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Unplanned Excision of Extremity and Trunk Wall Soft Tissue Sarcoma: To Re-resect or Not to Re-resect?

  • Sarcoma
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Purpose

The need for systematic reexcision in patients who underwent unplanned excision (UE) for extremity and superficial trunk soft tissue sarcoma (ESTSTS) has been questioned. We investigated the outcome of patients who underwent reexcision for ESTSTS compared with primarily resected at our institution and the prognostic impact of microscopic residual disease (MR) in the reexcision specimen.

Methods

Primary ESTSTS patients surgically treated at our institution between 1997 and 2017 were divided in three groups: primarily resected (A), reexcised after macroscopically complete UE (B), and incomplete UE (C). Weighted overall survival (OS), crude cumulative incidence of local relapse (CCI-LR), and distant metastasis (CCI-DM) were calculated and compared. In group B, multivariable models were performed to assess factors associated with the outcomes.

Results

A total of 1962 patients were identified: 1076, 697 and 189 in groups A, B, and C, respectively. Overall median follow-up was 85 months. Seven-year weighted-OS was 73.8%, 84.1%, and 80.7% (p < 0.001) for groups A, B, and C respectively. Seven-year CCI-LR and DM were 5.0% and 25.3%, 12.1% and 15.8%, and 13.6% and 29.4% (both p < 0.001) for groups A, B, and C, respectively. At multivariable analysis, the presence MR was associated with LR (p < 0.001) but not with OS nor CCI-DM.

Conclusions

UE and the presence of MR at pathology in reexcision specimen are associated to a higher risk of LR but not to a higher risk of DM or lower OS. After macroscopic complete UE, postponing reexcision until a LR occurs may be considered on an individualized basis.

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References

  1. Jemal A, Tiwari RC, Murray T, et al. Cancer statistics, 2004. CA Cancer J Clin. 2004;54(1):8–29.

    Article  Google Scholar 

  2. Fiore M, Casali PG, Miceli R, et al. Prognostic effect of re-excision in adult soft tissue sarcoma of the extremity. Ann Surg Oncol. 2006;13(1):110–7.

    Article  Google Scholar 

  3. Chandrasekar CR, Wafa H, Grimer RJ, Carter SR, Tillman RM, Abdu A. The effect of an unplanned excision of a soft-tissue sarcoma on prognosis. J Bone Joint Surg Br. 2008;90(2):203–8.

    Article  CAS  Google Scholar 

  4. Rehders A, Stoecklein NH, Poremba C, Alexander A, Knoefel W, Peiper M. Reexcision of soft tissue sarcoma: sufficient local control but increased rate of metastasis [published correction appears in World J Surg. 2010;34(8):1991]. World J Surg. 2009;33(12):2599–605.

  5. Smolle MA, Tunn PU, Goldenitsch E, et al. The prognostic impact of unplanned excisions in a cohort of 728 soft tissue sarcoma patients: a multicentre study. Ann Surg Oncol. 2017;24(6):1596–605.

    Article  Google Scholar 

  6. 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(19):3868–75.

    Article  Google Scholar 

  7. Noria S, Davis A, Kandel R, et al. Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am. 1996;78(5):650–5.

    Article  CAS  Google Scholar 

  8. Casali PG, Abecassis N, Aro HT, et al. Soft tissue and visceral sarcomas: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018;29(Suppl 4):iv51–67 [published correction appears in Ann Oncol. 2018;29(Suppl 4):iv268–9].

  9. Manoso MW, Frassica DA, Deune EG, Frassica FJ. Outcomes of re-excision after unplanned excisions of soft-tissue sarcomas. J Surg Oncol. 2005;91(3):153–8.

    Article  Google Scholar 

  10. Zagars GK, Ballo MT, Pisters PW, et al. Prognostic factors for patients with localized soft-tissue sarcoma treated with conservation surgery and radiation therapy: an analysis of 1225 patients. Cancer. 2003;97(10):2530–43.

    Article  Google Scholar 

  11. Venkatesan M, Richards CJ, McCulloch TA, et al. Inadvertent surgical resection of soft tissue sarcomas. Eur J Surg Oncol. 2012;38(4):346–51.

    Article  CAS  Google Scholar 

  12. Biau DJ, Ferguson PC, Chung P, et al. Local recurrence of localized soft tissue sarcoma: a new look at old predictors. Cancer. 2012;118(23):5867–77.

    Article  Google Scholar 

  13. Arai E, Sugiura H, Tsukushi S, et al. Residual tumor after unplanned excision reflects clinical aggressiveness for soft tissue sarcomas. Tumour Biol. 2014;35(8):8043–9.

    Article  CAS  Google Scholar 

  14. Trovik CS, Bauer HC, Alvegård TA, et al. Surgical margins, local recurrence and metastasis in soft tissue sarcomas: 559 surgically-treated patients from the Scandinavian Sarcoma Group Register. Eur J Cancer. 2000;36(6):710–6.

    Article  CAS  Google Scholar 

  15. Trojani M, Contesso G, Coindre JM, et al. Soft-tissue sarcomas of adults; study of pathological prognostic variables and definition of a histopathological grading system. Int J Cancer. 1984;33(1):37–42.

    Article  CAS  Google Scholar 

  16. McCaffrey DF, Griffin BA, Almirall D, Slaughter ME, Ramchand R, Burgette LF. A tutorial on propensity score estimation for multiple treatments using generalized boosted models. Stat Med. 2013;32(19):3388–414.

    Article  Google Scholar 

  17. Schemper M, Smith TL. A note on quantifying follow-up in studies of failure time. Control Clin Trials. 1996;17(4):343–6.

    Article  CAS  Google Scholar 

  18. Callegaro D, Miceli R, Bonvalot S, et al. Development and external validation of two nomograms to predict overall survival and occurrence of distant metastases in adults after surgical resection of localised soft-tissue sarcomas of the extremities: a retrospective analysis. Lancet Oncol. 2016;17(5):671–80.

    Article  Google Scholar 

  19. Flury BK, Riedwyl H. Standard distance in univariate and multivariate analysis. Am Stat. 1986;40:249–51.

    Google Scholar 

  20. Austin PC, Stuart EA. Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies. Stat Med. 2015;34(28):3661–79.

    Article  Google Scholar 

  21. Durrleman S, Simon R. Flexible regression models with cubic splines. Stat Med. 1989;8:551–61.

    Article  CAS  Google Scholar 

  22. Zaidi MY, Ethun CG, Liu Y, et al. 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(3):332–9.

    Article  Google Scholar 

  23. Bianchi G, Sambri A, Cammelli S, et al. Impact of residual disease after “unplanned excision” of primary localized adult soft tissue sarcoma of the extremities: evaluation of 452 cases at a single institution. Musculoskelet Surg. 2017;101(3):243–8.

    Article  CAS  Google Scholar 

  24. Lewis JJ, Leung D, Espat J, Woodruff JM, Brennan MF. Effect of reresection in extremity soft tissue sarcoma. Ann Surg. 2000;231(5):655–63.

    Article  CAS  Google Scholar 

  25. Saeed H, King DM, Johnstone CA, et al. 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.

    PubMed  PubMed Central  Google Scholar 

  26. Callegaro D, Miceli R, Bonvalot S, et al. Impact of perioperative chemotherapy and radiotherapy in patients with primary extremity soft tissue sarcoma: retrospective analysis across major histological subtypes and major reference centres. Eur J Cancer. 2018;105:19–27.

    Article  Google Scholar 

  27. Bonvalot S, Levy A, Terrier P, et al. Primary extremity soft tissue sarcomas: does local control impact survival? Ann Surg Oncol. 2017;24(1):194–201.

    Article  Google Scholar 

  28. Decanter G, Stoeckle E, Honore C, et al. 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(11):3526–34.

    Article  Google Scholar 

Download references

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Authors and Affiliations

  1. Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

    Maria Danieli MD, Marco Fiore MD, Stefano Radaelli MD, Dario Callegaro MD & Alessandro Gronchi MD

  2. Department of Clinical Epidemiology and Trial Organisation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

    Francesco Barretta PhD & Rosalba Miceli PhD

  3. Department of Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

    Claudia Sangalli MD

  4. Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

    Marta Barisella MD

  5. Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy

    Silvia Stacchiotti MD, Elena Palassini MD & Paolo Giovanni Casali MD

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  1. Maria Danieli MD
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  2. Francesco Barretta PhD
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Correspondence to Alessandro Gronchi MD.

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Disclosures

Paolo Casali: In the past years, I have had honoraria for speaker, consultancy, or advisory role from: Bayer, Deciphera, Eisai, Eli Lilly, Pfizer. At my institution, my Unit received funds from: Advenchen Laboratories, Amgen Dompé, AROG Pharmaceuticals, Bayer, Blueprint Medicines, Daiichi Sankyo, Deciphera, Eisai, Eli Lilly, Epizyme Inc, Glaxo, Karyopharm Pharmaceuticals, Novartis, Pfizer, PharmaMar. The other authors do not have any commercial interest in the subject of study and no funding was received in support of this work.

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Supplementary information

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10434_2020_9564_MOESM1_ESM.eps

Supplementary Fig. 1 Calibration plots of observed 10-yr OS and calculated OS according to Sarculator model for group A. (EPS document) (EPS 147 kb)

10434_2020_9564_MOESM2_ESM.eps

Supplementary Fig. 2 Calibration plots of observed 10-yr OS and calculated OS according to Sarculator model for group B. (EPS document) (EPS 133 kb)

10434_2020_9564_MOESM3_ESM.eps

Supplementary Fig. 3 Forest plots of the hazard ratio for OS overall and according to histology subtype. (EPS document) (EPS 292 kb)

10434_2020_9564_MOESM4_ESM.eps

Supplementary Fig. 4 Forest plots of the hazard ratio for CCI-LR overall and according to histology subtype. (EPS document) (EPS 294 kb)

10434_2020_9564_MOESM5_ESM.eps

Supplementary Fig. 5 Forest plots of the hazard ratio for CCI-DM overall and according to histology subtype. (EPS document) (EPS 325 kb)

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Danieli, M., Barretta, F., Fiore, M. et al. Unplanned Excision of Extremity and Trunk Wall Soft Tissue Sarcoma: To Re-resect or Not to Re-resect?. Ann Surg Oncol 28, 4706–4717 (2021). https://doi.org/10.1245/s10434-020-09564-6

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  • DOI: https://doi.org/10.1245/s10434-020-09564-6

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