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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

  • Sarcoma
  • Published:
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Abstract

Background

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

Objective

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.

Methods

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).

Results

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).

Conclusion

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.

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References

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

  4. Blay JY, Soibinet P, Penel N, et al. Improved survival using specialized multidisciplinary board in sarcoma patients. Ann Oncol. 2017;28:2852–9.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

  8. George S, Wagner AJ. Low levels of evidence for neoadjuvant chemotherapy to treat soft-tissue sarcoma. JAMA Oncol. 2018;4:1169–70.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

  17. Tedesco NS, Henshaw RM. Unplanned resection of sarcoma. J Am Acad Orthop Surg. 2016;24:150–9.

    Article  PubMed  Google Scholar 

  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.

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

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

Author information

Authors and Affiliations

  1. Department of Medical Oncology, Oscar Lambret Center, Lille, France

    Gauthier Decanter MD

  2. General Oncology Department, Oscar Lambret Cancer Center, Lille, France

    Gauthier Decanter MD

  3. Department of Surgery, Bergonie Institute, Bordeaux, France

    Eberhard Stoeckle MD

  4. Department of Surgical Oncology, Gustave Roussy Cancer Campus, Villejuif, France

    Charles Honore MD, PhD

  5. Department of Surgical Oncology, Centre Léon Bérard, Lyon, France

    Pierre Meeus MD

  6. Department of Orthopedic Surgery, Hôpital Nord, Marseille, France

    Jean Camille Mattei MD, PhD

  7. Department of Medical Oncology, Centre Jean Perrin, Clermont-Ferrand, France

    Pascale Dubray-Longeras MD

  8. Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France

    Gwenael Ferron MD

  9. Department of Surgical Oncology, Montpellier Cancer Centre, Montpellier, France

    Sébastien Carrere MD

  10. Department of Surgery, Centre Georges François Leclerc, Dijon, France

    Sylvain Causeret MD

  11. Department of Medical Oncology, Regional Cancer Centre, Caen, France

    Jean-Marc Guilloit MD

  12. Department of Medical Surgery, Centre Alexis Vautrin, Vandœuvre-lès-Nancy, France

    Magali Fau MD

  13. Department of Orthopedic Surgery, University Hospital of Tours, Tours, France

    Philippe Rosset MD, PhD

  14. Breast Cancer and Reconstructive Surgery Unit, Centre Antoine Lacassagne, Nice, France

    Jean-Christophe Machiavello MD

  15. Department of General and Digestive Surgery, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France

    Jean Baptiste Delhorme MD, PhD

  16. Department of Digestive Surgery, Nantes Hospital, Nantes, France

    Nicolas Regenet MD

  17. Department of Orthopedic Surgery, Leon Berard Center, Lyon, France

    François Gouin MD, PhD

  18. Department of Medical Oncology, Leon Berard Center, Lyon, France

    Jean-Yves Blay MD, PhD

  19. Department of Pathology, Bergonié Cancer Institute, Bordeaux, France

    Jean-Michel Coindre MD, PhD

  20. Medical Oncology Department, Centre Oscar Lambret and Lille University Hospital, Lille, France

    Nicolas Penel MD, PhD

  21. Department of Medical Oncology and Surgery, Gustave Roussy Institute, Villejuif, France

    Sylvie Bonvalot MD, PhD

Authors
  1. Gauthier Decanter MD
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  2. Eberhard Stoeckle MD
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  13. Jean-Christophe Machiavello MD
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  14. Jean Baptiste Delhorme MD, PhD
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  17. Jean-Yves Blay MD, PhD
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  20. Sylvie Bonvalot MD, PhD
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Corresponding author

Correspondence to Gauthier Decanter MD.

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Disclosure

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.

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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 26, 3526–3534 (2019). https://doi.org/10.1245/s10434-019-07494-6

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  • DOI: https://doi.org/10.1245/s10434-019-07494-6

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