Oncological outcome, functional results and costs after unplanned excision of musculoskeletal soft tissue sarcoma
Introduction
Musculoskeletal soft tissue tumors are frequent, often asymptomatic and therefore underdiagnosed. Benign lesions are much more common than malignant entities. Damron et al. estimated the incidence of benign lesions at 3/1000 persons per year, while the incidence of musculoskeletal soft tissue sarcomas (STS) is estimated at 2/100′000 persons per year [1]. History, symptoms or lesion location do not enable distinction between histotypes and in most cases not even between benign or malignant tumors. Extensive diagnostic work-up (e.g. MRI, CT, functional imaging and biopsy) is indicated in most cases to define an appropriate treatment strategy [2].
However, unplanned excisions (UPE) of STS remain frequent, occurring in up to 53% of cases [[3], [4], [5]]. In this setting, surgery was generally performed based on the assumption of benignity. These patients are often treated in non-specialized centers, without advanced imaging and histotype prior to surgery, as no biopsies were performed. Diagnosis is made only after surgery upon histological work-up of the specimen. As surgical margins are often insufficient (i.e. intralesional or marginal), subsequent tumor bed excision is usually necessary, with neo-adjuvant or adjuvant chemo- or radiotherapy [[6], [7], [8]]. Several studies have demonstrated that the oncological outcome is not different in such cases [3,[9], [10], [11]], whereas other authors showed that oncological results were worse after tumor bed excision [12,13] and that survival rate improved when STS were treated in a specialized center [12,13]. However, data on functional outcome in patients after UPE are currently scarce. We are aware of only one study comparing functional outcome in patients after UPE and PE of STS [9].
The purpose of this study was to assess functional and oncological outcomes as well as economic impact of STS management in patients referred to our tertiary center after UPE compared with patients who had PE in our institution.
Section snippets
Patients and methods
A retrospective single center study was performed in our sarcoma center. Ethical committee approval was obtained (CER-VD: 266/14).
Oncological outcome
Two hundred and one patients were included for this part of the study. One hundred and thirty seven out of 201 patients (68.2%) underwent PE while in 64/201 patients (31.8%) the diagnosis of STS was not known at the time of initial surgery (UPE).
Demographic data and tumor characteristics are detailed in Table 1.
These two groups did not differ in terms of gender, age or tumor grade, but there was a significant difference regarding localization of the tumor, with proportionally significantly more
Discussion
In our series, the proportion of UPE in STS patients was 31.8%. This is in line with the literature, with some studies reporting up to 53% of UE [[3], [4], [5]]. In their recent review, Grimer et al. [17] found rates between 18% and 53%, with an average of 33%. Interestingly, like in other studies, it remained stable throughout the analyzed period. Surgeons’ raise of awareness to this problematic is the keypoint to decreasing this rate. Nandra et al. created an aide-mémoire, “larger than a
Conclusion
Our study did not demonstrate any significant oncological or functional difference, regardless of the initial surgical management of STS of the musculoskeletal system in a reference center or by a non-specialist surgeon. However, we found a significantly higher number of surgical procedures and longer hospital stay after unplanned excision of STS, resulting in a 64% higher cost as compared to planned excision in a reference center.
The most common location for unplanned excision appears to be in
References (41)
Unplanned resection of a soft tissue sarcoma: clinical characteristics and impact on oncological and functional outcomes
J Orthop Sci
(2015)- et al.
If your lump is bigger than a golf ball and growing, think Sarcoma
Eur J Surg Oncol
(2015) - et al.
Local recurrence of extremity soft tissue sarcoma
Surg Clin
(2016) Combining limb-sparing surgery with radiation therapy in high-grade soft tissue sarcoma of extremities - is it effective?
Eur J Surg Oncol
(2016)Inadvertent surgical resection of soft tissue sarcomas
Eur J Surg Oncol
(2012)Unplanned excision of soft tissue sarcoma: the impact of the referring hospital
Surg Oncol
(2013)Functional outcome in extremity soft tissue sarcoma
Semin Radiat Oncol
(1999)- et al.
[Cost analysis of the diagnosis and treatment of soft tissue sarcomas in reference centres]
Rev Española Cirugía Ortopédica Traumatol
(2012) Soft-tissue lumps and bumps
J Bone Jt Surg Am Vol
(2003)The diagnosis and treatment of soft tissue sarcomas of the limbs
Dtsch Arztebl Int
(2011)