A. Dave1, L. Suarez-Kelly2, R. Shelby1, P. Yu1, J. H. Howard2, V. Grignol2 1The Ohio State University Wexner Medical Center,Division Of General Surgery,Columbus, OH, USA 2The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center,Division Of Surgical Oncology,Columbus, OH, USA
Introduction:
Many patients with extremity sarcoma are diagnosed incidentally after resection of what is thought to be a benign lesion. Re-excision to obtain microscopically negative margins is the standard practice. We sought to evaluate the rate of residual disease at re-excision in extremity sarcomas.
Methods:
A retrospective review of all adult patients diagnosed with extremity sarcoma between 2008-2014 who underwent re-excision at our institution was performed. Incidence of residual disease, margin status, and clinical outcomes were evaluated. Disease free survival was defined as time from date of diagnosis to recurrence or death. Patients were censored at date of last follow-up.
Results:
Twenty-nine patients with extremity sarcoma underwent re-resection during the relevant time period. Ten patients had imaging with MRI (n=6), US (n=1), MRI and US (n=2), or CT (n=1) before the initial excision. Twenty-two patients had their excisional biopsy at a referring institution and seven at our institution. The average primary tumor size was 3.2cm (0.2cm-10cm). The most common histologies were myxofibrosarcoma (n=8), leiomyosarcoma (n=5), and undifferentiated pleomorphic sarcoma (n=4). Overall, twenty-one (72%) patients had no further local or metastatic disease after re-resection. The overall disease free survival was 27.6 months (1.08-70.6 months). On microscopic analysis of re-resection specimen, eighteen patients (62%) had residual tumor. This rate was comparable for those who underwent primary surgery at our institution (57%) and at referring institution (63%). A total of nine patients (31%) had positive margins on the re-resection specimen. One patient underwent a third resection with residual sarcoma and negative margins. One underwent two further resections with residual sarcoma and positive margins, developed local recurrence, and underwent amputation with negative margins. Of the remaining seven patients who did not have further surgery, one developed local recurrence, one developed distant metastasis to lung, and five had no further disease. Overall, 33% of patients with positive margins had local recurrence or distant metastasis. Disease free survival with positive margins was 24.9 months (2.5- 54 months). Of the nine patients with negative margins on re-resection specimen, none developed local recurrence. However, three developed distant metastasis to lung, bone, small bowel, lymph nodes, and extremity. Disease free survival with negative margins was 25.57 months (1.08-70.6 months).
Conclusion:
Residual tumor is found in over 60% of patients with extremity sarcoma removed by excisional biopsy. When feasible, re-excision should be utilized to obtain microscopic negative margins. This data can be used in counseling patients and making multimodality treatment decisions after gross disease has been removed on excisional biopsy.