Oncological outcome, functional results and costs after unplanned excision of musculoskeletal soft tissue sarcoma

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Abstract

Background

Treatment of soft tissue sarcomas (STS) should only be initiated once the diagnosis is fully established. Resection of tumors of unknown nature should be avoided. Nevertheless, specialized centers continue to face numbers of unplanned excisions (UPE) in STS.

Aim

To compare oncologic and functional outcomes, number of surgeries, length of hospital stay and treatment costs of UPE versus planned excision (PE) in STS.

Method

A retrospective single tertiary center study was performed on 201 patients. Survival, local and distant recurrence rates were compared between PE (n = 137) and UPE (n = 64). In a subgroup analysis of 60 patients, functional outcome (MSTS and TESS scores), and socio-economic impact (number of surgeries, length of hospital stay and treatment costs) in “functional planned excision” (fPE) group (n = 30) and “functional unplanned excision” (fUPE) group (n = 29) were compared.

Results

There was no significant difference in oncological outcome between PE and UPE. In the subgroup analysis, we found a non-significant difference in functional outcome. Patients in the fUPE had significantly more surgeries (3.5 vs. 1.4; p < 0.00001) and costs of their management was 64% higher than fPE (p = 0.048). Hospital stay was longer after fUPE but not statistically significant (18.3 days vs. 11.8 days; p = 0.13).

Conclusion

Even though oncological and functional outcomes are comparable after PE and UPE of STS, the number of surgeries, length of hospital stay and treatment costs were higher in patients with UPE. Our data underscore the importance of specialized STS treatment centers including multidisciplinary management.

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)

  • M. Fiore

    Prognostic effect of re-excision in adult soft tissue sarcoma of the extremity

    Ann Surg Oncol

    (2006)
  • J. Pretell-Mazzini

    Unplanned excision of soft-tissue sarcomas current concepts for management and prognosis

    J Bone Jt Surg Am Vol

    (2015)
  • S. Kang et al.

    Unplanned excision of extremity soft tissue sarcoma in Korea: a nationwide study based on a claims registry

    PloS One

    (2015)
  • C. Collin

    Localized operable soft-tissue sarcoma of the upper extremity - presentation, management, and factors affecting local recurrence in 108 patients

    Ann Surg

    (1987)
  • A.M. Davis

    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)
  • G. Koulaxouzidis

    Is revisional surgery mandatory when an unexpected sarcoma diagnosis is made following primary surgery?

    World J Surg Oncol

    (2015)
  • M.A. Smolle

    The prognostic impact of unplanned excisions in a cohort of 728 soft tissue sarcoma patients: a multicentre study

    Ann Surg Oncol

    (2017)
  • V.K. Alamanda

    Primary excision compared with re-excision of extremity soft tissue sarcomas--is anything new?

    J Surg Oncol

    (2012)
  • F. Traub

    Influence of unplanned excisions on the outcomes of patients with stage III extremity soft-tissue sarcoma

    Cancer

    (2018)
  • O. Derbel

    Survival impact of centralization and clinical guidelines for soft tissue sarcoma (A prospective and exhaustive population-based cohort)

    PloS One

    (2017)
  • Cited by (0)

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