Annals of Surgical Oncology

, Volume 26, Issue 11, pp 3526–3534 | Cite as

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

  • Gauthier DecanterEmail author
  • Eberhard Stoeckle
  • Charles Honore
  • Pierre Meeus
  • Jean Camille Mattei
  • Pascale Dubray-Longeras
  • Gwenael Ferron
  • Sébastien Carrere
  • Sylvain Causeret
  • Jean-Marc Guilloit
  • Magali Fau
  • Philippe Rosset
  • Jean-Christophe Machiavello
  • Jean Baptiste Delhorme
  • Nicolas Regenet
  • François Gouin
  • Jean-Yves Blay
  • Jean-Michel Coindre
  • Nicolas Penel
  • Sylvie Bonvalot



The benefits of systematic re-excision (RE) after initial unplanned excision (UE) of soft tissue sarcoma (STS) are unknown.


The aim of this study was to evaluate the impact of delayed RE versus systematic RE after UE on overall survival (OS), metastatic relapse-free survival (MRFS), local relapse-free survival (LRFS), and rate of amputation.


Patients who underwent complete UE, without metastasis or residual disease, for primary extremity or superficial STS between 2007 and 2013 were analyzed. The amputation rate, LRFS, MRFS, and OS were assessed in cases of systematic RE in sarcoma referral centers (Group A), systematic RE outside of community centers (Group B), or without RE (Group C).


Groups A, B, and C included 300 (48.2%), 71 (11.4%), and 251 (40.4%) patients, respectively. Median follow-up was 61 months and 5-year OS was 88.4%, 87.3%, and 88% in Groups A, B, and C, respectively (p = 0.22), while 5-year MFRS was 85.4%, 86.2%, and 84.9%, respectively (p = 0.938); RE (p = 0.55) did not influence MRFS. The 5-year LRFS was 83%, 73.5%, and 63.8% in Groups A, B and C, respectively (p = 0.00001). Of the 123 local recurrences observed, 0/28, 1/15, and 5/80 patients in Groups A, B, and C, respectively, required amputation (p = 0.41). Factors influencing LRFS were adjuvant radiotherapy [hazard ratio (HR) 0.21; p = 0.0001], initial R0 resection (HR 0.24, p = 0.0001), and Group A (HR 0.44; p = 0.01).


Systematic RE in sarcoma centers offers best local control but does not impact OS. Delayed RE at the time of local relapse, if any, could be an option.



The authors thank Loïc Lebellec, Francoise Ducimetiere, Antoine Giraud, and Séverine Marchant.


Gauthier Decanter, Eberhard Stoeckle, Charles Honore, Pierre Meeus, Jean Camille Mattei, Pascale Dubray-Longeras, Gwenael Ferron, Sébastien Carrere, Sylvain Causeret, Jean-Marc Guilloit, Magali Fau, Philippe Rosset, Jean-Christophe Machiavello, Jean Baptiste Delhorme, Nicolas Regenet, François Gouin, Jean-Yves Blay, Jean-Michel Coindre, Nicolas Penel, and Sylvie Bonvalot have no conflicts of interest to disclose.


  1. 1.
    Pisters PW, Harrison LB, Leung DH, Woodruff JM, Casper ES, Brennan MF. Long-term results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol. 1996;14:859–68.CrossRefPubMedGoogle Scholar
  2. 2.
    Yang JC, Chang AE, Baker AR, et al. Randomized prospective study of the benefit of adjuvant radiation therapy in the treatment of soft tissue sarcomas of the extremity. J Clin Oncol. 1998;16:197–203.CrossRefPubMedGoogle Scholar
  3. 3.
    Casali PG, Abecassis N, Bauer S, 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.Google Scholar
  4. 4.
    Blay JY, Soibinet P, Penel N, et al. Improved survival using specialized multidisciplinary board in sarcoma patients. Ann Oncol. 2017;28:2852–9.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Italiano A, Le Cesne A, Mendiboure J, et al. Prognostic factors and impact of adjuvant treatments on local and metastatic relapse of soft-tissue sarcoma patients in the competing risks setting. Cancer. 2014;120:3361–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Italiano A, Delva F, Mathoulin-Pelissier S, et al. Effect of adjuvant chemotherapy on survival in FNCLCC grade 3 soft tissue sarcomas: a multivariate analysis of the French Sarcoma Group Database. Ann Oncol. 2010;21:2436–41.CrossRefPubMedGoogle Scholar
  7. 7.
    Gronchi A, Ferrari S, Quagliuolo V, et al. Histotype-tailored neoadjuvant chemotherapy versus standard chemotherapy in patients with high-risk soft-tissue sarcomas (ISG-STS 1001): an international, open-label, randomised, controlled, phase 3, multicentre trial. Lancet Oncol. 2017;18:812–22.Google Scholar
  8. 8.
    George S, Wagner AJ. Low levels of evidence for neoadjuvant chemotherapy to treat soft-tissue sarcoma. JAMA Oncol. 2018;4:1169–70.CrossRefPubMedGoogle Scholar
  9. 9.
    Potter BK, Adams SC, Pitcher JD Jr, Temple HT. Local recurrence of disease after unplanned excisions of high-grade soft tissue sarcomas. Clin Orthop Relat Res. 2008;466:3093–100.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    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;24:1596–605.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Stoeckle E, Gardet H, Coindre JM, et al. Prospective evaluation of quality of surgery in soft tissue sarcoma. Eur J Surg Oncol. 2006; 32:1242–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Bonvalot S, Levy A, Terrier P, Tzanis D, Bellefqih S, Le Cesne A, et al. Primary extremity soft tissue sarcomas: does local control impact survival? Ann Surg Oncol. 2017;24:194–201.CrossRefPubMedGoogle Scholar
  13. 13.
    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.CrossRefPubMedGoogle Scholar
  14. 14.
    Gundle KR, Kafchinski L, Gupta S, et al. Analysis of Margin Classification Systems for Assessing the Risk of Local Recurrence After Soft Tissue Sarcoma Resection. J Clin Oncol. 2018;36:704–9.CrossRefPubMedGoogle Scholar
  15. 15.
    McKee MD, Liu DF, Brooks JJ, Gibbs JF, Driscoll DL, Kraybill WG. The prognostic significance of margin width for extremity and trunk sarcoma. J Surg Oncol. 2004;85:68–76.CrossRefPubMedGoogle Scholar
  16. 16.
    Ray-Coquard I, Thiesse P, Ranchère-Vince D, et al. Conformity to clinical practice guidelines, multidisciplinary management and outcome of treatment for soft tissue sarcomas. Ann Oncol. 2004;15:307–15.Google Scholar
  17. 17.
    Tedesco NS, Henshaw RM. Unplanned resection of sarcoma. J Am Acad Orthop Surg. 2016;24:150–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Alamanda VK, Delisca GO, Archer KR, Song Y, Schwartz HS, Holt GE. Incomplete excisions of extremity sts are unaffected by insurance status or distance from a sarcoma center. J Surg Oncol. 2013;108:477–80.Google Scholar
  19. 19.
    Davis AM, Kandel RA, Wunder JS, et al. The impact of residual disease on local recurrence in patients treated by initial unplanned resection for soft tissue sarcoma of the extremity. J Surg Oncol. 1997;66;81–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Rehders A, Stoecklein NH, Poremba C, Alexander A, Knoefel WT, Peiper M. Reexcision of soft tissue sarcoma: sufficient local control but increased rate of metastasis. World J Surg. 2009;33:2599–605.CrossRefPubMedGoogle Scholar
  21. 21.
    Stojadinovic A, Leung DH, Hoos A, Jaques DP, Lewis JJ, Brennan MF. Analysis of the prognostic significance of microscopic margins in 2,084 localized primary adult soft tissue sarcomas. Ann Surg. 2002;235:424–34.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    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;36:710–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Koulaxouzidis G, Schwarzkopf E, Bannasch H, Stark GB. Is revisional surgery mandatory when an unexpected sarcoma diagnosis is made following primary surgery? World J Surg Oncol. 2015;13:306–16.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Pretell-Mazzini J, Barton MD Jr, 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.CrossRefPubMedGoogle Scholar
  25. 25.
    von Mehren M, Randall RL, Benjamin RS, et al. Soft tissue sarcoma, version 2.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2018;16:536–63.Google Scholar
  26. 26.
    Funovics PT, Vaselic S, Panotopoulos J, Kotz RI, Dominkus M. The impact of re-excision of inadequately resected soft tissue sarcomas on surgical therapy, results, and prognosis: a single institution experience with 682 patients. J Surg Oncol. 2010;102:626–33.CrossRefPubMedGoogle Scholar
  27. 27.
    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;101:243–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Bellera CA, Penel N, Ouali M, et al. Definition for the Assessment of Time-to-event Endpoints in Cancer Trials Initiative. Guidelines for time-to-event end point definitions in sarcomas and gastrointestinal stromal tumors (GIST) trials: results of the DATECAN initiative (Definition for the Assessment of Time-to-event Endpoints in CANcer trials). Ann Oncol. 2015;26:865–72.Google Scholar
  29. 29.
    Giuliano AE, Eilber FR. The rationale for planned reoperation after unplanned total excision of soft-tissue sarcomas. J Clin Oncol. 1985;3:1344–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Arai E, Nishida Y, Tsukushi S, Wasa J, Ishiguro N. Clinical and treatment outcomes of planned and unplanned excisions of soft tissue sarcomas. Clin Orthop Relat Res. 2010;468:3028–34.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Chandrasekar CR, Wafa H, Grimer RJ, Carter SR, Tillman RM, Abudu A. The effect of an unplanned excision of a soft-tissue sarcoma on prognosis. J Bone Joint Surg B. 2008;90:203–8.CrossRefGoogle Scholar
  32. 32.
    Ueda T, Yoshikawa H, Mori S, Araki N, Myoui A, Kuratsu S, et al. Influence of local recurrence on the prognosis of soft-tissue sarcomas. J Bone Joint Surg Br. 1997;79:553–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Noria S, Davis A, Kandel R, Levesque J, O’Sullivan B, Wunder J, et al. Residual disease following unplanned excision of soft tissue sarcoma. J Bone Joint Surg Am. 1996;78:650–5.CrossRefPubMedGoogle Scholar
  34. 34.
    Kepka L, Suit HD, Goldberg SI, Rosenberg AE, Gebhardt MC, Hornicek FJ, et al. Results of radiation therapy performed after unplanned surgery (without re-excision) for soft tissue sarcomas. J Surg Oncol. 2005;92:39–45.CrossRefPubMedGoogle Scholar
  35. 35.
    Zagars GK, Ballo MT, Pisters PW, Pollock RE, Patel SR, Benjamin RS. Surgical margins and reresection in the management of patients with soft tissue sarcoma using conservative surgery and radiation therapy. Cancer. 2003;97:2544–53.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Gauthier Decanter
    • 1
    • 2
    Email author
  • Eberhard Stoeckle
    • 3
  • Charles Honore
    • 4
  • Pierre Meeus
    • 5
  • Jean Camille Mattei
    • 6
  • Pascale Dubray-Longeras
    • 7
  • Gwenael Ferron
    • 8
  • Sébastien Carrere
    • 9
  • Sylvain Causeret
    • 10
  • Jean-Marc Guilloit
    • 11
  • Magali Fau
    • 12
  • Philippe Rosset
    • 13
  • Jean-Christophe Machiavello
    • 14
  • Jean Baptiste Delhorme
    • 15
  • Nicolas Regenet
    • 16
  • François Gouin
    • 17
  • Jean-Yves Blay
    • 18
  • Jean-Michel Coindre
    • 19
  • Nicolas Penel
    • 20
  • Sylvie Bonvalot
    • 21
  1. 1.Department of Medical OncologyOscar Lambret CenterLilleFrance
  2. 2.General Oncology DepartmentOscar Lambret Cancer CenterLilleFrance
  3. 3.Department of SurgeryBergonie InstituteBordeauxFrance
  4. 4.Department of Surgical OncologyGustave Roussy Cancer CampusVillejuifFrance
  5. 5.Department of Surgical OncologyCentre Léon BérardLyonFrance
  6. 6.Department of Orthopedic SurgeryHôpital NordMarseilleFrance
  7. 7.Department of Medical OncologyCentre Jean PerrinClermont-FerrandFrance
  8. 8.Department of Surgical OncologyInstitut Universitaire du Cancer de Toulouse – OncopoleToulouseFrance
  9. 9.Department of Surgical OncologyMontpellier Cancer CentreMontpellierFrance
  10. 10.Department of SurgeryCentre Georges François LeclercDijonFrance
  11. 11.Department of Medical OncologyRegional Cancer CentreCaenFrance
  12. 12.Department of Medical SurgeryCentre Alexis VautrinVandœuvre-lès-NancyFrance
  13. 13.Department of Orthopedic SurgeryUniversity Hospital of ToursToursFrance
  14. 14.Breast Cancer and Reconstructive Surgery UnitCentre Antoine LacassagneNiceFrance
  15. 15.Department of General and Digestive Surgery, Hautepierre HospitalStrasbourg University HospitalStrasbourgFrance
  16. 16.Department of Digestive SurgeryNantes HospitalNantesFrance
  17. 17.Department of Orthopedic SurgeryLeon Berard CenterLyonFrance
  18. 18.Department of Medical OncologyLeon Berard CenterLyonFrance
  19. 19.Department of PathologyBergonié Cancer InstituteBordeauxFrance
  20. 20.Medical Oncology DepartmentCentre Oscar Lambret and Lille University HospitalLilleFrance
  21. 21.Department of Medical Oncology and SurgeryGustave Roussy InstituteVillejuifFrance

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