Effect of reresection in extremity soft tissue sarcoma

Abstract

Objective: To determine whether reresection affects survival in patients with inadequately resected, primary extremity soft tissue sarcoma. This study correlates reresection with local recurrence-free survival, metastasis-free survival, and disease-free survival.

Summary background data: Soft tissue sarcomas are rare neoplasms, with an incidence of approximately 6,000 per year in the United States. Because these tumors are rare and benign soft tissue tumors are common, many are initially thought to be benign and are excised without wide margins.

Methods: Patients who underwent treatment for primary tumors from July 1982 to June 1999 at a single institution were the subject of study. Two groups of patients were analyzed: those who underwent one definitive resection (one operation) and those whose tumors were previously resected and who were then referred for subsequent reresection (two operations). Patients were given adjuvant radiation or chemotherapy according to the standard of care.

Results: Of 1,092 patients with primary extremity soft tissue sarcoma underwent resection, 685 underwent definitive radical resection and 407 underwent reresection after undergoing excisional resection elsewhere. Median follow-up was 4.8 years. The 5-year disease-free survival rate of the definitive resection (one operation) group was 70%; that of the reresection (two operations) group was 88%. On multivariate analysis, reresection was adjusted and controlled for age, grade, depth, size, histology, and margins. Reresection remained a significant predictor of improved disease-free survival, even after these adjustments. To determine whether this difference was stage- or referral-biased, the patient population was divided by AJCC stage. In all stages there was a trend toward improved outcome; this was most marked for those with stage III disease (>5 cm, high-grade, and deep).

Conclusions: Patients with extremity soft tissue sarcoma who undergo reresection with two "primary" operations have an improved survival compared with those who undergo one operation. The most plausible explanation, referral and selection bias, is questionable given the significance of reresection as a variable after adjusting for stage and other risk factors. This suggests that where indicated and possible, reresection should be liberally applied in patients with primary extremity soft tissue sarcoma.

Figure 1. Actuarial disease-specific survival for patients undergoing resection versus reresection for primary extremity sarcoma. Median follow-up for all patients was 4.8 years. The 5-year survival rate was 70% ± 6% for the resection group versus 88% ± 5% for the reresection group (P = .0001).

Figure 2. Actuarial metastasis-free survival for patients undergoing resection versus reresection for primary extremity sarcoma. Median follow-up for all patients was 4.8 years. The 5-year metastasis-free survival rate was 63% ± 6% for the resection group versus 83% ± 5% for the reresection group (P = .0001).

Figure 3. Actuarial local recurrence-free survival for patients undergoing resection versus reresection for primary extremity sarcoma. There was no difference between the groups (P = .7).