The impact of previous surgical manipulation of subcutaneous sarcoma on oncologic outcome

Early Complications of Planned Resection Versus Unplanned Excision of Sarcomas in the Distal Upper Extremity

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.

The Role of a Multidisciplinary Team in the Diagnosis and Treatment of Bone and Soft Tissue Sarcomas: A Single-Center Experience

Bone and soft tissue sarcomas with complex and varied clinical, imaging, and pathological characteristics cannot be diagnosed and treated by a single discipline, as each discipline has some limitations. This study aimed to explore the role of a multidisciplinary team (MDT) in the diagnosis and treatment of bone and soft tissue sarcomas over the past four consecutive years. The subjects were 269 patients discussed during MDT meetings at a Bone and Soft Tissue Sarcomas Center in South China. The diagnosis, relapse diagnosis, unplanned resection, management of pulmonary nodules, and treatment of refractory and advanced tumors were compared to similar data provided in the literature to (i) determine whether the MDT significantly affected the diagnosis and treatment of bone and soft tissue sarcomas, and (ii) explore trends in the types of patients with bone and soft tissue sarcomas and treatment decision-making since the establishment of the MDT. Results revealed that the MDT significantly improved preoperative diagnostic accuracy for patients with bone and soft tissue sarcomas; the accuracy of diagnosis and relapse diagnosis by the MDT reached 95.42% and 100%, respectively. After an MDT discussion, the positive pathology rate for extended resection after unplanned resection was 81.2%. The overall accuracy of the MDT in determining the nature of pulmonary nodules was 87.1-91.9%. For patients presenting with pulmonary nodules in osteosarcoma, no statistically significant difference in survival was shown between cases discussed by the MDT and those without an MDT discussion (p = 0.5751). Collectively, the MDT can play a positive role in accurate preoperative diagnosis, relapse diagnosis, the decision to extend resection after an unplanned resection, and the diagnostic accuracy of pulmonary nodules.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of the Effect of the Size and Grade of Soft Tissue Sarcoma on Rates of Unplanned Resection, Metastatic Disease, Mortality, and Morbid Re-Resection Over 20 Years

Soft tissue sarcomas are rare malignancies that are often presumed to be benign and are resected without the typical preoperative workup, such as imaging or biopsy. These unplanned resections occur in approximately 30% of all cases and frequently require further morbid treatments, resulting in worse oncologic outcomes. A retrospective review was performed of all patients who presented to a tertiary sarcoma center with a diagnosis of sarcoma between 1996 and 2017. In-depth chart reviews were performed for the 2600 patients who were identified, with 836 having a primary diagnosis of soft tissue sarcoma in an upper or lower extremity. Data collected included histologic features, grade, size, resection status, demographic features, referral information, metastatic disease, morbid procedures, and mortality rate. Patients were divided into 2 groups based on whether the tumor size was greater or less than 5 cm. This classification was in keeping with the guideline of referring patients to a tertiary sarcoma center for workup for tumors "larger than a golf ball." The difference in the rate of unplanned resection for tumors measuring less than 5 cm (41.6%) and those measuring 5 cm or greater (18.8%) was statistically significant (P<.001), with smaller tumors more likely to undergo unplanned resection, in keeping with the success of the "golf ball rule." The rate of metastatic disease for unplanned resection for tumors measuring 5 cm or greater (50.7%) was significantly greater than that for tumors measuring less than 5 cm (19.7%) (P<.001). The authors found a great deal of morbidity associated with unplanned resection, regardless of tumor size. Before resection is planned, delineation is required beyond tumor size. [Orthopedics. 2021;44(3):166-171.].

Effect of unplanned excision of soft tissue sarcomas on skin defects and reconstructive procedures

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.

A Retrospective Case Series of Synovial Sarcoma of the Upper Extremity

Purpose

Previous studies have grouped the treatment of axial and appendicular synovial sarcomas. The purpose of this study was to assess the prognostic variables of upper extremity synovial sarcomas (UESS) and compare the outcomes of those who underwent a nononcologic or inadvertent excision prior to definitive resection to those who underwent an initial oncologic resection.

Methods

We reviewed the records of 23 UESS treated with definitive surgery at our institution between 1990 and 2014. There were 13 women and 10 men with a median age of 30 years (6–60) and median follow-up of 63 months (15–248). Prognostic variables, recurrence-free survival (RFS), and overall survival (OS) were then assessed.

Results

Fifteen patients (65%) had a prior unplanned excision. Five patients required an amputation to obtain local control of disease. There were 3 observed local recurrences and 2 distant metastases at a median of 45 months from presentation. We found no difference in need for amputation, RFS, or OS between those who had undergone a planned excision and those who had an unplanned excision.

Conclusion

While we were unable to find a significant difference in outcomes or amputation rates between those who underwent reexcision of a previously unplanned excision and those who underwent an initial planned resection, the high rate of unplanned excision is troubling and should remind practitioners to consider sarcoma in the differential of all upper extremity masses.

Inadvertent excision of malignant soft tissue tumours

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.

Patterns of care of superficial soft tissue sarcomas: it is not always just a lump

AIM

Superficial soft tissue sarcomas (S-STS) are generally considered low-risk tumors and have an excellent prognosis when treated with appropriate surgery and adjuvant therapy. However, they are often misdiagnosed then mistreated, leading to significant morbidity. This study aims to examine the patterns of care and outcomes of patients with S-STS, comparing those initially managed through sarcoma units versus elsewhere.

METHODS

Patients with S-STS from Prince of Wales Hospital in NSW (1995-2013) and Peter MacCallum Cancer Centre in Victoria (2009-2013) were identified from a national sarcoma database. Baseline variables, treatment and disease outcomes were recorded. Statistical tests performed included univariate and multivariate analyses, chi-square tests, as well as the Kaplan-Meier method for 5-year local recurrence and survival rates.

RESULTS

Eighty-nine patients were identified, with 35% initially managed at a sarcoma unit and 65% elsewhere. Patients initially managed at sarcoma units had larger tumors (>5 cm 39% vs 17%; P  =  0.036) with a trend to higher grade (61% vs 48%; P = 0.39). Patients that were initially managed outside a sarcoma unit more often underwent open surgical biopsies (P < 0.0005), had multiple operations (P < 0.0005) and had higher rates of local recurrences (24% vs 6.5%, P  =  0.038). They also had lower 5-year local recurrence-free survival rates (P = 0.022), but had higher metastasis-free survival (P = 0.014). On multivariate analysis, only larger STS size and male gender predicted for poorer metastasis-free survival (P = 0.042 and 0.018, respectively).

CONCLUSION

Patients with S-STS initially managed outside specialized sarcoma units undergo more operations, with risk of greater morbidity, and have greater risk of local recurrence.

Reconstructive Surgery in Soft Tissue Sarcomas—Long-Term Outcome and Quality of Life

The long-term oncological and functional outcome including quality of life should be evaluated in soft tissue sarcomas (STS). The need for reconstructive surgery with possible influence on the results should also be analyzed. Tumor stage mainly influences the prognosis of STS. Advances in reconstructive surgery mostly allow limb salvage. Limited information exists about functional outcome and life quality. A total of 86 patients (51 men, 35 women, mean age 50.5 years) with a minimum follow-up of 10 years were analyzed. We determined the oncological outcome (local recurrences, metastases, overall survival) of tumors at varying stages: stage I (n = 30), stage II (n = 52), and stage III (n = 4). Functional outcome and quality of life of the survivors were measured using the Musculoskeletal Tumor Society (MSTS) criteria and the EORTC-QLQ-C-30 (European Organisation for Research and Treatment of Cancer-Quality of Life-Questionnaire-Core-30 module) questionnaire. Tumor stage influenced the survival and the development of metastases. Survival rates were 89.5 and 88% after 5 and 10 years in stage I, and 56.5 and 49% in stage II tumors. Surgical margin influenced the development of local recurrence. Reconstructive procedures were necessary in 27 patients. After a median follow-up of 144 months, 36 patients were dead: 29 of their malignancy and 7 of other diseases. Fifty long-term survivors presented good results for MSTS (mean score: 82.4) and EORTC-QLQ-C-30 (mean score: 79.8), the results were independent on the need of reconstructive surgery. In stage II STS, the survival drops even after 5 years. The surgical treatment of STS requires the knowledge of different reconstructive techniques; functional results and quality of life are not compromised by the need for reconstructive surgery.

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

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.

Predictors of residual disease after unplanned excision of soft tissue sarcomas

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.

Outcomes of unplanned sarcoma excision: impact of residual disease

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.

Unplanned Resection of Sarcoma

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.

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

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.

What are risk factors for local recurrence of deep high-grade soft-tissue sarcomas?

BACKGROUND

Patients with local recurrence of soft-tissue sarcomas have a poor overall survival. High-grade, soft-tissue sarcomas in deep locations may have a poorer prognosis regarding local recurrence than low-grade sarcomas or those located superficially. Although previous reports evaluated tumors at various depths, it is unclear what factors influence recurrence of deep, high-grade sarcomas.

QUESTIONS/PURPOSES

We therefore determined whether possible risk factors (tumor size, location, histologic subtype, unplanned excision, local recurrence at presentation, metastasis at diagnosis, surgical procedure, surgical margin, and adjuvant treatments) influenced local recurrence of deep, high-grade, soft-tissue sarcomas.

PATIENTS AND METHODS

We retrospectively reviewed 433 patients with deep, high-grade, soft-tissue sarcomas surgically treated between 1985 and 2005. For each patient, we reviewed tumor size, location, histologic subtype, unplanned excision, local recurrence at presentation, metastasis at diagnosis, surgical procedure, surgical margin, and adjuvant treatments and determined the effect of each prognostic variable on local recurrence. The minimum followup was 1 month (median, 51 months; range, 1-305 months).

RESULTS

Forty-seven patients had local recurrence at a median of 10.7 months. Local recurrence at presentation, metastasis at diagnosis, and positive margins independently predicted local recurrence. No other factors independently predicted local recurrence.

CONCLUSIONS

Unplanned excisions did not increase the rate of local recurrence of deep, high-grade, soft-tissue sarcomas if treated appropriately. Aggressiveness of tumor represented by metastasis or local recurrence at presentation may be a risk for local recurrence.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

The adverse effect of an unplanned surgical excision of foot soft tissue sarcoma

Background

Malignant soft tissue tumors of the foot are extremely rare and thus can be prematurely excised without appropriate preoperative evaluation. The present study compares adverse effects between unplanned and planned surgical excisions.

Methods

We retrospectively reviewed the clinical records, radiographs, pathology reports and pathological specimens of 14 consecutive patients with soft tissue sarcoma of the foot among 592 with sarcomas between 1973 and 2009. We then compared the incidence and clinical outcomes after unplanned (UT; n = 5) and planned (PT; n = 9) surgical excisions of foot sarcomas.

Results

The most frequent diagnosis was synovial sarcoma (n = 4; 28.6%). The overall 5-year survival rates of the PT and UT groups were 65.6% and 60.0%, respectively, and the event-free 5-year survival rates were 63.5% and 40.0%, respectively. Event-free and overall survival rates did not significantly differ between the two groups. However, tumors were significantly larger in the PT group than in the UT group (p < 0.05).

Conclusions

Unplanned resection lead to a relatively worse prognosis and a likelihood of recurrence despite additional resections. We recommend that soft tumors of the foot should only be excised after appropriate preoperative evaluation regardless of the size of the tumor.

Clinical and treatment outcomes of planned and unplanned excisions of soft tissue sarcomas

BACKGROUND

Soft tissue sarcomas are often inappropriately excised without adequate preoperative planning. Inappropriate (unplanned) excisions may adversely affect local recurrence, distant metastasis, patient survival, and /or postoperative function once properly evaluated.

QUESTIONS/PURPOSES

We asked whether the clinical and treatment characteristics, survival (overall, local recurrence-free, distant metastasis-free), and functional scores of patients with unplanned excisions differ from those with a planned excision.

METHODS

We retrospectively reviewed 128 patients with planned excisions and 63 patients with unplanned excisions at prereferral hospitals followed by additional reexcisions. We determined whether age, gender, tumor size, depth, histologic grade, operative duration, blood loss, survival, or functional scores differed between the two groups. The minimum followup was 6 months (mean, 55 months; range, 6-275 months).

RESULTS

The tumor was larger and its location deeper in the planned excision group. Overall, metastasis-free, and local recurrence-free survival were similar in the two groups: 86%, 71%, and 85% in the planned excision group and 96%, 86%, and 92% in the unplanned excision group, respectively. However, additional soft tissue reconstruction was more often necessary for patients with unplanned excisions. No difference in postoperative function was observed.

CONCLUSIONS

The data suggest an adequate additional wide excision may improve the local control and survival in patients with an unplanned excision as well as the patients with a planned excision. While patients with unplanned excisions had superficial and smaller tumors, survival and postoperative function were similar to those with planned excisions.

Superficial soft tissue sarcomas of the extremities and trunk

BACKGROUND

Superficial soft tissue sarcomas (sSTS) are an important and frequent subtype of soft tissue sarcoma (STS). A wider knowledge of this tumor type may lead to better strategies in tumor therapy.

METHODS

An institutional review was performed on all patients with primary sSTS of the extremities and trunk operated on between 1990 and 2003.

RESULTS

The medical records of 108 patients with sSTS were analyzed. The local recurrence rate was 11% after a median of 25 (mean 42) months. Metastases occurred in 21 patients (19%), and 79 patients lived without evidence of disease after a mean follow-up of 112 +/- 42 months. Mean survival time was 89 months at a cumulative 5-year survival rate of 85%. R0 resection significantly enhanced cumulative survival (p = .001), as did patient age < 60 years (p = .002), tumor grading G1 and G2 compared to G3 (p = .004), absence of positive lymph nodes (p = .018), and no occurrence of metastases (p = .001). Tumor size < or = 5 cm reduced the local recurrence rate significantly (p = .044). Significant multivariate risk factors for metastases were age > or = 60 years (p = .016) and tumor grade G3 (p = .021).

CONCLUSIONS

Patients with sSTS who are > or = 60 years of age or who have G3 tumors have a high risk of distant metastases. Patients with T2 tumors have an elevated risk for local recurrence. Certainly all patients with sSTS should be in a tight after-care program to allow early diagnosis of local recurrence or distant metastases. Age < 60 years, tumor grade G1/2, no positive regional lymph nodes (N0), and a R0 resection are significant prognostic factors for survival.

Standardized approach to the treatment of adult soft tissue sarcoma of the extremities

Soft tissue sarcomas are very rare tumors. Available data are based on only a few prospective randomized trials. Most studies are retrospective, reviewing the results of single institutions. Furthermore, universally accepted treatment protocols for adult patients are lacking. Several prognostic factors have been identified, including grading, tumor size and development of metastatic disease; however, the relevance of other important aspects in the treatment of patients with soft tissue sarcomas remains unknown or subject to controversy. The main issues concern: which surgical margin width is safe from an oncological perspective? Does local recurrence influence survival? Can systemic chemotherapy improve prognosis? Is radiotherapy necessary in every case? Should it be applied pre-, post- or intraoperatively? What is the value of assessing the response after neoadjuvant therapy? These topics are examined in this review.

Soft-tissue sarcoma

Soft-tissue sarcomas are rare malignancies of mesodermal origin. Common sites of involvement include the extremities, trunk, retroperitoneum, and the head and neck. Soft-tissue sarcomas of the extremities and pelvis are the most relevant to the orthopaedic surgeon. The patient with extremity soft-tissue sarcoma typically presents with a painless, enlarging mass. Advanced imaging techniques and biopsy, which are best done at tertiary referral centers, usually confirm the diagnosis. Factors such as sarcoma size, location, grade, histologic subtype, and stage, as well as patient age and comorbidities, determine the specific approach to management and patient outcome. Limb-sparing surgical resection is the mainstay of treatment. Radiation is used for unresectable tumors and as a neoadjuvant or an adjuvant to resection. The use of chemotherapy is controversial, and no standardized protocol has been established.

Uterine Leiomyosarcoma: Does the Primary Surgical Procedure Matter?

Background:

Uterine leiomyosarcoma (LMS) has a poor prognosis even after early-stage diagnosis. Because there are no accurate diagnostic tools for preoperatively distinguishing LMS from uterine leiomyoma, surgeons might opt for partial surgical procedures such as myomectomy or subtotal hysterectomy. We sought to determine whether a surgical procedure that cuts through the tumor influences prognosis.

Materials and Methods:

Demographic and clinical data of consecutive patients with stage I LMS treated between 1969 and 2005 were reviewed. The study population was divided into group A: patients whose first surgical intervention was total hysterectomy (n = 21); and group B: patients who underwent procedures involving tumor injury, for example, myomectomy, laparoscopic hysterectomy with a morcellator knife, or hysteroscopic myomectomy (n = 16). Survival rates were analyzed and compared. A Cox proportional hazards model was used to assess the association between variables of interest and prognosis.

Results:

The median age at diagnosis was 50 years (range, 30-74 years). Median follow-up duration was 44 months. The 2 groups did not differ significantly in age at diagnosis, menopausal status, gravidity, parity, postoperative radiotherapy, or time to last follow-up. Kaplan-Meier curves showed significantly better survival rates (P = 0.04) and a significant advantage in recurrence rate (P = 0.03) for group A compared with group B. Survival in group A was 2.8-fold better than that in group B (95% confidence interval, 1.02-7.67). These estimates remained stable after adjustment for age, menopausal status, and radiotherapy.

Conclusions:

In patients with stage I LMS, primary surgery involving tumor injury seems to be associated with a worse prognosis than total hysterectomy as a primary intervention.

Local recurrence of disease after unplanned excisions of high-grade soft tissue sarcomas

Unplanned excisions of soft tissue sarcomas occur with alarming frequency and result in high rates of residual disease, potentially affecting patient prognosis. To determine if unplanned excisions and residual disease status at tumor bed excision increased local recurrence rates and predicted disease-specific patient survival, we retrospectively reviewed 203 consecutive patients with high-grade soft tissue sarcomas treated operatively and followed for at least 2 years (mean, 4.8 years) or until patient death. Among the 64 patients (32%) who had undergone previous unplanned excisions, six had gross residual disease and 40 of the remaining 58 (69%) had microscopic residual disease in the tumor bed. We observed subsequent local recurrence in nine of the 139 patients (6%) after planned excision compared with 22 patients (34%) after unplanned excision. More patients with unplanned excisions who underwent limb salvage procedures required flap coverage and/or skin grafting with their definitive resection (30% versus 5%). In the unplanned excision cohort, residual disease status at tumor bed excision predicted increased rates of local recurrence and decreased disease-specific survival. Unplanned excisions of high-grade soft tissue sarcomas resulted in increased rates of local recurrence but not disease-specific survival. Residual disease at reexcision predicted the likelihood of local recurrence.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.