1. Quantifying the Morbidity of the Unplanned Sarcoma Excision
Robert Tamurian, Robert Zlotecki, Zach Adler,
Mark Scarborough, and Parker Gibbs
University of Florida College of Medicine
Division of Orthopaedic Oncology

2. The Unplanned Excision
The excision of a soft tissue mass not thought to be malignant, that upon subsequent pathologic examination results in the utterance: “whoops, that’s a sarcoma”
Standard of care: Wide excision of the tumor bed +/- adjuvant therapy
~50% have residual disease in re-excision specimen
Giuliano and Eilber JCO 1985

3. UF Protocol
MRI to best determine extent of bed and identify potential gross residual disease
Wide re-excision of tumor bed
Adjuvant radiotherapy for high risk tumor bed (most)
Tumor in re-excision bed
Large hematoma
Extensive edema

5. Wide Re-Excision Numerous Articles
The unplanned sarcoma excision has no significant effect on survival if wide re-excision is performed
Local recurrence may be increased
Morbidity is only obliquely mentioned
Difficult to assess
Difficult to identify a matched cohort

6. Goal
Attempt to quantify the morbidity to a patient who has undergone a wide re-excision following “whoops surgery”
Compare what had to be done to what could have been done had we seen them first
Each patient serves as his/her own comparison case

7. What to Measure? Volume of Tissue Resected upon Re-Excision
Larger resection volume directly associated with increased wound complications and need for soft tissue coverage
Geller et. al. CORR 2007

8. Adjuvant Therapy Radiation Field Size
Key determinant of long term adverse sequelae
Edema
Subcutaneous Fibrosis
Joint stiffness
These three variables most strongly associated with decreased functional outcome scores
Davis et. al. Radiother Oncol 2005

9. Study
Retrospective review of our prospectively collected database to identify patients having had an unplanned excision of a sarcoma and subsequently referred for definitive management.
55 patients identified in the contemporary period from with adequate data

10. Patients M:F 1.2:1 Mean age 55 (range 17-56)
Avg F/U 55mos (range mos)
Oncologic data only on those with 2yr f/u

11. Tumors MFH most common histology (55%) Avg tumor size 34.5 cm3
Hi Grade 65%
Low Grade 35%
Superficial 64%
Deep 36%
Small (< 5cm) 60%
Large (> 5cm) 40%

12. Volume of Tissue Resected
Optimal resection volume (what we would have done) determined as original tumor volume plus one cm in all directions to simulate wide margin.
Tumor Bed resection volume (what had to be done) determined by direct measurement of pathologic specimen after re-excision of tumor bed
Tumor Bed Excision

13. Radiation Plan
Optimal Plan What Had to Be Done

14. Oncologic Outcome Overall Survival 89% Local Recurrence rate 21%
Residual Disease in 44%
Increased risk of LR (p < 0.05)

15. Re-Excision Procedure P< 0.01
348 cm3
Optimal Resection VS
Re-Excision Procedure
P< 0.01
95 cm3
35 cm3 15

16. Actual radiation field size 220% greater than Optimal P < 0.001
vs.
Optimal field area
(p < 0.001)
362.4cm2
Actual radiation field size
220% greater than Optimal
P < 0.001
163.4 cm2 16

17. Soft Tissue Coverage STSG 57% 12% Flap 26% 7% Total 83% 19%
Re-Excision Primary Excision*
STSG 57% 12%
Flap 26% 7%
Total 83% 19%
Contemporary unmatched cohort of 403
STS managed primarily at UF

18. Morbidity
By definition, at least one additional operative intervention
Three times the Volume of Tissue (patient) Resected
Twice the Radiation Field Size
Marked Increase in Soft Tissue Coverage
Procedures

19. Res Ipsa Loquitur

20.
Thank You