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

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

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

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

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

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

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

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 1995-2007 with adequate data

Patients M:F 1.2:1 Mean age 55 (range 17-56) Avg F/U 55mos (range 6-150 mos) Oncologic data only on those with 2yr f/u

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%

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

Radiation Plan Optimal Plan What Had to Be Done

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

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

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

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

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

Res Ipsa Loquitur

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