Abstract
BackgroundPrimary bone and soft tissue sarcoma treatment includes surgical resection, with or without peri-operative chemoradiotherapy. The aim of surgery is to achieve complete excision, to prevent localised recurrence and achieve cure. For various reasons, excision with adequate margins is not always possible. Our aim is to assess the occurrence of unexpected positive margins following primary excision within a tertiary centre and the impact on patient outcomes.MethodsA retrospective analysis of 567 patients discussed at the Royal National Orthopaedic Hospital Multi-disciplinary team (MDT) meeting with positive margins between 1999-2020 was performed. Exclusion criteria included: excisions performed externally and lesions treated with curettage. Information gathering from electronic records highlighted 23 cases with unexpected positive margins following primary excision.ResultsAll patients pre-operatively expected to achieve complete primary resection. The median age was 60 years (8-92), 10M:13F. Tumour location included lower limb (12), upper limb (six), pelvis (two) and trunk (three); eight bone tumours and 15 soft tissue. The overall recurrence rate was 30.4% (7/23). In those recommended for re-excision (n=16), the recurrence rate was 31.25% (5/16). Of the patients not initially recommended for re-excision (n=7), four proceeded to surveillance alone with 50% recurrence (2/4), both with metastatic disease not surviving to follow-up. A further three patients underwent post-operative radiotherapy alone with no recurrences at follow-up, one patient not surviving for further treatment due to stroke. The mean follow-up for patients was 3.1 years.ConclusionWhen positive margins do occur unexpectedly, the impact due to the need for further treatment and ultimately increased risk of recurrence can be significant. Results can be compared to those for unplanned excisions. Therefore, surgeons should be aware of the different circumstances in which positive margins occur to help guide treatment planning and managing patient expectations.
Highlights
The standardised treatment of primary bone and soft tissue sarcoma includes surgical resection, either in isolation or accompanied by peri/post-operative radiotherapy with or without the addition of chemotherapy
Of the patients not initially recommended for re-excision (n=7), four proceeded to surveillance alone with 50% recurrence (2/4), both with metastatic disease not surviving to follow-up
There is no clear consensus on the exact surgical margin required to prevent local recurrence, but it has been well established that marginal or positive margins are associated with increased recurrence risk [2,3,4]
Summary
The standardised treatment of primary bone and soft tissue sarcoma includes surgical resection, either in isolation or accompanied by peri/post-operative radiotherapy with or without the addition of chemotherapy. The primary aim of surgical treatment is for complete excision to prevent localised recurrence, metastasis and achieve disease control [1]. Owing to the rarity of bone and soft tissue sarcomas, some of these tumours are often unknowingly resected without prior investigation or multi-disciplinary team involvement. In such cases, in the absence of appropriate planning and intent to achieve tumour-free margins, there is often a significant residual tumour burden left behind, increasing the likelihood of local recurrence and the need for further treatment [5,6]. Our aim is to assess the occurrence of unexpected positive margins following primary excision within a tertiary centre and the impact on patient outcomes
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