. PE). We compared the histologic grade, skin defect, reconstructive procedures, depth of the reconstruction layer. For superficial reconstructions, we also compared procedures involving skin graft-only or flap. 105 cases (23.8%) were UE. Histologic grade in PE was significantly higher (p = .024). The reconstruction rate and size of skin defect in UE was significantly higher (76.2% vs. 27.3%, p < .001) and larger (124.5 cm2 vs. 65.7 cm2, p < .001). The rate of deep layer reconstruction was significantly higher in PE (7.5% vs. 26.1%, p = .001). In superficial reconstructions, 18 (24.3%) skin graft-only procedures were performed in UE and 15 (22.1%) in PE, all other superficial reconstructive procedures involved flap, and there was no significant difference (p = .45). Skin defects were 1.9 times larger after UE than PE. UE did not affect the superficial reconstructive procedure.
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Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
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Fujibuchi T, Miyawaki J, Kidani T, Imai H, Miura H. Prediction of Soft Tissue Sarcoma from Clinical Characteristics and Laboratory Data. Cancers (Basel) 2020; 12:E679. [PMID: 32183216 PMCID: PMC7140089 DOI: 10.3390/cancers12030679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 12/15/2022] Open
Abstract
The accurate diagnosis of soft tissue tumors may be difficult. Simple clinical characteristics or laboratory data that can predict tumor malignancy can be useful tools for diagnosing soft tissue tumors. Between 2003 and 2018, 588 patients with primary soft tissue tumors were retrospectively reviewed. Their clinical characteristics and laboratory data were evaluated to determine their association with the diagnosis of benign, intermediate, or malignant tumor. Multivariable analysis revealed that tumor size ≥ 5.6 cm (odds ratio (OR), 6.15; p < 0.001), white blood cell (WBC) count ≥ 5700/µL (OR, 2.49; p = 0.002), hemoglobin (Hb) count ≤ 12.4 g/dL (OR, 2.56; p = 0.004), C-reactive protein (CRP) level ≥ 0.17 mg/dL (OR, 2.64; p < 0.001), and lactate dehydrogenase (LDH) level ≥ 240 IU/L (OR, 4.94; p < 0.001) were significant predictive factors for sarcoma. The sensitivity and specificity in the presence of three or more predictive factors for detecting malignant tumors were 0.58 and 0.90 respectively, and it was an appropriate threshold with the maximum Youden's index of 0.49. Simple clinical and laboratory data were useful tools for predicting whether the tumor is malignant. Patients with soft tissue tumors that meet any three or more predictive factors should be referred to a specialist.
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Affiliation(s)
- Taketsugu Fujibuchi
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan; (J.M.); (T.K.); (H.I.); (H.M.)
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Abstract
After initial treatment of sarcoma, disease progression may occur in the form of local recurrence, pulmonary metastases, or extrapulmonary metastases. As such, surveillance is an important aspect of management, but no universally accepted practice standards are found. In the absence of strong evidence, and to allow for individualized care, existing guidelines contain flexibility in terms of both the frequency and modality of surveillance. In general, they agree that follow-up should be more intense in the early years after treatment, especially for high-grade sarcomas, and continue for at least 10 years. For local recurrence, data suggest that physical examination is usually sufficient for monitoring; in addition, some guidelines endorse imaging routinely, whereas others only as clinically indicated. For pulmonary metastasis, either radiograph or CT is recommended, with the latter having theoretical advantages but no proven survival benefit to date. Extrapulmonary metastases are rare in most sarcoma types, so the literature only supports extrapulmonary surveillance for certain diagnoses. This topic is complicated by the diversity of sarcomas, the limited evidence, and the indefinite, often conflicting recommendations; therefore, it is critical for providers to understand the existing research and guidelines to determine optimal surveillance strategies for their patients.
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Kang J, Xu M, Wang B, Yu X. Wide resection of soft tissue sarcomas after unplanned primary procedures: A long-term follow-up study. Medicine (Baltimore) 2020; 99:e19067. [PMID: 32080080 PMCID: PMC7034676 DOI: 10.1097/md.0000000000019067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Unplanned resection of soft-tissue sarcomas (STS) predispose the patients to recurrences and metastases, secondary wide resection is usually warranted.To investigate the outcomes of re-excision of STS after unplanned initial resection.The records of 39 patients undergoing re-excision of STS after unplanned initial resection from January 2006 through December 2015 were retrospectively investigated.There were 17 males and 22 females, the mean age was 45.7 years. Most initial unplanned resections were performed in rural hospitals by surgeons from general surgery department, dermatology department, plastic surgery department, and orthopedic department. Thirty-five patients underwent secondary wide resections in our department. Histopathological findings indicated positive margins after primary surgeries in 18 patients. Until the conclusion of 37.2-month follow-up, 7 patients developed metastasis, 3 had local recurrence, and 7 were dead. Positive margins were associated with increased metastases and lower survival rates (P < .05). There was no significant difference in recurrences between the 2 groups.Unplanned initial resection of STS often lead to unfavorable prognosis. Primary wide resections are warranted for this disease entity.
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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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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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Zaidi MY, Ethun CG, Liu Y, Poultsides G, Howard JH, Mogal H, Tseng J, Votanopoulos K, Fields RC, Cardona K. The impact of unplanned excisions of truncal/extremity soft tissue sarcomas: A multi‐institutional propensity score analysis from the US Sarcoma Collaborative. J Surg Oncol 2019; 120:332-339. [DOI: 10.1002/jso.25521] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Mohammad Y. Zaidi
- Division of Surgical Oncology, Winship Cancer InstituteEmory University Atlanta Georgia
| | - Cecilia G. Ethun
- Division of Surgical Oncology, Winship Cancer InstituteEmory University Atlanta Georgia
| | - Yuan Liu
- Department of Biostatistics and BioinformaticsEmory University Atlanta Georgia
| | - George Poultsides
- Department of SurgeryStanford University Medical Center Palo Alto California
| | - J. Harrison Howard
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Columbus Ohio
| | - Harveshp Mogal
- Department of SurgeryMedical College of Wisconsin Milwaukee Wisconsin
| | - Jennifer Tseng
- Department of SurgeryUniversity of Chicago Medicine Chicago Illinois
| | | | - Ryan C. Fields
- Department of SurgeryWashington University School of Medicine St. Louis Missouri
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer InstituteEmory University Atlanta Georgia
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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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Evaluation of Planned versus Unplanned Soft-Tissue Sarcoma Resection Using PROMIS Measures. Sarcoma 2019; 2019:1342615. [PMID: 30956533 PMCID: PMC6425353 DOI: 10.1155/2019/1342615] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/02/2019] [Accepted: 02/14/2019] [Indexed: 11/24/2022] Open
Abstract
Background The Patient Reported Outcomes Measurement Information System (PROMIS) is a tool developed by the National Institutes of Health that allows comparisons across conditions or even the United States (U.S.) general population. Objectives Our purpose was to compare PROMIS outcomes between patients who underwent a planned resection to those who underwent an initial unplanned excision of their sarcoma followed by a definitive oncologic resection. We then compared these groups to the U.S. general population. Methods Eighty-five patients were included and were divided into those who underwent an initial planned resection (67) and unplanned excision (18). These patients were then further categorized based on the length of follow-up since their last surgery, either early (<12 months) or late (>12 months). Results We evaluated seven PROMIS domains and found no differences between patients who underwent planned resection versus those who underwent an initial unplanned excision followed by a wide resection of the previous wound bed. When compared to the U.S. population, both cohorts demonstrated significantly improved scores in several emotional health domains. Conclusions Patients who undergo an unplanned excision followed by a definitive oncologic procedure have similar PROMIS scores compared to patients who undergo an initial planned resection.
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Diagnostic value of tumor-fascia relationship in superficial soft tissue masses on magnetic resonance imaging. PLoS One 2018; 13:e0209642. [PMID: 30596710 PMCID: PMC6312209 DOI: 10.1371/journal.pone.0209642] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 12/10/2018] [Indexed: 11/21/2022] Open
Abstract
Purpose Many surgeons participate in the management of superficial soft tissue masses, and a preoperative incorrect diagnosis frequently results in dismal oncological outcomes. The aim of this study was to identify distinguishing magnetic resonance imaging features between malignant and non-malignant lesions. Methods The clinicopathological data for 219 patients (men 114; women 105) with superficial soft tissue masses treated from January 2007 to December 2016 in our institution were retrospectively analyzed. The median age at the first visit was 55.6 years (range 1–90 years). MRI findings of tumor size, margin, lobulation, intratumoral hemorrhage, peritumoral edema, and tumor-fascia relationship were compared with the final histological diagnosis and tumor grade. Results Univariate analysis revealed significant relationships between histologically malignant lesions and tumor size ≥5 cm (p = 0.035), positive peritumoral edema (p = 0.031), and tumor-fascia relationship (p<0.001), but not margin (p = 0.107), lobulation (p = 0.071), and intratumoral hemorrhage (p = 0.17). In addition, using multivariate analysis, the tumor-fascia relationship (p<0.001) and tumor size were significant factors. A significant correlation between tumor-fascia relationship and malignancy (p<0.001) was observed; such a relationship was, however, not observed for tumor grade (p = 0.43). Conclusions Tumors measuring ≥5 cm and the tumor-fascia relationship on magnetic resonance imaging are highly indicative of malignancy. When superficial soft tissue masses cross the superficial fascia and form obtuse angles with the fascia, sarcoma should be considered. The tumor-fascia relationship can offer surgeons useful information regarding the status of superficial soft tissue masses.
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Dean BJF, Branford-White H, Giele H, Critchley P, Cogswell L, Athanasou N, Gibbons CLM. Management and outcome of acral soft-tissue sarcomas. Bone Joint J 2018; 100-B:1518-1523. [DOI: 10.1302/0301-620x.100b11.bjj-2018-0301.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to evaluate the surgical management and outcome of patients with an acral soft-tissue sarcoma of the hand or foot. Patients and Methods We identified 63 patients with an acral soft-tissue sarcoma who presented to our tertiary referral sarcoma service between 2000 and 2016. There were 35 men and 28 women with a mean age of 49 years (sd 21). Of the 63 sarcomas, 27 were in the hands and 36 in the feet. The commonest subtypes were epithelioid sarcoma in the hand (n = 8) and synovial sarcoma in the foot (n = 11). Results In 41 patients (65%), the tumour measured less than 5 cm in its largest dimension (median size 3 cm (2 to 6)); 27 patients (43%) were diagnosed after inadvertent excision prior to their referral to the specialist sarcoma unit. After biopsy and staging, primary surgical intervention at the sarcoma unit was excision and limb salvage in 43 (68%), partial (digit or ray) amputation in 14 (22%), and more proximal amputation in six (10%). At final follow up, local recurrence had been treated by one partial amputation and six amputations, resulting in a partial amputation rate of 24% and a proximal amputation rate of 19%. The five-year survival rate was 82%. Patients who underwent inadvertent excision showed no statistically significant difference in survival or local recurrence, but were more likely to undergo amputation (p = 0.008). Large tumour size (> 5 cm) was associated with lower survival (p = 0.04) and a higher risk of local recurrence (p = 0.009;). Conclusion Most acral soft-tissue sarcomas measure less than 5 cm at presentation, indicating that while size can be a useful prognostic factor, it should not be used as a diagnostic threshold for referral. Increased tumour size is associated with a higher rate of local recurrence and reduced survival. Sarcoma excision with limb preservation does not result in an increased risk of local recurrence. Cite this article: Bone Joint J 2018;100-B:1518–23.
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Affiliation(s)
- B. J. F. Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre and Nuffield Orthopaedic Centre, Oxford, UK
| | | | - H. Giele
- Nuffield Orthopaedic Centre, Oxford, UK
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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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Hashimoto K, Nishimura S, Kakinoki R, Akagi M. Treatment of angiomatoid fibrous histiocytoma after unplanned excision: a case report. BMC Res Notes 2018; 11:628. [PMID: 30170609 PMCID: PMC6119284 DOI: 10.1186/s13104-018-3736-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 08/28/2018] [Indexed: 11/23/2022] Open
Abstract
Background Angiomatoid fibrous histiocytoma (AFH) is a relatively uncommon soft tissue tumor of intermediate biologic potential. It occurs in subcutaneous regions of the extremities or the trunk, usually presenting in children or young adults. This is the first reported case of subcutaneous AFH that developed in the iliac region and was treated with an unplanned resection. Case presentation An 11-year-old girl noticed a small subcutaneous nodule in the iliac region. As the nodule was asymptomatic, it was observed naturally for a year, after which her parents consulted her doctor due to gradual growth of the nodule. The tumor was resected marginally without biopsy by a non-specialized surgeon. Based on the histology of the resected specimen, the tumor was suspected to be a sarcoma. The patient was referred to our hospital where we reinvestigated the histology of the tumor using immunohistochemistry. After confirming diagnosis of the tumor as an AFH, we undertook additional extensive resection in the iliac region where the tumor had developed. There was no evidence of tumor residue in the resected specimen. It has been 3 years since the operation, and there has been no evidence of recurrence. Conclusion We treated a case of AFH after unplanned resection. If subcutaneous tumors in the iliac region are detected, a diagnosis of AFH should be considered and a simple resection avoided.
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Affiliation(s)
- Kazuhiko Hashimoto
- Department of Orthopedic Surgery, Kindai University Hospital, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan.
| | - Shunji Nishimura
- Department of Orthopedic Surgery, Kindai University Hospital, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Ryosuke Kakinoki
- Department of Orthopedic Surgery, Kindai University Hospital, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Masao Akagi
- Department of Orthopedic Surgery, Kindai University Hospital, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
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Nakamura T, Kawai A, Sudo A. Analysis of the patients with soft tissue sarcoma who received additional excision after unplanned excision: report from the Bone and Soft Tissue Tumor Registry in Japan. Jpn J Clin Oncol 2017; 47:1055-1059. [DOI: 10.1093/jjco/hyx123] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu-city
| | - Akira Kawai
- Department of Musculoskeletal Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu-city
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Management of Unplanned Excision for Soft-Tissue Sarcoma With Preoperative Radiotherapy Followed by Definitive Resection. Am J Clin Oncol 2017; 39:586-592. [PMID: 24879470 DOI: 10.1097/coc.0000000000000095] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES The purpose of this study was to review the outcomes after preoperative radiotherapy and definitive surgery for patients who initially had inadvertent excision for sarcoma. MATERIALS AND METHODS Treatment records of 44 consecutive patients, who initially underwent unplanned excision of soft-tissue sarcoma between January 2004 and January 2012, were reviewed. All patients had clinically localized disease before treatment and received preoperative external-beam radiotherapy followed by definitive oncologic surgery at our institution. RESULTS The median follow-up was 36 months. Residual tumor after preoperative radiotherapy and wound bed excision was identified in 39% (17/44) of the cases. Kaplan-Meier estimates for 5-year local control, recurrence-free survival, and overall survival are 95% (95% confidence interval [CI], 80-99), 86% (95% CI, 69-94), and 94% (95% CI, 79-99) respectively. Perioperative morbidity occurred in 25% of patients (11/44.) All patients with perioperative wound complications had lower extremity sarcomas. CONCLUSIONS Optimal management for unplanned excision of soft-tissue sarcoma is unknown. Our institution has adopted the approach of preoperative radiotherapy, followed by definitive surgery. In our series of 44 patients, local control was excellent at 95%, with perioperative complications seen only in patients with lower extremity sarcomas, suggesting that this is a reasonable approach to manage inadvertently resected sarcoma.
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Multidisciplinary Approach to Salvage of Unplanned Sarcoma Resections. Sarcoma 2017. [DOI: 10.1007/978-3-319-43121-5_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Preoperative Radiation Therapy Followed by Reexcision May Improve Local Control and Progression-Free Survival in Unplanned Excisions of Soft Tissue Sarcomas of the Extremity and Chest-Wall. Int J Surg Oncol 2016; 2016:5963167. [PMID: 27803813 PMCID: PMC5075633 DOI: 10.1155/2016/5963167] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 09/14/2016] [Indexed: 11/18/2022] Open
Abstract
Background. The management for unplanned excision (UE) of soft tissue sarcomas (STS) has not been established. In this study, we compare outcomes of UE versus planned excision (PE) and determine an optimal treatment for UE in STS. Methods. From 2000 to 2014 a review was performed on all patients treated with localized STS. Clinical outcomes including local recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival (OS) were evaluated using the Kaplan-Meier estimate. Univariate (UVA) and multivariate (MVA) analyses were performed to determine prognostic variables. For MVA, Cox proportional hazards model was used. Results. 245 patients were included in the analysis. 14% underwent UE. Median follow-up was 2.8 years. The LR rate was 8.6%. The LR rate in UE was 35% versus 4.2% in PE patients (p < 0.0001). 2-year PFS in UE versus PE patients was 4.2 years and 9.3 years, respectively (p = 0.08). Preoperative radiation (RT) (p = 0.01) and use of any RT for UE (p = 0.003) led to improved PFS. On MVA, preoperative RT (p = 0.04) and performance status (p = 0.01) led to improved PFS. Conclusions. UEs led to decreased LC and PFS versus PE in patients with STS. The use of preoperative RT followed by reexcision improved LC and PFS in patients who had UE of their STS.
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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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Charoenlap C, Imanishi J, Tanaka T, Slavin J, Ngan SY, Chander S, Dowsey MM, Goyal C, Choong PFM. Outcomes of unplanned sarcoma excision: impact of residual disease. Cancer Med 2016; 5:980-8. [PMID: 26929181 PMCID: PMC4924354 DOI: 10.1002/cam4.615] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/16/2015] [Accepted: 11/22/2015] [Indexed: 12/29/2022] Open
Abstract
This study aimed to compare the oncological results between unplanned excision (UE) and planned excision (PE) of malignant soft tissue tumor and to examine the impact of residual tumor (ReT) after UE. Nonmetastatic soft tissue sarcomas surgically treated in 1996-2012 were included in this study. Disease-specific survival (DSS), metastasis-free survival (MFS), and local-recurrence-free survival (LRFS) were stratified according to the tumor location and American Joint Committee on Cancer Classification 7th edition stage. Independent prognostic parameters were identified by Cox proportional hazard models. Two-hundred and ninety PEs and 161 UEs were identified. Significant difference in oncological outcome was observed only for LRFS probability of retroperitoneal sarcomas (5-year LRFS: 33.0% [UE] vs. 71.0% [PE], P = 0.018). Among the 142 UEs of extremity and trunk, ReT in re-excision specimen were found in 75 cases (53%). UEs with ReT had significantly lower survival probabilities and a higher amputation rate than UEs without ReT (5-year DSS: 68.8% vs. 92%, P < 0.001; MFS: 56.1% vs. 90.9%, P < 0.001; LRFS: 75.8% vs. 98.4%, P = <0.001; amputation rate 18.5% vs. 1.8%, P = 0.003). The presence of ReT was an independent poor prognostic predictor for DSS, MFS, and LRFS with hazard ratios of 2.02 (95% confidence interval (CI), 1.25-3.26), 1.62 (95% CI, 1.05-2.51) and 1.94 (95% CI, 1.05-3.59), respectively. Soft tissue sarcomas should be treated in specialized centers and UE should be avoided because of its detrimental effect especially when ReT remains after UE.
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Affiliation(s)
- Chris Charoenlap
- Department of Orthopaedics, St. Vincent's Hospital Melbourne, Victoria, Australia.,Department of Orthopaedics, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10400, Thiland, Thailand
| | - Jungo Imanishi
- Department of Orthopaedics, St. Vincent's Hospital Melbourne, Victoria, Australia
| | - Takaaki Tanaka
- Department of Orthopaedics, St. Vincent's Hospital Melbourne, Victoria, Australia
| | - John Slavin
- Department of Pathology, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia
| | - Samuel Y Ngan
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, 2 St Andrews Place, East Melbourne 3002, Victoria, Australia.,Bone and Soft Tissue Sarcoma Unit, Peter MacCallum Cancer Centre, 2 St Andrews Place, East Melbourne 3002, Victoria, Australia
| | - Sarat Chander
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, 2 St Andrews Place, East Melbourne 3002, Victoria, Australia.,Bone and Soft Tissue Sarcoma Unit, Peter MacCallum Cancer Centre, 2 St Andrews Place, East Melbourne 3002, Victoria, Australia
| | - Michelle Maree Dowsey
- Department of Orthopaedics, St. Vincent's Hospital Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, 29 Regent Street, Fitzroy 3065, Victoria, Australia
| | - Chatar Goyal
- Department of Orthopaedics, St. Vincent's Hospital Melbourne, Victoria, Australia
| | - Peter F M Choong
- Department of Orthopaedics, St. Vincent's Hospital Melbourne, Victoria, Australia.,Bone and Soft Tissue Sarcoma Unit, Peter MacCallum Cancer Centre, 2 St Andrews Place, East Melbourne 3002, Victoria, Australia.,Department of Surgery, University of Melbourne, 29 Regent Street, Fitzroy 3065, Victoria, Australia
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Abstract
Unplanned resection is a common problem in the management of sarcoma. Because sarcomas are so rare, they may be misdiagnosed initially as more common benign lesions. When the treating surgeon is unaware of or does not adhere to proper surgical principles of orthopaedic oncology, an intralesional procedure may be performed without the requisite preoperative imaging, staging, or wide resection margins for optimal management of sarcoma. Studies show that oncologic outcomes after unplanned resections are mixed; however, surgical outcomes drastically deteriorate. Failure to adhere to oncologic principles accounts for increased morbidity and amputation rates with re-resection. No diagnostic modality has been proven to accurately predict residual disease in the resection bed following unplanned resection. Thus, repeat surgery with or without adjuvant treatment is usually offered to these patients, thereby adding considerable cost and morbidity. Medical malpractice litigation associated with unplanned sarcoma resection is common, with delayed diagnosis and unnecessary amputation most often cited in cases decided in favor of the plaintiff.
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Dyrop HB, Safwat A, Vedsted P, Maretty-Kongstad K, Hansen BH, Jørgensen PH, Baad-Hansen T, Keller J. Characteristics of 64 sarcoma patients referred to a sarcoma center after unplanned excision. J Surg Oncol 2016; 113:235-9. [PMID: 26776152 DOI: 10.1002/jso.24137] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 12/05/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND METHODS Unplanned excision of sarcoma before referral to specialist centers can affect prognosis and surgical outcome. The diagnostic pathway of these patients is uncertain and needs to be reviewed. We aimed to describe patient and tumor characteristics, initial symptoms, initial and final diagnosis, and explore reasons for unplanned excision in this patient group. From a previous study on 258 sarcoma patients, we identified 64 patients referred after surgery. Medical records were reviewed. RESULTS The majority were soft tissue sarcomas, most often with thoracic location. Leiomyosarcoma was the most frequent final diagnosis, lipoma, and fibroma/dermatofibroma the most frequent initial diagnoses. Fifty percent were superficial small tumors, and 60.9% had not received diagnostic imaging before surgery. Fifty percent were referred from public surgical departments, and 1/3 from private specialists. Twenty-three patients had initial presence of alarm symptoms registered before surgery, the remaining 2/3 fell outside referral criteria or alarm symptoms were not discovered. CONCLUSIONS Patients referred after unplanned excision often have small superficial tumors and the majority fall outside of defined referral criteria. Referral criteria are not a guarantee for detection of all sarcomas and surgeons should always be aware of the possibility of malignancy when removing a tumor.
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Affiliation(s)
- Heidi Buvarp Dyrop
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus C, Denmark.,Department of Orthopedics, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | - Akmal Safwat
- Department of Oncology, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | - Peter Vedsted
- The Research Unit for General Practice, Aarhus University, Aarhus C, Denmark
| | - Katja Maretty-Kongstad
- Department of Pathology, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | - Bjarne Hauge Hansen
- Department of Orthopedics, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | | | - Thomas Baad-Hansen
- Department of Orthopedics, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | - Johnny Keller
- Department of Orthopedics, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
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Siegel GW, Kuzon WM, Hasen JM, Biermann JS. Staged Soft Tissue Reconstruction Following Sarcoma Excision with Anticipated Large Cutaneous Defects: An Oncologically Safe Alternative. THE IOWA ORTHOPAEDIC JOURNAL 2016; 36:104-108. [PMID: 27528845 PMCID: PMC4910795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND We hypothesized that select patients undergoing planned soft tissue sarcoma (STS) excision with anticipated skin and soft tissue deficits could be treated with a two stage surgical procedure which would allow some flexibility in coverage options while not significantly increasing local recurrence rate or wound complication rate. METHODS A retrospective review was undertaken in a series of consecutive patients with a minimum 2-year follow-up treated by a single orthopedic oncologist and a single reconstructive plastic surgeon who were managed with a staged approach STS excision and reconstruction. RESULTS There were 73 patients identified over a ten-year period that underwent staged STS excision and soft tissue reconstruction. There were 12 (16%) initial positive margins resected to negative final margins, and a variety of coverage procedures performed. Wound complication rate was 21%. Local recurrence rate was 11%. CONCLUSION Staged STS excision and reconstruction is an acceptable tool in the armamentarium of the orthopedic oncologist for managing major soft tissue deficits without an increase in local recurrence rates.
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Affiliation(s)
| | | | - Jill M Hasen
- University of Michigan Department of Orthopaedic Surgery
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Austin JL, Temple WJ, Puloski S, Schachar NS, Oddone Paolucci E, Kurien E, Sarkhosh K, Mack LA. Outcomes of surgical treatment alone in patients with superficial soft tissue sarcoma regardless of size or grade. J Surg Oncol 2015; 113:108-13. [PMID: 26661586 DOI: 10.1002/jso.24091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 10/28/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Currently, standard treatment of soft tissue sarcoma (STS) is wide local excision and adjuvant radiation, but radiation may be unnecessary in superficial STS. The primary objective is to assess local recurrence rates in patients treated with surgical management alone for superficial STS. METHODS A retrospective cancer registry review of patients treated with surgery alone for superficial STS at the Tom Baker Cancer Center (TBCC) was performed. Patient and tumor characteristics as well as recurrence data were collected. RESULTS Sixty-one patients met study criteria. Local and overall recurrence rates were 7/61 (11.5%) and 12/61 (19.7%), respectively. The proportion with a T2 tumor was 38.8% versus 33.3% (P = 0.69), with Grade 2 or 3 tumors was 59.2% versus 83.3% (P = 0.14), and with resection margins <1 cm was 28.6% versus 75.0% (P = 0.008) for patients without and with recurrence, respectively. Median time to recurrence was 1.7 (0.4-5.2) years. CONCLUSIONS Surgical resection alone appears to be a viable option for superficial STS that can save patients from potential side effects of radiation. The association between recurrence and inadequate margins (<1 cm) requires additional treatment be offered to this subset of patients.
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Affiliation(s)
- Janice L Austin
- Division of General Surgery, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Walley J Temple
- Division of Surgical Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Shannon Puloski
- Division of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Norman S Schachar
- Division of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth Oddone Paolucci
- Departments of Surgery and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Elizabeth Kurien
- Division of Radiation Oncology, University of Calgary, Calgary, Alberta, Canada
| | | | - Lloyd A Mack
- Division of Surgical Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Association of short duration from initial symptoms to specialist consultation with poor survival in soft-tissue sarcomas. Am J Clin Oncol 2015; 38:266-71. [PMID: 23648441 DOI: 10.1097/coc.0b013e318295aea2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The association of symptom duration with survival remains controversial in soft-tissue sarcoma (STS). MATERIALS AND METHODS We determined whether the length from initial symptoms to specialist consultation affects prognosis in STSs. We retrospectively reviewed 152 primary STS patients (with 142 non-small round cell sarcomas) who consulted our specialist hospital. The factors that affected the length of the period from the initial symptoms to specialist consultation and the length of the delay at the clinic before specialist hospital referral were investigated. The relation between the length of the period from symptom onset and overall survival was also analyzed. RESULTS Unplanned excision and superficial tumor were significantly associated with increasing duration from the initial symptoms to specialist hospital referral. Multivariate analysis revealed that tumors over 5 cm (P=0.002 and 0.005) and symptoms within 6 months (P=0.017 and 0.016) were independent poor prognostic factors of overall survival among the pretreatment factors when analyzing all and non-small round cell STSs. CONCLUSIONS This is a first report to show the independent prognostic role of symptom duration in STSs on multivariate analysis. Considering the impact of symptom duration on survival in these heterogenous tumors, careful follow-up and consideration of treatment are necessary for patients with short symptom duration.
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Pretell-Mazzini J, Barton MD, Conway SA, Temple HT. Unplanned excision of soft-tissue sarcomas: current concepts for management and prognosis. J Bone Joint Surg Am 2015; 97:597-603. [PMID: 25834085 DOI: 10.2106/jbjs.n.00649] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Biopsy, staging, preoperative imaging and planning, as well as surgical treatment of soft-tissue sarcomas, are best carried out in specialized sarcoma centers, with the support of a multidisciplinary tumor board.➤ Tumor bed excision is recommended after most unplanned excisions, with a goal of obtaining complete tumor removal with an appropriately wide margin of resection.➤ The surgical resection area tends to be more extensive during tumor bed excision than during primary resection because of the need to resect potential areas of contamination, resulting in the need for more reconstructive procedures (flaps and skin grafts) and wider radiation fields.➤ Unplanned excisions are associated with an increased rate of local recurrence related to residual disease and positive margins after tumor bed excision, a deep location, and certain histologic subtypes, such as malignant peripheral nerve sheath tumor, myxofibrosarcoma, and dermatofibrosarcoma protuberans.➤ While adjuvant radiation therapy has not been found to mitigate the risk of local recurrence in unplanned excisions, it is generally utilized in the treatment of unplanned excisions as it is in the treatment of primary soft-tissue sarcomas.➤ Given the surgical and oncologic sequelae of unplanned excisions, prevention through the diffusion of concepts by means of provider education on how to approach soft-tissue masses, which can be potential soft-tissue sarcomas, is the best strategy.
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Affiliation(s)
- Juan Pretell-Mazzini
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Division, University of Miami Miller School of Medicine, 1400 NW 12th Avenue, Fourth floor, Room 4036, Miami, FL 33136. E-mail address for J. Pretell-Mazzini: . E-mail address for M.D. Barton Jr.: . E-mail address for S.A. Conway: . E-mail address for H.T. Temple:
| | - Mark D Barton
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Division, University of Miami Miller School of Medicine, 1400 NW 12th Avenue, Fourth floor, Room 4036, Miami, FL 33136. E-mail address for J. Pretell-Mazzini: . E-mail address for M.D. Barton Jr.: . E-mail address for S.A. Conway: . E-mail address for H.T. Temple:
| | - Sheila A Conway
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Division, University of Miami Miller School of Medicine, 1400 NW 12th Avenue, Fourth floor, Room 4036, Miami, FL 33136. E-mail address for J. Pretell-Mazzini: . E-mail address for M.D. Barton Jr.: . E-mail address for S.A. Conway: . E-mail address for H.T. Temple:
| | - H Thomas Temple
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Division, University of Miami Miller School of Medicine, 1400 NW 12th Avenue, Fourth floor, Room 4036, Miami, FL 33136. E-mail address for J. Pretell-Mazzini: . E-mail address for M.D. Barton Jr.: . E-mail address for S.A. Conway: . E-mail address for H.T. Temple:
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Morii T, Aoyagi T, Tajima T, Yoshiyama A, Ichimura S, Mochizuki K. Unplanned resection of a soft tissue sarcoma: clinical characteristics and impact on oncological and functional outcomes. J Orthop Sci 2015; 20:373-9. [PMID: 25613392 DOI: 10.1007/s00776-014-0689-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 12/15/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Over the past three decades, several studies have reported worse outcomes with unplanned resection for malignant soft tissue tumors. However, the impact of these studies on preventing unnecessary unplanned resection remains unknown. METHODS In a retrospective survey on the treatment of soft tissue sarcomas, we compared cases of unplanned resection with cases of planned resection in terms of the properties of unplanned resection and the oncological and functional outcomes. For the unplanned resection cases, an additional wide resection was performed. RESULTS Of 92 cases, unplanned resection was performed in 24 (26 %). Small or subcutaneous tumors were significantly more frequently subjected to unplanned resection. In 17 of 24 unplanned resection cases, residual tumors (70.8 %) were noted. Plastic surgery was more frequently needed for unplanned resection cases. There was no significant difference between the unplanned resection and control cases with regard to oncological outcome. However, as to local recurrence and overall survival, the events occurred only in the cases with residual tumors in the additional wide resection specimen in the unplanned resection group. There was no significant difference in functional evaluation, except for emotional acceptance, which had a better score in the unplanned resection group. CONCLUSIONS Despite repeated cautions regarding unplanned resection in terms of its inadequate procedure which contradicts the principles of soft tissue sarcoma treatment, unplanned resections are still frequently performed. Perhaps the small size and subcutaneous location of the sarcomas in the unplanned resection group did not evoke the probability of malignancy for the surgeons who initially managed them. Even though an additional wide resection was performed, a residual tumor would lead to a worse outcome. An effective awareness program to avoid unnecessary unplanned resections for soft tissue sarcoma should be considered.
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Affiliation(s)
- Takeshi Morii
- Department of Orthopedic Surgery, Kyorin University, 6-20-2 Shinwaka, Mitaka, Tokyo, 161-8611, Japan,
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Abstract
Soft-tissue masses of the extremities are common entities encountered by nearly all providers of musculoskeletal patient care. Proper management of these lesions requires a specific process of evaluation. A detailed history and physical examination must be performed. Appropriate imaging studies must be obtained based on clinical indications. MRI is the imaging modality of choice for diagnosis of soft-tissue masses, with CT and ultrasonography used as secondary options. These modalities aid the clinician in developing an appropriate differential diagnosis and treatment plan. When the initial evaluation is inconclusive, biopsy must be performed. A diagnosis must be established before definitive treatment with surgical excision or, in rare cases, radiation therapy is performed. Clinicians without significant experience in treating soft-tissue masses should consider referral to a musculoskeletal oncologist for specialized care when a definitive diagnosis of a benign lesion cannot be made. Several studies have shown that multidisciplinary care in specialized referral centers optimizes outcomes and diminishes comorbid complications.
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