Lewis J J, Leung D, Espat J, Woodruff J M, Brennan M F
Departments of Surgery, Biostatistics, and Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Ann Surg. 2000 May;231(5):655-63. doi: 10.1097/00000658-200005000-00005.
To determine whether reresection affects survival in patients with inadequately resected, primary extremity soft tissue sarcoma. This study correlates reresection with local recurrence-free survival, metastasis-free survival, and disease-free survival.
Soft tissue sarcomas are rare neoplasms, with an incidence of approximately 6,000 per year in the United States. Because these tumors are rare and benign soft tissue tumors are common, many are initially thought to be benign and are excised without wide margins.
Patients who underwent treatment for primary tumors from July 1982 to June 1999 at a single institution were the subject of study. Two groups of patients were analyzed: those who underwent one definitive resection (one operation) and those whose tumors were previously resected and who were then referred for subsequent reresection (two operations). Patients were given adjuvant radiation or chemotherapy according to the standard of care.
Of 1,092 patients with primary extremity soft tissue sarcoma underwent resection, 685 underwent definitive radical resection and 407 underwent reresection after undergoing excisional resection elsewhere. Median follow-up was 4.8 years. The 5-year disease-free survival rate of the definitive resection (one operation) group was 70%; that of the reresection (two operations) group was 88%. On multivariate analysis, reresection was adjusted and controlled for age, grade, depth, size, histology, and margins. Reresection remained a significant predictor of improved disease-free survival, even after these adjustments. To determine whether this difference was stage- or referral-biased, the patient population was divided by AJCC stage. In all stages there was a trend toward improved outcome; this was most marked for those with stage III disease (>5 cm, high-grade, and deep).
Patients with extremity soft tissue sarcoma who undergo reresection with two "primary" operations have an improved survival compared with those who undergo one operation. The most plausible explanation, referral and selection bias, is questionable given the significance of reresection as a variable after adjusting for stage and other risk factors. This suggests that where indicated and possible, reresection should be liberally applied in patients with primary extremity soft tissue sarcoma.
确定再次手术对初次手术切除不彻底的肢体原发性软组织肉瘤患者的生存情况是否有影响。本研究将再次手术与局部无复发生存率、无转移生存率及无病生存率进行关联分析。
软组织肉瘤是罕见肿瘤，在美国每年发病率约为6000例。由于这些肿瘤罕见而良性软组织肿瘤常见，许多最初被认为是良性的，在切除时未保证足够的切缘。
研究对象为1982年7月至1999年6月在单一机构接受原发性肿瘤治疗的患者。分析两组患者：一组接受一次根治性切除（一次手术），另一组肿瘤先前已切除，随后转诊接受再次切除（两次手术）。患者根据护理标准接受辅助放疗或化疗。
1092例接受切除的肢体原发性软组织肉瘤患者中，685例行根治性彻底切除，407例在其他地方接受切除术后接受再次切除。中位随访时间为4.8年。根治性切除（一次手术）组的5年无病生存率为70%；再次切除（两次手术）组为88%。多因素分析时，对年龄、分级、深度、大小、组织学及切缘等因素进行了调整和控制。即使进行了这些调整，再次手术仍是无病生存率改善的显著预测因素。为确定这种差异是否存在分期或转诊偏倚，将患者人群按美国癌症联合委员会（AJCC）分期进行划分。在所有分期中均有预后改善的趋势；在Ⅲ期疾病（>5cm、高级别且位于深部）患者中最为明显。
与接受一次手术的患者相比，接受两次“原发性”手术再次切除的肢体软组织肉瘤患者生存率有所提高。最合理的解释，即转诊和选择偏倚，在调整分期和其他风险因素后再次手术作为一个变量具有显著意义的情况下受到质疑。这表明在有指征且可行的情况下，应在肢体原发性软组织肉瘤患者中广泛应用再次手术。
