Does Unplanned Soft Tissue Sarcoma Surgery Have a Negative Effect on Prognosis?

Demographic and clinical profile of 1106 adult soft tissue sarcoma patients: A single institutional prospective database experience from India

BACKGROUND

Adult soft tissue sarcomas (STS) are rare and diverse. Current management is based on limited literature from the West. Therefore, data from different geographical regions is required, including the low-middle-income countries. This is our experience managing adult sarcomas in the tertiary cancer center of North India.

MATERIALS AND METHODS

This is a retrospective analysis of the structured sarcoma database of patients treated in the surgical oncology department between 1992 and 2020. The descriptive analysis includes demography, site distribution, diagnosis, histopathology variations, prior surgical interventions, and stage.

RESULTS

A total of 1106 soft tissue sarcoma patients were treated in three decades. Age distribution was 13%, 43%, 31%, and 11% in <20, 21-40, and 41-60 and >60 years, respectively. The male-to-female ratio was 1.73. The anatomical distribution was 17%, 42%, 23%, 7%, 7%, and 3% in upper extremity, lower extremity, trunk, retroperitoneum, head and neck, and viscera, respectively. Overall, 49% of patients had undergone prior suboptimal surgeries at community hospitals. Common histology subtypes were synovial sarcoma (18%), undifferentiated pleomorphic sarcoma (UPS) (13%), dermatofibrosarcoma protuberans (12%), and liposarcoma (9%). A pathological discordance of 13% was identified between the initial and the final histologies. Overall, 61% of tumors were high-grade. Memorial Sloan Kettering Stages II and III were present in 33% and 35% of patients, respectively.

CONCLUSIONS

This is one of the largest single institutional experiences of STS from the Asian population. Mostly young adults were affected with male preponderance. The lower extremity and trunk were common subsites. Frequent histologies were synovial sarcoma and UPS. A high rate of suboptimal surgical intervention at the community level and pathological discordance was noted. This study highlights the need to establish prospective structured databases for capturing quality information related to rare malignancies and providing insights for future research.

Undifferentiated soft-tissue sarcoma (STS) in a 34-year-old woman: A case report

INTRODUCTION AND IMPORTANCE: soft tissue sarcoma (STS) is a type of cancer that can affect connective tissue. Diagnosis of this malignant tumor is difficult, and complications are related to the pressure it can exert on surrounding body organs. Up to 50 % of STS patients develop metastatic disease, which greatly affects the prognosis and is challenging for the treating physician.

CASE PRESENTATION

This case report is about a 34-year-old woman who was found to have significant growth of malignant tumor in her lower back due to misdiagnosis and negligence about her disease. After the cancer invaded the abdominal cavity, she died from related complications.

CLINICAL DISCUSSION

STS are among the rare malignant tumors, and the mortality rate of these cancers is very high because they are often not properly diagnosed.

CONCLUSION

Educating medical personnel, especially primary care physicians, about the symptoms and manifestations of STS can make a significant contribution to successful treatment. Due to the complexity of treatment, any soft-tissue swelling suspected of malignancy is best referred directly to a sarcoma center, where therapeutic management is carefully planned by an experienced multidisciplinary team.

The added value of the visual analysis of DWI in post-surgery follow-up of soft tissue sarcoma of the extremities: do we really need ADC?

INTRODUCTION

MRI has a fundamental role in the follow-up of soft tissue sarcomas (STSs). However, the differentiation of recurrences/residual disease from post-surgical changes is a complex task, with a central role for the radiologist.

MATERIALS AND METHODS

We retrospectively evaluated 64 post-surgery MRI for extremities STSs. MR protocol included DWI (b = 0, 1000). Two radiologists were asked to consensually evaluate: presence/absence of tumoral nodules, lesion conspicuity, imaging diagnostic confidence, ADC values, and DWI overall image quality. The gold standard was histology or MR follow-up.

RESULTS

Thirty-seven lesions in 29/64 patients were confirmed as local recurrence or residual disease (n = 16 ≤ 1 cm) with 1 MR false positive. On DWI, the conspicuity of the proved tumor lesions resulted excellent in 29/37, good in 3/37 and low in 5/37, higher than conventional imaging. A statistically significant higher diagnostic confidence of DWI compared to conventional imaging (p < 0.001) and DCE (p = 0.009) was observed. In the 37 histologically confirmed lesions, mean ADC value was 1.31 × 10^-9 m²/s. Overall scar tissues mean ADC was 1.70 × 10^-9 m²/s. DWI quality resulted adequate in 81% and unsatisfactory in 5%.

CONCLUSIONS

In this highly heterogeneous group of tumors, the role of ADC seems to be limited. Based on our experience, looking at DWI images makes the lesions promptly and easily detectable. This technique gives less deceptive findings making the reader more confident in detecting/excluding tumoral tissue; the main drawback is the image quality and the lack of standardization.

Diagnostic performance of MRI in detecting residual soft tissue sarcoma after unplanned excision: Systematic review and meta-analysis

OBJECTIVE

To investigate, in a systematic review and meta-analysis, the diagnostic performance of MRI in detecting residual disease after unplanned excision of soft tissue sarcoma.

METHODS

Medline and Embase were searched for original studies on the diagnostic performance of MRI detecting residual soft tissue sarcoma after unplanned excision. Study quality was assessed using QUADAS-2. Sensitivity and specificity were pooled using a bivariate random-effects model. A Chi-squared test was used to test for heterogeneity.

RESULTS

Ten studies were included, comprising a total of 469 patients. Median frequency of residual soft tissue sarcoma was 54.6% (range 31.6-73.1%). There was high risk of bias with respect to flow and timing in one study. There were applicability concerns with respect to patient selection in four studies. Nine studies reported to use the presence of a mass as a diagnostic criterion for residual soft tissue sarcoma. Sensitivities of included studies ranged between 36.4% and 86.7%, and specificities ranged between 77.8% and 100%. Pooled sensitivity was 65.9% (95% confidence interval [CI]: 55.5-74.9%) and pooled specificity was 85.1% (95% CI: 79.1-89.6%). The area under the summary receiver operating characteristic curve was 0.852. The included studies were statistically heterogeneous in their estimates of sensitivity (P = 0.016) and statistically homogeneous in their estimates of specificity (P = 0.793).

CONCLUSION

The presence of a mass is the most commonly reported diagnostic criterion to diagnose residual soft tissue sarcoma after unplanned resection. MRI achieves moderate sensitivity and fairly high specificity. Pooled estimate of sensitivity was subject to heterogeneity, which needs further exploration.

MRI after Whoops procedure: diagnostic value for residual sarcoma and predictive value for an incomplete second resection

OBJECTIVE

To determine the value of MRI for the detection and assessment of the anatomic extent of residual sarcoma after a Whoops procedure (unplanned sarcoma resection) and its utility for the prediction of an incomplete second resection.

MATERIALS AND METHODS

This study included consecutive patients who underwent a Whoops procedure, successively followed by gadolinium chelate-enhanced MRI and second surgery at a tertiary care sarcoma center.

RESULTS

Twenty-six patients were included, of whom 19 with residual tumor at the second surgery and 8 with an incomplete second resection (R1: n = 6 and R2: n = 2). Interobserver agreement for residual tumor at MRI after a Whoops procedure was perfect (κ value: 1.000). MRI achieved a sensitivity of 47.4% (9/19), a specificity of 100% (7/7), a positive predictive value of 100% (9/9), and a negative predictive value of 70.0% (7/17) for the detection of residual tumor. MRI correctly classified 2 of 19 residual sarcomas as deep-seated (i.e., extending beyond the superficial muscle fascia) but failed to correctly classify 3 of 19 residual sarcomas as deep-seated. There were no significant associations between MRI findings (presence of residual tumor, maximum tumor diameter, anatomic tumor extent, tumor margins, tumor spiculae, and tumor tail on the superficial fascia) with an incomplete (R1 or R2) second resection.

CONCLUSION

Gadolinium chelate-enhanced MRI is a reproducible method to rule in residual sarcoma, but it is insufficiently accurate to rule out and assess the anatomic extent or residual sarcoma after a Whoops procedure. Furthermore, MRI has no utility in predicting an incomplete second resection.