Introduction Soft tissue sarcomas STSs

Introduction Soft tissue sarcomas (STSs) are rare and heterogenic primary malignant tumors. They originate from the T-5224 and comprise < 1% of adult malignancies and 15% of all pediatric malignancies. Because of the rarity of this disease, patients and physicians are often unaware of the involved tumor, thus delaying diagnosis and initial proper treatment. In addition, most general surgeons may not be familiar with the advanced multidisciplinary management. Therefore, hasty biopsy and unplanned surgery before referral frequently complicate the subsequent definite surgery and lead to a poor clinical outcome. Unplanned surgery is defined as an operation undertaken for any excision of STSs without appropriate preoperative imaging, biopsy, or attention to the wide surgical margin. Once unplanned surgery has been performed, the margin of reexcision must to be more extensive than the standard wide margin. This may necessitate soft tissue reconstruction and result in a longer operation time, complications, and functional loss. Referrals after unplanned surgery account for between 14.7% and 53% of new patients in sarcoma centers. Even if there is no gross evidence of disease from clinical examination or contrast-enhanced magnetic resonance imaging (MRI), 35–74% of residual sarcomas have been found in the reexcised specimen. Reexcision is generally warranted to remove the residual tumor or obtain an adequately safe margin. Numerous reports have addressed clinical problems that could occur after initial unplanned excision. However, considerable controversy exists regarding the criteria of reexcision and the sequencing of radiation and surgery.
Inappropriately executed biopsy On the basis of biopsy diagnosis and definitive diagnosis, Mankin et al reported an error rate of 17.8% in 597 patients. Of these 106 erroneous diagnoses, 81 (76%) were considered major errors and two-thirds occurred at referring institutions. When the biopsy was performed in a referring institute, the errors, complications, and dismal results were from two to 12 times greater compared with the biopsy performed in a sarcoma center. In addition, a 16% unnecessary amputation rate and 10% mortality rate were attributed to the complications of hasty biopsy. Therefore, although the biopsy is not a technically demanding procedure, motor neurons should be performed by the surgeon who will perform the definitive excision for the patient. Moreover, adhering to certain guidelines of the biopsy for extremity STSs is crucial (Table 1).
Evaluation after referral Evaluating a referred patient consists of a physical examination, MRI of the tumor bed, computed tomography of the chest to determine the presence of metastases, and a complete review of the clinical data provided from the referring surgeon. Moreover, the original histologic material should be reviewed by an experienced musculoskeletal pathologist to confirm the diagnosis of STS. Determining the presence of a residual tumor after unplanned surgery remains challenging. Noria et al reported a 42% residual tumor rate in 65 patients who presented no gross evidence of a tumor from physical examination or MRI. Moreover, Manso et al reported that MRI may have a false-negative rate of 25%. Chandrasekar et al suggested several clinical parameters for determining the increased rates of a residual tumor, including tumors that are high grade, > 5 cm, and deep to the fascia.
Does unplanned surgery always require reexcision? The reported rate of reresection has varied from 35% to 100%, with the residual tumor rate ranging from 24% to 74%. According to the definition, for the patients presenting after unplanned surgery where margin is uncertain or positive, reexcision is generally recommended. RT alone without additional excision was occasionally indicated in patients who were either medically inoperable or in whom further surgery would increase morbidity. Bell et al reported a 50% local control (LC) rate for patients who were received RT only without reexcision following unplanned surgery. Zagars et al, 371 of 666 patients who could not receive reexcision because of various reasons underwent RT only at a total dosage of 60–70 Gy. The 15-year LC, disease-free survival, and distant metastasis-free survival rates were 73%, 48%, and 64%, respectively. The results were less favorable compared with the group that underwent reexcision with postoperative RT.