Inadvertent Inguinal Sarcoma Excision during Hernia Surgery: Outcomes, Gender Analysis, and Prevention

Abstract

Introduction: Inadvertent excision of a soft tissue sarcoma during hernia surgery is a preventable clinical scenario that leads to unnecessary patient morbidity. Prior series are few, which only include male patients with little focus on prevention. The purpose of this study is to report the presenting features and outcomes of both male and female patients who underwent inadvertent inguinal sarcoma excision during hernia surgery.

Methods: A retrospective analysis of a single sarcoma referral center identified 33 patients who were referred for definitive treatment. Patients were divided into three clinically relevant groups based on intraoperative diagnosis, sex, and location of the mass relative to the inguinal ligament. T-tests and Fisher's exact tests were performed to compare continuous and categorical variables, respectively. Kaplan-Meier modeling was performed to assess sarcoma-specific survival.

Results: Females were younger (47 years vs. 61 years, p=0.003) and had smaller sarcomas (6.7 cm vs. 11 cm, p=0.012) compared to males. Only two sarcomas (2/33, 6%) were <4 cm in size. The majority of sarcomas in females were above the inguinal ligament (12/14, 86%). Twenty-nine (88%) underwent definitive R0 excision. The mean number of surgeries per patient was three (range 1-13), with nineteen (58%) patients requiring flap reconstruction and six (18%) requiring vascular bypass. Five patients locally recurred (15%) at a mean of 38 months after definitive excision (range 5-128 months). Overall sarcoma-specific disease-free survival was 64%, with no difference between males (80 ± 11%) and females (59 ± 17%) (p=0.885). Mean follow-up was 75 months (range 5-212).

Conclusion: This is the second largest study regarding inadvertent inguinal sarcoma excision and the first to include females. When a suspected hernia is >4 cm, irreducible, firm, and is growing, especially in females, consider obtaining preoperative advanced three-dimensional imaging (CT or MRI) that can differentiate a neoplasm from a hernia.

Figure 1

Study groups and design.

Figure 2

Kaplan–Meier survival curves. The graphs show Kaplan–Meier survival curves for the (a) entire cohort and for (b) males and females. (a) Overall sarcoma-specific survival in the entire cohort of 33 patients who underwent incomplete excision of an inguinal sarcoma was 64 ± 14% (time in months). (b) A comparison of sarcoma-specific survival curves between (1) females (59 ± 17%) and (2) males (80 ± 11%) who underwent incomplete excision of an inguinal sarcoma revealed no difference in long-term prognosis (p=0.885) (time in months).

Figure 3

Case example: inguinal sarcoma reexcision and reconstruction. The images (a–c) and photos are of a 57-year-old male with a high-grade soft tissue sarcoma of the left groin who was referred to our institution after incomplete inguinal sarcoma excision during hernia surgery. (a) Axial T1 images of a pelvic MRI prior to reexcision surgery demonstrate a subfascial solid mass (∗) of the left inguinal region. (b) Wide reexcision specimen is shown, which included abdominal wall resection and left hemiscrotectomy/orchiectomy performed with multidisciplinary coordination between orthopaedic oncology, surgical oncology, and urology. (c) The resultant left groin soft tissue defect was covered with a rotational gracilis flap (∗) to protect the iliac vessels, and an acellular dermal matrix strattice with local tissue rearrangement (not shown).

Figure 4

Case example: preoperative imaging comparison of ultrasound and CT scan. The images are of a 72-year-old male who presented with a firm testicular mass with associated scrotal swelling. (a) A scrotal ultrasound shows a mixed echotexture heterogeneous lesion within the left scrotum. Unfortunately, sonographic evaluation of inguinal or scrotal lesions lacks specificity in distinguishing fat- or bowel-containing inguinal hernia from a soft tissue sarcoma, such as a liposarcoma. (b–d) Sagittal, coronal, and axial contrast-enhanced preoperative CT images in the same patient demonstrate a predominately low-attenuation fatty 10 cm mass lesion within the inferior left inguinal canal and left scrotum. The presence of a thickened capsule around the periphery of the lesion as well as prominent enhancing internal septations with nodularity increases suspicion of a well-differentiated liposarcoma.