Inadvertent surgical resection of soft tissue sarcomas

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Abstract

Background

The National Institute of Clinical Excellence (NICE) published Improving Outcome Guidance in 2006 defining urgent referral criteria for soft tissue sarcoma (STSs) with the twin aims of improving diagnostic accuracy and overall outcome. Despite these guidelines inadvertent excisions of soft tissue sarcomas continue to occur with alarming frequency, potentially compromising patient outcomes.

Objective

We reviewed the East Midlands Sarcoma Service experience of treating inadvertent excision of STSs and highlight the patient profile, referral pattern, subsequent management and oncological outcome associated with inadvertent resection.

Methods

Patients were identified from our sarcoma database and a retrospective case note review performed.

Results

Over a 3-year period, 42 patients presented to our specialist centre after unplanned excision of soft tissue sarcomas. There were 29 men and 13 women, with a mean age at presentation of 59 years (19–90). 50% of the tumours were located in lower extremity, 33% around the trunk and 17% in the upper extremity. The unplanned surgery was most commonly from general surgeons, plastic surgeons, orthopaedic surgeons, general practitioners followed by vascular surgeons. Re-resection was undertaken in 40 cases to achieve clear margins with residual tumour present in 74% of cases. Limb salvage surgery was not possible in 5 cases.

Conclusion

Unplanned excision of sarcoma by non-oncologic surgeons remains a problem. It appears that it is equally prevalent in varied surgical community and general practitioners. Excision of large or deep solid soft tissue masses without tissue diagnosis is unacceptable.

Introduction

Soft Tissue Sarcomas (STSs) are rare malignant mesenchymal tumours and have been reported to comprise only 0.8% of all adult malignant tumours.1 Soft tissue sarcomas may occur at any age, and common sites of involvement include the extremities, trunk, retroperitoneum, and the head and neck. Most STSs present as painless, enlarging masses. These tumours feature local invasiveness with propensity for local recurrence and distant metastasis. Advanced imaging techniques and biopsy, ideally performed at tertiary referral centres, usually confirm the diagnosis. Surgical excision followed by post-operative radiotherapy is the standard management of deep high grade limb sarcomas although occasionally amputation remains the only option. Approximately half of all STS patients with high grade tumours develop metastatic disease2 and the overall survival is approximately 50% at 5 years.3, 4

The rarity of such tumours may lead to a lack of consideration of sarcoma in initial diagnosis when one is faced with a soft tissue lump in daily practice and not infrequently soft tissue sarcomas are wrongly diagnosed clinically as benign lesions. Consequently, some soft tissue sarcomas are inadvertently excised without appropriate pre-operative imaging, biopsy, or attention to wide surgical margins. These procedures are described in the literature as “unplanned excisions”.5, 6, 7 The risk of the residual disease after such an operation is high and reported range from 24% to 60% of cases.5, 6, 7, 8, 9, 10 The treatment options for cases of unplanned resection include no further resection, radiotherapy alone, wide re-resection followed by adjuvant therapy. Most authors advocate subsequent ‘well-planned re-resection’ with adjuvant radiotherapy in a sarcoma centre to improve overall local control.5, 8, 11, 12, 13

In the United Kingdom, the National Institute of Clinical Excellence (NICE) published “Improving Outcome Guidance for Sarcomas” in 2006 defining urgent referral criteria for soft tissue sarcoma to improve the diagnostic accuracy and avoid delay in referral pathway.14 They recommended that a lump with any one of the following suspicious features should be referred to a specialist centre: (1) size larger than 5 cm, (2) a rapid increase in size, (3) pain in a previously painless lump and (4) sub-fascial (deep) location of the lump. Despite these well-publicised management and referral guidelines, diagnostic and therapeutic errors of soft tissue sarcomas continue to remain a common problem. Referrals after an inadvertent initial excision have been reported as ranging from 18% to 53% of the new patients seen in sarcoma centres.6, 8, 10, 16

We report our experience of treating primary STSs after an inadvertent excision and highlight the patient profile, referral pattern, subsequent management and oncological outcome associated with inadvertent resection of STSs.

Section snippets

Patient selection

A review of our East Midlands Sarcoma Service database identified 42 consecutive STS patients referred from outside institutions after so called “unplanned excision” and treated at our specialist centre by our three sarcoma surgeons (AGBP, AR and RUA) between January 2008 and December 2010. This period represents the formation of the East Midlands Sarcoma Service. The median follow-up was 19 months (range 3–36 months).

All 42 patients had undergone an initial unplanned incomplete excision of a

Demographics

Over a 36 months period we treated 216 patients for trunk or limb soft tissue sarcoma, of whom 42 (19.4%) had undergone an initial inadvertent excision elsewhere. The remaining 174 were biopsied and managed in the centre in their entirety.

The clinical and tumour characteristics of all 42 patients were summarised in Table 1. The tumours were located in the trunk in 14 patients, thigh in 12, upper arm in 6, leg in 5, foot in 4 and forearm in 1. A total of 19 of 42 patients (45.2%) had tumours

Discussion

Our series is more evidence that inadvertent resection of soft tissue sarcomas continues to happen. Whilst resection of small, superficial lesions that turn out to be sarcomas is unfortunate, resection of large deeper lesions is unacceptable. Proper investigation of these lesions including MRI scan and biopsy in a sarcoma centre is mandatory.

The characteristics of the patient population in this study, though of small size, did not differ with regard to age, site, depth, stage and grade

Conclusion

Unplanned excision of sarcoma by non-oncologic surgeons remains a problem. It appears that it is equally prevalent in varied surgical community and general practitioners. Patients with soft tissue masses of unknown identity should be appropriately imaged and if the diagnosis remains unclear be transferred to centres that specialize in treating sarcomas for biopsy and adequate initial resection. This is an issue of importance for clinical education and requires a high level of clinical suspicion

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