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  • Once unplanned surgery has been performed the surgical

    2018-11-06

    Once unplanned surgery has been performed, the surgical margin of reexcision must be more extensive than the initial margin.
    Reexcision timing The mean interval from the initial unplanned surgery to reexcision varies from 36 days to 108 days. Delay of a reexcision theoretically allows the proliferation of residual tumor cells, thus increasing the likelihood of local recurrence. Patients\' delay was presumed to be one of the main reasons. Patients are recommended to receive reexcision as soon as possible, ideally within 3 weeks after the unplanned surgery. However, delaying reexcision could improve wound healing and prevent wound complications. In addition, increased fibroblastic scar formation could capture the tumor cell and provide a more defined margin, thus allowing more effective LC. Han et al reported that any influence of delayed remargin surgery is likely to be of minor clinical importance.
    Adjuvant radiotherapy and chemotherapy RT would not be recommended for patients without a residual tumor after reexcision or for patients with a low-grade STS with a negative margin. Adjuvant RT is generally used if the sarcoma is large, high grade, and deeply located. Most series have used at least selective adjuvant therapy after reexcision for high-risk patients following unplanned surgery. RT can be administrated prior to, during, or following the reexcision. Regarding the sequencing of RT and reexcision, substantial controversy exists. The differences between preoperative RT and postoperative RT are quality and the timing of toxicity. In addition, preoperative RT has theoretical advantages such as producing less stavudine Supplier at a lower dosage, sterilizing the reactive zone, avoiding tumor hypoxia, and reducing radiosensitivity. However, increased wound complications are a major concern in preoperative RT. Postoperative RT does not interfere with the pathological evaluation of the residual tumor and avoids increasing the risk of wound complications. However, postoperative RT may result in greater long-term toxicity including fibrosis, edema, bone fracture, and functional impairment. Adjuvant chemotherapy remains controversial because of its marginal benefits. A recent study indicated grana adjuvant chemotherapy, an ifosfamide/epidoxorubicin protocol, showed 19% improvement in overall survival at 4 years. Therefore, adjuvant chemotherapy should be reserved for patients with a large, high-grade, localized lesion, and stage-IV disease.
    Impact of unplanned surgery on prognosis Several studies have investigated the disease-specific survival, metastasis, and local recurrence rates of patients who underwent unplanned surgery of STSs. Variable outcomes have been reported from several sarcoma centers. Ueda et al found that the local recurrence rate was higher in patients who received unplanned surgery than those who received successful primary wide excision. Fiore et al analyzed 597 consecutive patients with primary STSs. Of the 597 patients, 318 were referred after unplanned surgery and the remaining 279 patients underwent primary resection. The 10-year cumulative incidences in the reexcision and primary-operated groups were respectively 18.7% and 16.4% for local recurrence, 17.6% and 20.2% for metastasis, and 20.4% and 22.4% for mortality. The outcome of patients who underwent reexcision was similar to that of patients who had primary resection. Hoshi et al reported that the 5-year overall survival was 76.3% and the outcomes were almost equivalent to those in previous reports. They addressed the significant role of wide reexcision in improving the outcome of unplanned resection compared with inadequate treatment without reexcision. Chandrasekar et al found that despite reexcision, the risk of local recurrence remains high. The risk is doubled when a residual tumor is present in reexcised specimens and for high-grade tumors, marginal reexcision, and deep-seated tumors.