The changing paradigm of resection margins in sarcoma resection

Kamran Harati, Marcus Lehnhardt, Kamran Harati, Marcus Lehnhardt

Abstract

Soft tissue sarcomas (STS) are a heterogeneous group of rare mesenchymal tumors that account for approximately 1% of all adult malignancies. They can arise throughout the body due to their mesenchymal origin, although 60% of all STS occur in the extremities. Locally advanced STS can lead to significant functional morbidity and tend to local recurrences despite surgical resection. About 30% of all STS patients develop distant metastases with a median overall survival of less than 15 months. The treatment of choice in patients with localized disease is still surgical resection with negative margins. However, there has been a paradigm shift in the last few decades. Large retrospective analyses could not establish a strong association between radical resections and improved local control or survival. Previous radical concepts in STS surgery have been gradually replaced by more moderate approaches with function- and limb-sparing resections combined with radiotherapy. Here, the margin status appears to be of prognostic significance. However, several large retrospective analyses have presented inconsistent results, questioning the independent prognostic impact of surgical margins. This article reviews the literature critically, focusing on the changing role of surgical margins in STS surgery.

Keywords: margins; recurrence; soft tissue sarcoma; survival; width.

©2017 Harati K., Lehnhardt M., published by De Gruyter, Berlin/Boston.

Figures

Figure 1:
Figure 1:
Algorithm for the treatment of non-intraabdominal STS. The histologic grades refer to the grading system of the French Federation of Cancer Centers. RT, Radiotherapy; CT, chemotherapy.

References

    1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43–66.
    2. Jemal A, Siegel R, Ward E. et al. Cancer statistics, 2007. CA Cancer J Clin. 2007;57:43–66.
    1. Mastrangelo G, Coindre JM, Ducimetiere F, et al. Incidence of soft tissue sarcoma and beyond: a population-based prospective study in 3 European regions. Cancer 2012;118:5339–48.
    2. Mastrangelo G, Coindre JM, Ducimetiere F. et al. Incidence of soft tissue sarcoma and beyond: a population-based prospective study in 3 European regions. Cancer. 2012;118:5339–48.
    1. Wibmer C, Leithner A, Zielonke N, Sperl M, Windhager R. Increasing incidence rates of soft tissue sarcomas? A population-based epidemiologic study and literature review. Ann Oncol 2010;21:1106–11.
    2. Wibmer C, Leithner A, Zielonke N, Sperl M, Windhager R. Increasing incidence rates of soft tissue sarcomas? A population-based epidemiologic study and literature review. Ann Oncol. 2010;21:1106–11.
    1. Goldblum JR, Weiss SW, Folpe AL. Enzinger and Weiss’s Soft Tissue Tumors. 6th ed. Ontario: Elsevier Canada; 2014.
    2. Goldblum JR, Weiss SW, Folpe AL. Enzinger and Weiss’s Soft Tissue Tumors. 6th. Ontario; Elsevier Canada: 2014.
    1. Zagars GK, Ballo MT, Pisters PW, et al. Prognostic factors for patients with localized soft-tissue sarcoma treated with conservation surgery and radiation therapy: an analysis of 1225 patients. Cancer 2003;97:2530–43.
    2. Zagars GK, Ballo MT, Pisters PW. et al. Prognostic factors for patients with localized soft-tissue sarcoma treated with conservation surgery and radiation therapy: an analysis of 1225 patients. Cancer. 2003;97:2530–43.
    1. Stojadinovic A, Leung DH, Hoos A, et al. Analysis of the prognostic significance of microscopic margins in 2,084 localized primary adult soft tissue sarcomas. Ann Surg 2002;235:424–34.
    2. Stojadinovic A, Leung DH, Hoos A. et al. Analysis of the prognostic significance of microscopic margins in 2,084 localized primary adult soft tissue sarcomas. Ann Surg. 2002;235:424–34.
    1. Fernebro J, Bladstrom A, Rydholm A, et al. Increased risk of malignancies in a population-based study of 818 soft-tissue sarcoma patients. Br J Cancer 2006;95:986–90.
    2. Fernebro J, Bladstrom A, Rydholm A. et al. Increased risk of malignancies in a population-based study of 818 soft-tissue sarcoma patients. Br J Cancer. 2006;95:986–90.
    1. Fletcher CD. The evolving classification of soft tissue tumours – an update based on the new 2013 WHO classification. Histopathology 2014;64:2–11.
    2. Fletcher CD. The evolving classification of soft tissue tumours – an update based on the new 2013 WHO classification. Histopathology. 2014;64:2–11.
    1. Coindre JM, Terrier P, Guillou L, et al. Predictive value of grade for metastasis development in the main histologic types of adult soft tissue sarcomas: a study of 1240 patients from the French Federation of Cancer Centers Sarcoma Group. Cancer 2001;91:1914–26.
    2. Coindre JM, Terrier P, Guillou L. et al. Predictive value of grade for metastasis development in the main histologic types of adult soft tissue sarcomas: a study of 1240 patients from the French Federation of Cancer Centers Sarcoma Group. Cancer. 2001;91:1914–26.
    1. Harati K, Daigeler A, Lange K, et al. Somatic leiomyosarcoma of the soft tissues: a single-institutional analysis of factors predictive of survival in 164 patients. World J Surg 2017;41:1534–41.
    2. Harati K, Daigeler A, Lange K. et al. Somatic leiomyosarcoma of the soft tissues: a single-institutional analysis of factors predictive of survival in 164 patients. World J Surg. 2017;41:1534–41.
    1. Harati K, Daigeler A, Goertz O, et al. Primary and secondary soft tissue angiosarcomas: prognostic significance of surgical margins in 43 patients. Anticancer Res 2016;36:4321–8.
    2. Harati K, Daigeler A, Goertz O. et al. Primary and secondary soft tissue angiosarcomas: prognostic significance of surgical margins in 43 patients. Anticancer Res. 2016;36:4321–8.
    1. Fiore M, Miceli R, Mussi C, et al. Dermatofibrosarcoma protuberans treated at a single institution: a surgical disease with a high cure rate. J Clin Oncol 2005;23:7669–75.
    2. Fiore M, Miceli R, Mussi C. et al. Dermatofibrosarcoma protuberans treated at a single institution: a surgical disease with a high cure rate. J Clin Oncol. 2005;23:7669–75.
    1. Sanfilippo R, Miceli R, Grosso F, et al. Myxofibrosarcoma: prognostic factors and survival in a series of patients treated at a single institution. Ann Surg Oncol 2011;18:720–5.
    2. Sanfilippo R, Miceli R, Grosso F. et al. Myxofibrosarcoma: prognostic factors and survival in a series of patients treated at a single institution. Ann Surg Oncol. 2011;18:720–5.
    1. Billingsley KG, Burt ME, Jara E, et al. Pulmonary metastases from soft tissue sarcoma: analysis of patterns of diseases and postmetastasis survival. Ann Surg 1999;229:602–10; discussion 10–2.
    2. Billingsley KG, Burt ME, Jara E. et al. Pulmonary metastases from soft tissue sarcoma: analysis of patterns of diseases and postmetastasis survival. Ann Surg. 1999;229:602–10. discussion 10–2.
    1. Novais EN, Demiralp B, Alderete J, et al. Do surgical margin and local recurrence influence survival in soft tissue sarcomas? Clin Orthop Relat Res 2010;468:3003–11.
    2. Novais EN, Demiralp B, Alderete J. et al. Do surgical margin and local recurrence influence survival in soft tissue sarcomas? Clin Orthop Relat Res. 2010;468:3003–11.
    1. Trovik CS, Bauer HC, Alvegard TA, et al. Surgical margins, local recurrence and metastasis in soft tissue sarcomas: 559 surgically-treated patients from the Scandinavian Sarcoma Group Register. Eur J Cancer 2000;36:710–6.
    2. Trovik CS, Bauer HC, Alvegard TA. et al. Surgical margins, local recurrence and metastasis in soft tissue sarcomas: 559 surgically-treated patients from the Scandinavian Sarcoma Group Register. Eur J Cancer. 2000;36:710–6.
    1. Eilber FC, Rosen G, Nelson SD, et al. High-grade extremity soft tissue sarcomas: factors predictive of local recurrence and its effect on morbidity and mortality. Ann Surg 2003;237:218–26.
    2. Eilber FC, Rosen G, Nelson SD. et al. High-grade extremity soft tissue sarcomas: factors predictive of local recurrence and its effect on morbidity and mortality. Ann Surg. 2003;237:218–26.
    1. Gronchi A, Casali PG, Mariani L, et al. Status of surgical margins and prognosis in adult soft tissue sarcomas of the extremities: a series of patients treated at a single institution. J Clin Oncol 2005;23:96–104.
    2. Gronchi A, Casali PG, Mariani L. et al. Status of surgical margins and prognosis in adult soft tissue sarcomas of the extremities: a series of patients treated at a single institution. J Clin Oncol. 2005;23:96–104.
    1. Pisters PW, Leung DH, Woodruff J, Shi W, Brennan MF. Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities. J Clin Oncol 1996;14:1679–89.
    2. Pisters PW, Leung DH, Woodruff J, Shi W, Brennan MF. Analysis of prognostic factors in 1,041 patients with localized soft tissue sarcomas of the extremities. J Clin Oncol. 1996;14:1679–89.
    1. Lewis JJ, Leung D, Casper ES, et al. Multifactorial analysis of long-term follow-up (more than 5 years) of primary extremity sarcoma. Arch Surg 1999;134:190–4.
    2. Lewis JJ, Leung D, Casper ES. et al. Multifactorial analysis of long-term follow-up (more than 5 years) of primary extremity sarcoma. Arch Surg. 1999;134:190–4.
    1. Potter BK, Hwang PF, Forsberg JA, et al. Impact of margin status and local recurrence on soft-tissue sarcoma outcomes. J Bone Joint Surg Am 2013;95:e151.
    2. Potter BK, Hwang PF, Forsberg JA. et al. Impact of margin status and local recurrence on soft-tissue sarcoma outcomes. J Bone Joint Surg Am. 2013;95:e151.
    1. Willeumier J, Fiocco M, Nout R, et al. High-grade soft tissue sarcomas of the extremities: surgical margins influence only local recurrence not overall survival. Int Orthop 2015;39: 935–41.
    2. Willeumier J, Fiocco M, Nout R. et al. High-grade soft tissue sarcomas of the extremities: surgical margins influence only local recurrence not overall survival. Int Orthop. 2015;39:935–41.
    1. Bonvalot S, Levy A, Terrier P, et al. Primary extremity soft tissue sarcomas: does local control impact survival? Ann Surg Oncol 2016;24:194–201.
    2. Bonvalot S, Levy A, Terrier P. et al. Primary extremity soft tissue sarcomas: does local control impact survival? Ann Surg Oncol. 2016;24:194–201.
    1. Gronchi A, Lo Vullo S, Colombo C, et al. Extremity soft tissue sarcoma in a series of patients treated at a single institution: local control directly impacts survival. Ann Surg 2010;251: 506–11.
    2. Gronchi A, Lo Vullo S, Colombo C. et al. Extremity soft tissue sarcoma in a series of patients treated at a single institution: local control directly impacts survival. Ann Surg. 2010;251:506–11.
    1. Enneking WF, Spanier SS, Malawer MM. The effect of the anatomic setting on the results of surgical procedures for soft parts sarcoma of the thigh. Cancer 1981;47:1005–22.
    2. Enneking WF, Spanier SS, Malawer MM. The effect of the anatomic setting on the results of surgical procedures for soft parts sarcoma of the thigh. Cancer. 1981;47:1005–22.
    1. Grimer RJ. On the effect of setting of a positive surgical margin in soft tissue sarcoma. Cancer 2014;120:2803–5.
    2. Grimer RJ. On the effect of setting of a positive surgical margin in soft tissue sarcoma. Cancer. 2014;120:2803–5.
    1. Rosenberg SA, Tepper J, Glatstein E, et al. The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. Ann Surg 1982;196:305–15.
    2. Rosenberg SA, Tepper J, Glatstein E. et al. The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. Ann Surg. 1982;196:305–15.
    1. Williard WC, Hajdu SI, Casper ES, Brennan MF. Comparison of amputation with limb-sparing operations for adult soft tissue sarcoma of the extremity. Ann Surg 1992;215:269–75.
    2. Williard WC, Hajdu SI, Casper ES, Brennan MF. Comparison of amputation with limb-sparing operations for adult soft tissue sarcoma of the extremity. Ann Surg. 1992;215:269–75.
    1. Reilly JJ, Goodgame JT, Jones DC, Brennan MF. DNA synthesis in rat sarcoma and liver: the effect of starvation. J Surg Res 1977;22:281–6.
    2. Reilly JJ, Goodgame JT, Jones DC, Brennan MF. DNA synthesis in rat sarcoma and liver: the effect of starvation. J Surg Res. 1977;22:281–6.
    1. Gross JL, Younes RN, Haddad FJ, et al. Soft-tissue sarcomas of the chest wall: prognostic factors. Chest 2005;127:902–8.
    2. Gross JL, Younes RN, Haddad FJ. et al. Soft-tissue sarcomas of the chest wall: prognostic factors. Chest. 2005;127:902–8.
    1. McKee MD, Liu DF, Brooks JJ, et al. The prognostic significance of margin width for extremity and trunk sarcoma. J Surg Oncol 2004;85:68–76.
    2. McKee MD, Liu DF, Brooks JJ. et al. The prognostic significance of margin width for extremity and trunk sarcoma. J Surg Oncol. 2004;85:68–76.
    1. Dickinson IC, Whitwell DJ, Battistuta D, et al. Surgical margin and its influence on survival in soft tissue sarcoma. ANZ J Surg 2006;76:104–9.
    2. Dickinson IC, Whitwell DJ, Battistuta D. et al. Surgical margin and its influence on survival in soft tissue sarcoma. ANZ J Surg. 2006;76:104–9.
    1. Kainhofer V, Smolle MA, Szkandera J, et al. The width of resection margins influences local recurrence in soft tissue sarcoma patients. Eur J Surg Oncol 2016;42:899–906.
    2. Kainhofer V, Smolle MA, Szkandera J. et al. The width of resection margins influences local recurrence in soft tissue sarcoma patients. Eur J Surg Oncol. 2016;42:899–906.
    1. Ahmad R, Jacobson A, Hornicek F, et al. The width of the surgical margin does not influence outcomes in extremity and truncal soft tissue sarcoma treated with radiotherapy. Oncologist 2016;21:1269–76.
    2. Ahmad R, Jacobson A, Hornicek F. et al. The width of the surgical margin does not influence outcomes in extremity and truncal soft tissue sarcoma treated with radiotherapy. Oncologist. 2016;21:1269–76.
    1. Harati K, Goertz O, Pieper A, et al. Soft tissue sarcomas of the extremities: surgical margins can be close as long as the resected tumor has no ink on it. Oncologist 2017;22:1400–10.
    2. Harati K, Goertz O, Pieper A. et al. Soft tissue sarcomas of the extremities: surgical margins can be close as long as the resected tumor has no ink on it. Oncologist. 2017;22:1400–10.
    1. Trovik CS, Skjeldal S, Bauer H, Rydholm A, Jebsen N. Reliability of margin assessment after surgery for extremity soft tissue sarcoma: the SSG experience. Sarcoma 2012;2012:290698.
    2. Trovik CS, Skjeldal S, Bauer H, Rydholm A, Jebsen N. Reliability of margin assessment after surgery for extremity soft tissue sarcoma: the SSG experience. Sarcoma. 2012;2012:290698.
    1. von Mehren M, Randall RL, Benjamin RS, et al. Soft tissue sarcoma, version 2.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2016;14:758–86.
    2. von Mehren M, Randall RL, Benjamin RS. et al. Soft tissue sarcoma, version 2.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2016;14:758–86.
    1. Lin PP, Guzel VB, Pisters PW, et al. Surgical management of soft tissue sarcomas of the hand and foot. Cancer 2002;95:852–61.
    2. Lin PP, Guzel VB, Pisters PW. et al. Surgical management of soft tissue sarcomas of the hand and foot. Cancer. 2002;95:852–61.
    1. Brennan MF. Lessons learned from the study of soft tissue sarcoma. Int J Surg 2013;11(Suppl 1):8–10.
    2. Brennan MF. Lessons learned from the study of soft tissue sarcoma. Int J Surg. 2013;11(Suppl 1):8–10.
    1. Stojadinovic A, Jaques DP, Leung DH, Healey JH, Brennan MF. Amputation for recurrent soft tissue sarcoma of the extremity: indications and outcome. Ann Surg Oncol 2001;8:509–18.
    2. Stojadinovic A, Jaques DP, Leung DH, Healey JH, Brennan MF. Amputation for recurrent soft tissue sarcoma of the extremity: indications and outcome. Ann Surg Oncol. 2001;8:509–18.
    1. Tanabe KK, Pollock RE, Ellis LM, et al. Influence of surgical margins on outcome in patients with preoperatively irradiated extremity soft tissue sarcomas. Cancer 1994;73:1652–9.
    2. Tanabe KK, Pollock RE, Ellis LM. et al. Influence of surgical margins on outcome in patients with preoperatively irradiated extremity soft tissue sarcomas. Cancer. 1994;73:1652–9.
    1. Williard WC, Collin C, Casper ES, Hajdu SI, Brennan MF. The changing role of amputation for soft tissue sarcoma of the extremity in adults. Surg Gynecol Obstet 1992;175:389–96.
    2. Williard WC, Collin C, Casper ES, Hajdu SI, Brennan MF. The changing role of amputation for soft tissue sarcoma of the extremity in adults. Surg Gynecol Obstet. 1992;175:389–96.

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