Comparison of soft tissue sarcoma patients' results who had re-excisions after unplanned excisions with patients' results who had been operated with preoperative multidisciplinary planning

Introduction Treatment of soft tissue sarcomas can be very challenging. First of all; the history of patient should be questioned carefully. Soft tissue mass should be evaluated with physical examination and appropriate imaging techniques. Full body scans also needed to evaluate possible preoperative distant metastasis lesions. After these steps the patient should be considered at multidisciplinary meetings. Biopsy tract should be close to the incision of further planned operation. These steps are crucial for the optimum oncologic outcome. Unfortunately unplanned excisions (whoops procedures) of soft tissue sarcomas are serious medical problems that can be seen all around the world. Most of these operations are performed to underestimated masses which are smaller in size and more superficial. With good planning the results of these patients are expected to be well. The aim of this study was to analyze the effects of unplanned excisions over local recurrence, metastasis and overall survival. Materials and Methods We retrospectively reviewed all soft tissue sarcoma patients who have been operated in our department between 2000 and 2018. We divided these patients into 2 groups. Group 1 (EGE) includes 345 patients whose initial operations were performed in our department with multidisciplinary approach and planning. Group 2 (OTHER) includes 145 patients whose first operations were performed elsewhere without multidisciplinary approach and planning. After initial treatment some patients directly referred to our clinic and appropriate operations such as re-excisions of these patients were performed in our department. Some patients were followed with adjuvant therapies after unplanned excisions and they were referred to our clinic after local recurrence. Secondary wide excisions of these patients' recurrent tumors were performed at our clinic. Local recurrence, Metastasis and Overall Survival curves were studied with Kaplan-Meier method considering follow up time starting from the intervention day till the end of the follow up or till the date of the local recurrence. A Log Rank test was also performed in order to compare 2 different curves obtained from the 2 groups. Cox Regression tests were performed in order to obtain hazard ratio. Competing Risks Analysis was also performed. Results Mean age of group 1 was 50.1, mean diameter of tumor was 10.2 cm, mean follow up was 57.1 months. Mean age of group 2 was 47, mean diameter of tumor was 6.2 cm, mean follow up was 55.8 months. There were 26 (17.9%) local recurrences in group 2 while there were 30 (8.7%) local recurrences in group 1. The difference of local recurrence between two groups was statistically significant (HR:2.13, p=0.005, CI%95: 1.26/3.60). There were 47 (32.6%) metastasis in group 2 while there were 115 (33.8) metastasis in group 1. The difference of metastasis between two groups was not statistically significant (HR:0.81, p=0.312, CI%95: 0.54/1.21). The mean survival time of group 2 was 147.6 months while the mean survival time of group 1 was 141.8 months. There was no statistically difference between the survival time of two groups (p=0.946). Local recurrences effect over metastasis and overall survival have been analyzed. Patients with local recurrence had 2.5 times more risk of metastasis than the patients without local recurrence (HR:2.506, p=0.001). Patients with local recurrence had 1.7 times more risk of disease associated overall mortality than the patients without local recurrence (HR:1.724, p=0.007). Conclusion It has been shown that diameter of soft tissue sarcomas are directly related with oncologic outcome. Even though there is a big difference in mean diameters of tumors between two groups (6.2cm vs 10.2cm), there is no statistically significant difference in metastasis free survival and overall survival. We believe that if initial operations of group 2 patients had been performed in sarcoma centers; the oncological outcomes of these patients would be much better than group 1 patients. There is 2.13 times more risk of local recurrence in group 2 even though these patients received appropriate treatments in our clinic after their unplanned surgeries that had been performed elsewhere. Planning is one of the most important factors that effect over oncologic outcome of soft tissue sarcoma patients. Resection of soft tissue sarcomas without enough experience and planning causes uncorrectable mistakes which effects oncologic outcome of the patient negatively. Keywords: soft tissue sarcomas, unplanned excision, re-excision