Staged Reconstruction Is Not Necessary Following Oncologic Resection of Superficial Myxofibrosarcoma

TL;DR

This study shows that single-stage surgery with immediate reconstruction for superficial myxofibrosarcoma can achieve low recurrence rates without needing multiple procedures.

Contribution

The study demonstrates the effectiveness of single-stage resection and reconstruction for myxofibrosarcoma, challenging the need for staged approaches.

Findings

A 10-year local recurrence-free survival rate of 90% was achieved with single-stage surgery.

Frozen margin assessment was highly accurate (92.92–98.23%) in predicting final margin status.

Only 19% of patients required an additional procedure, mostly due to wound complications.

Abstract

Myxofibrosarcomas are a common superficial soft-tissue sarcoma and are known for an infiltrative growth pattern along a fascial plane. To achieve a wide margin, large resections are often required, which need skin-grafting or soft-tissue coverage. Recent publications have advocated for staged resection and only reconstructing once the final permanent margin is negative to reduce the risk of local recurrence. This increases the cost of care and patient morbidity secondary to additional procedures. We have historically utilized a combination of wide local resection, with intraoperative frozen section analysis and immediate soft-tissue coverage, with a low rate of local recurrence.

Background: Myxofibrosarcomas are notoriously highly infiltrative soft-tissue sarcomas, making negative surgical margins difficult to obtain. Recently, vacuum-assisted closure (VAC) is used to delay wound closure until a negative margin has been achieved; however, this can delay care and increase costs. Our institution has historically performed single-stage resections with intraoperative frozen margin analysis and reconstruction in these patients. The purpose of this study is to report the outcomes of this technique. Methods: We reviewed 112 patients (62 males, mean age 70 ± 14 years) with superficial myxofibrosarcoma. Eighty-eight patients received preoperative radiation. All patients underwent surgical resection with intraoperative frozen margin analysis, and the planned reconstruction was performed in a single anesthetic. Results: The 10-year local recurrence-free survival was 90%; positive intraoperative frozen section (HR 7.44, p = 0.004) and final permanent margins (HR 8.53, p = 0.007) were associated with local recurrence. Intraoperative margins were negative in 103 (92%) of patients, 1 of which was positive on final permanent section. There were nine cases of microscopically positive margins, of which seven underwent immediate re-excision to a negative margin. The accuracy of frozen margin assessment for myxofibrosarcoma was between 92.92 and 98.23%. All patients underwent reconstruction at the time of resection, with 19% needing an additional procedure, most commonly due to a wound complication (12%). Conclusions: Multidisciplinary single-stage excision with intraoperative frozen margin assessment and soft-tissue reconstruction yields low rates of local recurrence in patients with superficial myxofibrosarcoma.

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