Excision Of Soft Tissue Sarcoma Research Articles

The effect of an unplanned excision of a soft-tissue sarcoma on prognosis

We investigated whether our policy of routine re-excision of the tumour bed after an unplanned excision of a soft-tissue sarcoma was justified. Between April 1982 and December 2005, 2201 patients were referred to our hospital with the diagnosis of soft-tissue sarcoma, of whom 402 (18%) had undergone an unplanned excision elsewhere. A total of 363 (16.5%) were included in this study. Each patient was routinely restaged and the original histology was reviewed. Re-excision was undertaken in 316 (87%). We analysed the patient, tumour and treatment factors in relation to local control, metastasis and overall survival. Residual tumour was found in 188 patients (59%). There was thus no residual disease in 128 patients of whom 10% (13) went on to develop a local recurrence. In 149 patients (47%), the re-excision specimen contained residual tumour, but it had been widely excised. Local recurrence occurred in 30 of these patients (20%). In 39 patients (12%), residual tumour was present in a marginal resection specimen. Of these, 46% (18) developed a local recurrence. A final positive margin in a high-grade tumour had a 60% risk of local recurrence even with post-operative radiotherapy. Metastases developed in 24% (86). The overall survival was 77% at five years. Survival was related to the grade of the tumour and the finding of residual tumour at the time of re-excision. We concluded that our policy of routine re-excision after unplanned excision of soft-tissue sarcoma was justified in view of the high risk of finding residual tumour.

54 INVITED Long-term cancer survivorship issues: Is there a role for CAM?

Upper limb preservation after soft tissue sarcoma resection often requires flap reconstruction. The aim of this study was to compare pre- and post-operative upper limb function following shoulder, elbow or wrist/hand sarcoma resection and soft tissue reconstruction with a pedicled or free flap.Between 1989 and 2008, 113 patients underwent resection of an upper limb soft tissue sarcoma and required flap reconstruction. Perioperative morbidity, mortality and flap loss were studied. Functional outcome was assessed pre and postoperatively using the Toronto Extremity Salvage Score (TESS), a measure of disability, and the Musculoskeletal Tumour Society Rating Scale (MSTS), a measure of impairment. Statistical analyses were performed to evaluate the relationship between flap type and functional outcome scores.Patients underwent soft tissue sarcoma excision in the shoulder (n = 64), elbow (n = 27) or wrist/hand (n = 22) region with soft tissue reconstruction using either a pedicled (n = 76) or free flap (n = 37). Comparison of the post-operative MSTS (n = 88) and TESS (n = 84) revealed no significant differences between the free and pedicled flap groups. A significant pre- to post-operative difference was identified in MSTS 87 scores for patients in both the pedicled (p < 0.02) and free flap groups (p < 0.04). Comparison of the pre- and post-operative MSTS 93 scores also revealed a significant difference (p < 0.01) but this was limited to the free flap group. The most notable post-operative score reductions in these patients were due to major joint, nerve, tendon or muscle group resection.Reconstruction of the soft tissue defect following sarcoma resection in the upper limb maintains a similar satisfactory level of upper limb activity with either pedicled or free flap reconstructions. Based on TESS scores, patients rated themselves as having better function compared to impairment measures such as MSTS.

Cryoablation and Resection Influences Patient Survival for Soft Tissue Sarcomas

Cryosurgical ablation has been used successfully for treating various carcinomas and bone tumors; however, few studies report the use of cryosurgery followed by tumor resection for the treatment of soft tissue sarcomas. We evaluated local recurrence, progression of disease, histologic necrosis from the cryoablation, complications, patient survival, and functional outcomes using this approach. We retrospectively reviewed 38 patients with no prior treatment for their neoplasm who underwent cryosurgery followed by wide excision of soft tissue sarcomas. Three patients developed local recurrence. Sixteen patients had evidence of more than 95% tumor necrosis, and 11 of these had 100% histologic necrosis. We observed a difference in overall survival and disease-free survival based on the adequacy of freezing process. Patients with more than 95% necrosis had a survival rate of 94% at 2 years and 86% at 5 years, while those with less than 95% necrosis survived 53% at 2 years and 34% at 5 years. Complications included transient neuropraxia (13%), superficial wound infections (8%), and seroma (21%). Cryosurgical ablation appears a safe and effective method of devitalizing tumor cells of soft tissue sarcomas.

Late treatment–related complications in 214 patients with extremity soft-tissue sarcoma treated by surgery and postoperative radiation therapy

Background We assessed the occurrence of long-bone fracture and other side effects in a group of 214 consecutive patients who underwent radical excision for soft-tissue sarcoma of the limb followed by postoperative irradiation. Methods Two hundred fourteen patients underwent postoperative irradiation after radical excision of soft-tissue sarcoma of the limb; 156 (73%) received postoperative brachytherapy (BRT) plus external-beam radiation therapy (EBRT), and 58 (27%) underwent postoperative EBRT only. All patients were followed-up for a median time of 4.5 years (range 3 months to 10 years). Results Seven patients developed bone fracture, which is considered severe morbidity; time between surgery and occurrence of fracture ranged between 10 and 72 months (average 31). Severe sclerosis with impairment of limb function was diagnosed in 5 and peripheral nerve damage in 3 patients. Wound complications were detected in 8 patients. Conclusions In our series, no statistically significant correlation between bone fracture and clinical features or “technical” parameters was found, but all of the patients who experienced bone fracture (7 of 7) were postmenopausal women >55 years old.

Bone primary sarcomas undergone unplanned intralesional procedures—the possibility of limb salvage and their oncologic results

It is quite rare but some primary sarcomas of the bone can be misdiagnosed as benign and be treated using intralesional procedures. An unplanned surgical excision occurs when tumors are removed without the appropriate preoperative evaluation and consideration for the need to obtain tumor-free margins. Residual tumor tissue as a result of unplanned excision of soft tissue sarcoma is a risk factor for local recurrence. Twenty-five patients, undergone unplanned intralesional procedures of lower extremities, were enrolled in this study. There were 22 (88%) cases of osteosarcomas, 2 (8%) MFH of bone and 1 (4%) adamantinoma. Twenty-two (88%) cases had a limb salvage and among them, 4 (18%) cases had local recurrences. Three cases (12%) had amputation without any local event. Lung metastasis developed in 6 (24%) cases. The CDF 5 year survival for 22 osteosarcoma cases was 65%(confidence interval: 52-82%). Despite the high recurrence rate, the CDF survival of osteosarcoma cases was comparable to the primary one. Limb salvage procedures are worthwhile in cases whose initial radiographic findings simulate benign lesions, showing favorable response to neoadjuvant chemotherapy. The relative contraindication to the limb salvage is cases with a history of a pathologic fracture and extensive operative fixation.

Cost Analysis of Functional Restoration Surgery for Extremity Soft-Tissue Sarcoma

Limb-sparing surgery, consisting of wide-margin tumor resection and preoperative or postoperative radiotherapy/chemotherapy, has become the surgical treatment of choice for extremity sarcomas. However, adequate tumor resection can sometimes compromise crucial limb function, necessitating functional restoration surgery. The purpose of this study was to determine the cost impact and functional outcomes of such procedures. Patients receiving either functional restoration surgery or soft-tissue-only reconstruction following extremity soft-tissue sarcoma excision were identified. Patients were then compared along several dimensions: overall length of stay and its subdivisions, surgical time, and total charges and its subdivisions. Patients' functional outcomes were assessed with the Toronto Extremity Salvage Score. Sixty-seven patients who underwent 69 limb-sparing procedures were identified. Fifteen of these procedures (eight upper extremity, seven lower extremity) required functional restoration surgery; 54 of these procedures (13 upper extremity, 41 lower extremity) required only soft-tissue coverage. In the upper extremity, there was a statistically significant increase in overall length of stay (2.8 days) and its subdivisions, surgical time (3.7 hours), and total charges (12,484 dollars) and its subdivisions associated with performing functional restoration surgery. In lower extremity cases, statistically significant increases were determined in only the total charges (9190 dollars) and medical supply charges (13,204 dollars) following functional restoration. Patients who underwent functional restoration surgery had better postoperative function (mean Toronto Extremity Salvage Score, 82 versus 80), but this difference was not statistically significant. Although functional restoration surgery is more costly than soft-tissue reconstruction alone, the authors believe that the associated better functional outcome justifies its performance.

Re-excision of soft tissue sarcoma after inadequate initial operation.

Between January 1988 and October 1993, 189 patients with soft tissue sarcoma of the extremities and trunk underwent surgery and since 1988, patients in whom the initial operation did not achieve safe margins underwent reoperation (67 of the 189). At re-excision an en block resection of the area with wide margins was achieved in 59 patients. Residual tumour was found in 30 specimens (45 per cent). Thirty-six patients received postoperative radiotherapy and/or chemotherapy. After a mean follow-up of 32 (range 1-69) months five patients (7 per cent) had local recurrence. In view of the high rate of local recurrence after local excision of soft tissue sarcoma (70-90 per cent), primary re-excision is indicated after an inadequate initial operation.

Reconstruction after excision of soft tissue sarcomas of the limbs and trunk.

From a retrospective analysis of 180 surgical interventions for soft tissue sarcoma of the limbs and trunk, it was concluded that complete excision of the tumour can usually be achieved without sacrifice of major artery, vein, nerve or bone. In this series five major arteries were resected but only one required reconstruction. None of six resected major veins or seven resected nerves were reconstructed. Bone resection in the limb required plating in only two of eleven patients who had limb-sparing resection (there were nine amputations). Both in the limbs and the thorax, resection of bone often involved such a wide excision of the superficial soft tissues as to require a flap repair: four were used in the limbs and three in five chest wall resections. In the majority of operations (140/180) primary wound closure was possible. After 15 procedures for tumour predominantly involving the superficial tissues, split skin grafts were used. These were generally successful (13/15), even occasionally when high-dose radiotherapy had been given. In 16 cases earlier radiotherapy influenced the decision to use a flap repair. A total of 18 flap repairs were performed. In various situations Mersiline mesh (Ethicon, Ltd., UK), Silastic implants and omental swings were used. Wound breakdown in heavily irradiated tissues presented a major challenge for reconstruction. Although major reconstruction was required in only 27 operations (15 per cent), a thorough knowledge of the available methods of reconstruction and repair is essential to allow uninhibited resection with an optimal aesthetic and functional result.

The Result of Re-excision Following Unplanned Excision of Soft Tissue Sarcoma of the Extremities

Purpose: This study examined the effect of a microscopic residual tumor on the survival and recurrence rate by analyzing patients who had undergone a re-excision after an unplanned excision of a soft tissue sarcoma. Materials and Methods: From December 1985 to June 2002, 68 unplanned excisions of a soft tissue sarcoma at other institutes were referred to our service. All cases had undergone a re-excision and were re-evaluated for residual tumors. The male to female ratio was the same with an average age of 34.7 years. Staging followed the AJCC classification and there were 3 cases of la, 2 lb, 5 lIa,34 lIb, 24 III.Twenty six cases underwent surgical treatment only and 42 had added adjuvant therapy. The mean follow-up was 58.9 months. Results: At the final follow up, there were 48 CDF, 9 NED, 3AWD and 8 DOD. The CDF 5/16 year survival rates were 68.1/61.3%. Eight of the 23 residual tumor positive cases and 6 of the 45 residual tumor negative cases had a local recurrence. The tumor size, residual tumor, interval between the excision and reexcision, and stage were significant factors fora local recurrence. Statistical analysis revealed a local recurrence, metastasis and stage to be significant factors for survival. Conclusion: Local recurrence was the only controllable factor for survival. The presence of a residual tumor had an impact on the local recurrence. A re-excision afteran unplanned excision may reduce the incidence of a local recurrence.

Outcomes of re-excision after unplanned excisions of soft-tissue sarcomas

Unplanned excisions of soft-tissue sarcomas of the extremities occur commonly. Our goal was to evaluate the presence of residual disease, the treatment outcomes as they relate to local and distant recurrence and 5-year survival, and the limb functional outcomes in patients with unplanned sarcoma excision who were treated with re-excision and adjuvant therapy. Between 1993 and 1999, 42 patients presented to our institution after unplanned excision of soft-tissue sarcomas. Of those 42 patients, 38 without gross residual disease or metastatic lesions formed the basis of this review. All 38 patients underwent revision wide excision; most (31) also received adjuvant therapy (radiation and/or chemotherapy). Clinical data were obtained from analysis of patient records and radiographic studies. Univariate analysis was performed with logistical regression, and multivariate analysis was performed with Cox modeling. The overall 5-year survival rate was 91.3% and the disease-free 5-year survival rate was 82.2%. Univariate analysis showed that stage-III disease (American Joint Committee on Cancer classification of soft-tissue sarcomas), lesions below the fascia, a histologic high-grade, and the development of organ metastasis were statistically significant factors for mortality. Stage-III disease also was significant for mortality on multivariate analysis. Only stage-III disease was significant for the development of local recurrence. Eighty-four percent of the patients had good to excellent functional outcomes. Re-excision with adjuvant therapy proved to be a safe and effective method for treating the disease and preserving limb function.

MR imaging in the assessment of residual tumour following inadequate primary excision of soft tissue sarcomas.

The purpose of this retrospective study was twofold: firstly, to assess the ability of MR imaging in confirming/excluding the presence of residual tumour following inadequate primary excision of soft tissue sarcomas; and secondly, to assess the accuracy of the original radiologists report as compared with a retrospective review of the scan hard copy in confirming/excluding. A total of 111 cases were identified that fulfilled the inclusion criteria of inadequate primary surgery followed by a MR scan and subsequent wide re-excision of the surgical field. The gold standard for the assessment of the MR imaging studies was histological examination of the re-excision specimens. Histological examination revealed residual tumour in 63 (56.7%) cases. In 48 cases the residual tumour was classified macroscopic (maximum diameter >10 mm) and 15 cases microscopic (maximum diameter </=10 mm). The original radiologists reports failed to indicate the presence or absence of tumour in 7 (6.3%) cases. In the remaining 104 cases the diagnostic performance of MR imaging gave a sensitivity of 0.64, specificity of 0.93, positive predictive value of 0.93 and negative predictive value of 0.67. In 12 of the 21 false-negative scans the residual tumour was microscopic. Subjective assessment of the radiologist's reports indicated that the proportion of equivocal reports was much higher in both the false-negative and false-positive groups as compared with the true groups. An unblinded retrospective review of the scan hard copies only differed from the original radiologists report in 8 (7.2%) cases. Contrast-enhanced sequences were not routinely obtained in this series. The results suggest that the poor negative predictive value can be attributed more to limitations of the MR scan and not to failures in observation or interpretation by the radiologists. Despite the low negative predictive value, MR imaging remains useful in planning the re-excision surgery by identifying the site and extent of the original operation and size of major residual tumour.

Sequencing radiotherapy for soft tissue sarcoma when re-resection is planned

Purpose To evaluate whether disease outcome for localized soft-tissue sarcoma (STS) excised before referral to a specialist center and there re-resected was influenced by the timing of radiation therapy (XRT)—before or after re-resection. Methods and materials Two hundred ninety-five consecutive patients with localized grossly excised STS were retrospectively evaluated for local control, freedom from metastasis, disease-free survival, and disease-specific survival, according to whether they had XRT before (121) or after (174) re-resection of their tumor bed. Univariate and multivariate statistical techniques were employed. Results At re-resection, residual STS was found in 159 patients (54%), including gross tumor in 73 (25%). The incidence of residual disease was lower in those receiving preoperative XRT (median dose 50 Gy) (36%) than in those having postoperative RT (median dose 60 Gy) (54%) ( p = 0.024). With a median follow-up of 9.1 years, the local control rates for all patients at 5, 10, and 15 years were 86%, 84%, and 81%, respectively, and there were no differences between the two XRT sequences. In multivariate regression, there was no evidence that XRT sequence influenced local control, metastatic control, disease-free survival, or disease-specific survival. There was a trend toward fewer XRT-related late complications with preoperative XRT, but this was not significant, and the incidence of complications was low (5% at 15 years). Conclusions Patients who present after total but oncologically inadequate excision of STS can receive approximately 50 Gy before re-resection or approximately 60 Gy after re-resection, with approximately equivalent, satisfactory local control and overall disease outcome. Decisions as to the most appropriate treatment sequence for any individual patient can be made regardless of considerations as to the effectiveness of one sequence compared with the other.

Unplanned surgical excision of tumors of the foot and ankle.

Soft-tissue tumors of the foot and ankle are relatively common and mostly benign. Thus, many malignant tumors in this region are improperly treated initially. Unplanned excisions can lead to complications that may adversely affect patient outcomes and prognosis. A retrospective review of patients treated at our institute over a 20-year period for malignant soft-tissue tumors of the foot and ankle was performed. The effect of unplanned surgical excisions on outcomes was examined. When limb salvage was attempted, patients who underwent unplanned surgical excisions had more complications and more extensive surgical procedures involving free flaps, and they were more likely to require adjuvant radiotherapy. No difference in recurrence and disease-free survival was evident between the two patient populations. Despite the lack of statistical power to demonstrate differences in recurrence and survival, unplanned surgical excisions of soft-tissue sarcomas of the foot and ankle probably adversely affect quality of patient care. Suspicious lesions should be referred to surgeons trained in oncologic principles for evaluation and treatment.

Limb-sparing surgery with reinnervated free-muscle transfer following radical excision of soft-tissue sarcoma in the extremity.

Limb-sparing surgery is the preferred approach in the management of patients with high-grade soft-tissue sarcomas when local disease can be completely resected. However, conventional treatment focuses only on restoration of basic functions to the remnant limb. Lost functions are not restored to normal, leaving the patient with variable degrees of functional disabilities. This in turn may necessitate further massive reconstructive procedures. Transferred reinnervated free muscles were used to reconstruct functions lost after radical resection of malignant soft-tissue sarcoma of the extremities in 17 patients. The long-term functional outcome included survival of transplanted muscle, speed of neural recovery, and muscle strength and disabilities. All muscles survived. Postoperative follow-up ranged from 27 to 106 months. All muscles except those in a 75-year-old patient were successfully reinnervated. Powerful strength and almost normal limb functions were obtained. Functional scoring of the patients according to the rating system of the Musculoskeletal Tumor Society was 87 percent for the lower extremity and 93 percent for the upper extremity. All patients are presently disease-free. Use of the reinnervated free-muscle transfer in limb-sparing surgery after resection of soft-tissue sarcoma in the extremity may be indicated in the young adult when radical excision of the tumor will result in severe motor functional loss, provided adequate clearance can be obtained and that there is no presence of distant metastasis.

Augmented reality: An aid to soft-tissue sarcoma excision

Augmented reality: An aid to soft-tissue sarcoma excision

Early post-operative brachytherapy and free flap reconstruction in the management of sarcomas

Brachytherapy delivered within the early post-operative period has been associated with delayed healing and wound breakdown. The objective of this study was to determine whether reconstruction with a microvascular free flap reduced the incidence of wound breakdown after early post-operative brachytherapy and wide excision of soft tissue sarcomas. Four patients with sarcomas underwent excision and free flap reconstruction. Brachytherapy was administered in the early post-operative period using Iridium-192 wires via tubes inserted intraoperatively. In three of the four patients the wounds healed uneventfully, demonstrating that brachytherapy can be delivered in the early post-operative period following free flap reconstruction without an increase in the frequency of wound breakdown. There has been no local recurrence to date in this group of patients.

Early postoperative brachytherapy following free flap reconstruction

Brachytherapy delivered within the early postoperative period has been associated with delayed wound healing and wound breakdown. The objective of this study was to determine whether reconstruction with a microvascular free flap reduced the incidence of wound breakdown in the presence of early postoperative brachytherapy following wide excision of soft tissue sarcomas and head and neck carcinomas. Ten patients with malignant tumours underwent wide excision and free flap reconstruction. Brachytherapy was administered using Iridium-192 wires in the early postoperative period via tubes inserted intra-operatively. In 9 of the 10 patients the wounds healed uneventfully, demonstrating that brachytherapy can be delivered in the early postoperative period following free flap reconstruction without an increase in the frequency of wound breakdown.

The rationale for planned reoperation after unplanned total excision of soft-tissue sarcomas.

Multimodality management of soft-tissue sarcomas of the extremity is often based on the presence or absence of residual primary disease. Reoperation is warranted or radiotherapy doses altered if the physician is aware that the tumor was incompletely excised. Most patients with soft-tissue masses undergo an initial excision before definitive therapy. These initial unplanned total excisions are usually excisional biopsies for presumably benign disease. Ninety patients were reviewed to evaluate the adequacy of unplanned total excision. All patients underwent unplanned supposed total excisions. Most patients were then treated with preoperative intraarterial Adriamycin (Adria Laboratories, Columbus, Ohio) and radiation therapy, followed by wide reexcision of the prior operative field. Forty-six patients (51.1%) had no gross residual tumor in the reoperative specimen. In two patients, there was microscopic but not macroscopic disease. Forty-four patients (48.9%) had identifiable macroscopic residual disease in the reoperative specimen. When comparing these 44 patients with visible (macroscopic) residual tumor to the remaining 46, no differences were seen in age, sex, stage, histologic type, time from excision to reoperation, or size of initial lesion. This previously unrecognized high incidence of gross residual disease must be considered when planning definitive therapy. Unplanned total excisions are inadequate to remove local disease and, despite multimodality therapy, may result in local failure. Reoperation should be a planned part of definitive management for patients with soft-tissue sarcoma of the extremity whenever the initial surgical procedure was done without a histologic diagnosis or was not planned to be a wide excision. If reoperation cannot be performed, radiotherapy doses to treat gross residual disease should be used.