Improved Metastatic-Free Survival after Systematic Re-Excision Following Complete Macroscopic Unplanned Excision of Limb or Trunk Soft Tissue Sarcoma

TL;DR

Re-excising soft tissue sarcomas after initial unplanned surgery improves metastatic-free survival in most patients, except those over 70 or with large tumors.

Contribution

The study identifies re-excision as an independent favorable factor for metastatic-free survival in specific patient subgroups.

Findings

Re-excision (RE) is an independent favorable factor for metastatic-free survival (MFS) with a hazard ratio of 0.7.

Patients over 70 years and those with tumors larger than 10 cm do not benefit from re-excision in terms of MFS.

R1 initial resection is associated with better MFS than R0 initial resection.

Abstract

The quality of resection after unplanned excision of soft tissue sarcoma (STS) performed outside of a reference center or at second resection potentially impacts local and metastatic recurrence and survival. The French cohort NETSARC prospectively collected data from patients with unplanned excision outside reference centers from 2010 to 2019 and reported survival in patients reexcised (RE) or not (No-RE). Patients who would most benefit from RE need to be identified. A total of 2371 patients had unplanned excision for STS outside reference centers, including 1692 patients with no multidisciplinary board review (RE: 913; No-RE: 779). Discrepancies in RE/No-RE subgroups were observed regarding age, tumor site, size, depth, grade and histotype. R0 final resection associated with better MFS; R1 initial resection showed better MFS than R0 initial resection. The study identified RE as an independent favorable factor for MFS (HR 0.7, 95% CI 0.53–0.93; p = 0.013). All subgroups except patients > 70 years, and patients with large tumors (>10 cm) showed better MFS with RE. RE in patients with STS of limb or trunk after macroscopic complete resection out of NETSARC reference center, and also in R0 resections to improve LRFS and MFS. Systematic RE should not be advocated for patients ≥ 70 years, or tumor size ≥ 10 cm.

Background: Whether re-excision (RE) of a soft tissue sarcoma (STS) of limb or trunk should be systematized as adjuvant care and if it would improve metastatic free survival (MFS) are still debated. The impact of resection margins after unplanned macroscopically complete excision (UE) performed out of a NETSARC reference center or after second resection was further investigated. Methods: This large nationwide series used data from patients having experienced UE outside of a reference center from 2010 to 2019, collected in a French nationwide exhaustive prospective cohort NETSARC. Patient characteristics and survival distributions in patients reexcised (RE) or not (No-RE) are reported. Multivariate Cox proportional hazard model was conducted to adjust for classical prognosis factors. Subgroup analysis were performed to identify which patients may benefit from RE. Results: Out of 2371 patients with UE for STS performed outside NETSARC reference centers, 1692 patients were not reviewed by multidisciplinary board before treatment decision and had a second operation documented. Among them, 913 patients experienced re-excision, and 779 were not re-excised. Characteristics were significantly different regarding patient age, tumor site, size, depth, grade and histotype in patients re-excised (RE) or not (No-RE). In univariate analysis, final R0 margins are associated with a better MFS, patients with R1 margins documented at first surgery had a better MFS as compared to patients with first R0 resection. The study identified RE as an independent favorable factor for MFS (HR 0.7, 95% CI 0.53–0.93; p = 0.013). All subgroups except older patients (>70 years) and patients with large tumors (>10 cm) had superior MFS with RE. Conclusions: RE might be considered in patients with STS of limb or trunk, with UE with macroscopic complete resection performed out of a reference center, and also in originally defined R0 margin resections, to improve LRFS and MFS. Systematic RE should not be advocated for patients older than 70 years, or with tumors greater than 10 cm.

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