Predictors of residual disease after unplanned excision of soft tissue sarcomas

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 re-excision, we sought to determine predictors of residual STS following unplanned excision. Methods We identified 76 patients from a prospective database (1/1/2008 – 9/30/2014) 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 re-excision. Results Mean age was 52 years, and 63.2% were male. 50% had fragmented unplanned excision. Among patients undergoing re-excision, residual STS was identified in 70%. On univariable analysis, MRI showing gross disease and fragmented excision were significant predictors of residual STS (OR 10.59, 95% CI 2.14–52.49, P=0.004 and OR 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 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.

Clinical and Radiologic Features Together Better Predict Lung Nodule Malignancy in Patients with Soft-Tissue Sarcoma

“…However, our data confirm the irrefutable evidence that thin-section CT scan still play a central role in early detection of PNs [31] but it must be implemented by patient-related clinical factors.…”

The impact of unplanned excisions of truncal/extremity soft tissue sarcomas: A multi‐institutional propensity score analysis from the US Sarcoma Collaborative

“…Further, tumor histology has been demonstrated to play a significant prognostic importance in STS, but due to the rarity of STS relative to other malignancies, we were limited in the number of patients we could analyze based on tumor histology alone and were thus unable to match patients on this variable. Also, this study did not capture the influence residual disease on re‐excision has on oncologic outcomes, though this has been described in numerous reports in the literature . Finally, the study cohort analyzed were all surgical patients who underwent re‐excision after UE.…”

“…Also, this study did not capture the influence residual disease on re-excision has on oncologic outcomes, though this has been described in numerous reports in the literature. 5,6,[8][9][10][11]14 Finally, the study cohort analyzed were all surgical patients who underwent re-excision after UE. The USSC database did not capture those patients who did not pursue reexcision after an UE and then present later unable to undergo surgery due to metastatic spread of disease.…”

“…Due to the rarity of STS compared to the prevalence of benign soft tissue masses, up to 50% of patients with STS will undergo a nononcologic, unplanned excision (UE) for a mass initially presumed to be benign . Patients who undergo unplanned, nononcologic resections are commonly referred to tertiary referral centers, and due to the high probability of residual tumor left in the surgical bed after UE, the current standard of care recommends re‐excision with or without radiation of the tumor bed in an effort to achieve appropriate oncologic margins and local control …”

“…[4][5][6][7] Patients who undergo unplanned, nononcologic resections are commonly referred to tertiary referral centers, and due to the high probability of residual tumor left in the surgical bed after UE, the current standard of care recommends re-excision with or without radiation of the tumor bed in an effort to achieve appropriate oncologic margins and local control. 6,[8][9][10][11][12][13][14][15][16] Historically, patients who undergo UE have been described as having worse oncologic outcomes compared with patients who undergo planned oncologic excision (PE) primarily, explained by fragmented excisions and disruptions of the tumor capsule associated with UE. 15,17 Subsequent reports have shown that patients who undergo UE have similar, or even improved, recurrence-free, metastasis-free, and disease-specific survivals compared with patients with planned excisions.…”