Noria S, Davis A, Kandel R, Levesque J, O'Sullivan B, Wunder J, Bell R
University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Ontario, Canada.
J Bone Joint Surg Am. 1996 May;78(5):650-5. doi: 10.2106/00004623-199605000-00003.
Sixty-five patients who had been referred to our unit for additional management after an unplanned excision of a soft-tissue sarcoma of an extremity at another institution were studied retrospectively to determine the prevalence of residual tumor and to identify factors that predict which patients will have a tumor following such an excision. Unplanned excision was defined as excisional biopsy or unplanned resection of the lesion without benefit of preoperative imaging and without regard for the necessity to resect the lesion with a margin of normal tissue. In each patient, histological evaluation of the specimen removed at the unplanned excision had demonstrated positive resection margins, but postoperative physical examination on our unit revealed no gross evidence of residual tumor and no tumor was identified on cross-sectional imaging of the local site. Patients who had evidence of residual disease on physical examination or on imaging were thought to have definite evidence of sarcoma at the site of the operative wound and were therefore excluded from the study. After multidisciplinary consultation, all patients had a repeat resection at our cancer center. Extensive pathological sampling of the specimen from this second procedure was carried out, with sections obtained at mean intervals of 1.2 +/- 0.7 centimeters. Nodules initially thought to indicate disease were identified grossly in twenty-seven (42 percent) of the sixty-five patients, but histological evaluation confirmed the presence of tumor in only sixteen (59 percent). Histological evidence of sarcoma was identified in seven additional patients in whom gross nodules were not apparent in the specimen. Thus, sarcoma was identified in a total of twenty-three (35 percent) of the sixty-five patients. The mean duration of follow-up was forty-six months (range, twenty-four to eighty months; median, thirty-nine months). The margins of the second resection were positive in nine (39 percent) of the twenty-three patients who had residual sarcoma. Five (22 percent) of the twenty-three had a local recurrence. Four of the five patients who had a local recurrence had positive margins on repeat resection. This rate of local recurrence (five of twenty-three patients) was significantly higher than that in the remainder of our patients who had a soft-tissue sarcoma of an extremity (sixteen [7 percent] of 227) (p = 0.03). There was no association between the detection of sarcoma at the second procedure and the initial size or grade of the tumor, the use of irradiation preoperatively, or the interval between the initial, unplanned excision and referral to our cancer center. These data indicate that it is not possible to predict which patients will have residual tumor at the site of the operative wound. Therefore, it is prudent to advise repeat excision for all patients who have had an unplanned excision of a soft-tissue sarcoma of an extremity. Unplanned excision complicates decision-making in the treatment of this disease and should be avoided.
65例患者因在其他机构意外切除肢体软组织肉瘤后被转至我院接受进一步治疗，我们对其进行了回顾性研究，以确定残留肿瘤的发生率，并找出能够预测哪些患者在这种切除术后会残留肿瘤的因素。意外切除被定义为切除活检或对病变进行意外切除，术前未进行影像学检查，且未考虑切除病变时需保留正常组织边缘。在每例患者中，意外切除时所取标本的组织学评估显示切缘阳性，但我院的术后体格检查未发现残留肿瘤的明显证据，且局部横断面影像学检查也未发现肿瘤。体格检查或影像学检查有残留疾病证据的患者被认为手术伤口部位有明确的肉瘤证据，因此被排除在研究之外。经过多学科会诊，所有患者均在我院癌症中心接受了再次切除。对第二次手术标本进行了广泛的病理采样，切片平均间隔为1.2±0.7厘米。在65例患者中的27例（42%）大体上发现了最初被认为提示疾病的结节，但组织学评估仅证实其中16例（59%）存在肿瘤。在另外7例标本中未发现明显大体结节的患者中，组织学检查发现了肉瘤证据。因此，65例患者中共有23例（35%）被确诊为肉瘤。平均随访时间为46个月（范围为24至80个月；中位数为39个月）。在23例残留肉瘤的患者中，9例（39%）第二次切除的切缘为阳性。23例中有5例（22%）发生了局部复发。发生局部复发的5例患者中有4例再次切除时切缘为阳性。这种局部复发率（23例患者中的5例）显著高于我院其余肢体软组织肉瘤患者（227例中的16例[7%]）（p = 0.03）。第二次手术时肉瘤的检出与肿瘤的初始大小或分级、术前是否使用放疗或首次意外切除与转诊至我院癌症中心之间的间隔时间均无关联。这些数据表明，无法预测哪些患者手术伤口部位会残留肿瘤。因此，对于所有意外切除肢体软组织肉瘤的患者，建议再次切除是谨慎的做法。意外切除使这种疾病的治疗决策变得复杂，应予以避免。
