Prevention in non-oncologic intent sarcoma surgery

Abstract

Background: Non-oncologic resection of soft tissue sarcomas (STS) continue to be a common referral to multidisciplinary sarcoma centers. While previous literature has reported tumor characteristics and outcomes related to non-oncologic resections, little is known regarding the surgical specialties most likely to excise such a mass and the non-oncological manner in which they do so. Such information can facilitate preventative strategies.

Purpose: The goals of this study are: 1) Investigate the surgical specialties that most often perform unplanned excisions and their diagnostic imaging approach, 2) Identify the frequency of non-oncological techniques utilized in initial unplanned excisions, and 3) Define indications for the use of radiation (XRT) in patients with initial non-oncologic resections of STS.

Methods: Patient data were collected from a large tertiary referral sarcoma center between 2005 and 2022. Eligible patients had a diagnosis of soft tissue sarcoma that was excised at an outside institution in a non-oncologic manner and subsequently underwent tumor bed re-excision using wide resection. Data regarding the index procedures at outside hospitals were obtained from referral documents and tumor bed re-excisions, along with follow-up care. A total of 124 patients were identified.

Results: Forty-three percent of referrals for non-oncologic resection of soft tissue sarcomas (STS) involved tumors located deep to the fascia. The majority of these referrals originated from General Surgery (N = 54, 44 %), Orthopedic Surgery (N = 35, 28 %), and Plastic Surgery (N = 11, 9 %). Preoperative imaging was conducted in 59 % of cases. General surgeons were less likely to obtain preoperative imaging (p = 0.009) and perform MRI scans (p = 0.013) than orthopaedic surgeons. The proper orientation of the incision based on location was incorrect for general surgeons in 26 % (N = 20) of cases. General surgeons were less likely to make an appropriate incision (p = 0.052) and to use a tourniquet during the initial procedure (p < 0.001). There were no differences among surgical subspecialties in the use of local anesthetic, drain use, or excision type regarding the initial non-oncologic resection. Residual disease following tumor bed re-excision was linked to masses removed in the clinic (p = 0.030) and initial stage IIIB tumors (p = 0.019). Our institutional use of radiation therapy (XRT) correlated with large initial size, high-grade histology, location deep to fascia, and tumors that were re-excised with staged coverage by plastic surgery.

Conclusion: Most referrals for initial non-oncologic resection of STS come from general surgery followed by orthopaedic surgery. Indications for pre-operative MRI imaging, incision orientation, and tourniquet use are education targets for general surgeons in training. Interpretation of MRI scans is an education target for orthopaedic surgeons in training. Clinic procedures are associated with residual disease on tumor re-excision. Radiation before tumor bed re-excision can be considered for larger, high-grade tumors that are deep to the fascia and when plastics coverage is planned.

Level of evidence: Level IV.