Long-term Oncologic Outcomes After Unplanned Soft Tissue Sarcoma Surgery: Implications for Surveillance Strategies

BACKGROUND: Unplanned excision refers to the resection of soft tissue sarcomas without appropriate preoperative imaging, histologic confirmation, or oncologic planning. Although the short-term oncologic risks of unplanned excisions are well described, data on long-term outcomes remain limited. QUESTIONS/PURPOSES: After controlling for tumor grade, clinical stage, Charlson comorbidity index (CCI), and surgical margin status, is unplanned excision independently associated with (1) worse overall survival, (2) local recurrence-free survival, and (3) metastatic disease-free survival compared with planned excision? METHODS: In this study of 1100 patient records initially identified by Current Procedural Terminology code query, 403 were identified as duplicate records, 253 were excluded for insufficient baseline data or lack of cancer center entry, and 48 were excluded for insufficient follow-up or not undergoing surgery at the institution, yielding 396 patients, 279 who underwent planned excision and 117 who underwent unplanned excision. We defined an unplanned excision as resection of a soft tissue mass performed without appropriate preoperative advanced imaging (such as MRI) or histologic tissue diagnosis (such as core needle biopsy), or when imaging and biopsy findings were misinterpreted as benign, leading to resection without oncologic planning. The mean ± SD age was similar between groups (planned excision 59 ± 17 years versus unplanned excision 56 ± 18 years); however, groups differed in sex distribution, CCI, clinical stage, and histologic subtype distribution, underscoring the importance of multivariable adjustment. Overall survival, local recurrence-free survival, and metastatic disease-free survival were compared using Kaplan-Meier analysis, log-rank testing, and multivariable Cox regression at 5-, 10-, and 15-year intervals. RESULTS: Overall survival did not differ at 5 years between patients with unplanned excisions and planned excisions (79% [95% confidence interval (CI) 68% to 87%] versus 87% [95% CI 81% to 91%]; p = 0.21), but it was lower after unplanned versus planned excision at 10 years (65% [95% CI 49% to 77%] versus 81% [95% CI 71% to 87%]; p < 0.01) and 15 years (43% [95% CI 11% to 73%] versus 74% [95% CI 58% to 85%]; p = 0.02; log-rank, p = 0.02). Metastatic disease-free survival was lower after unplanned excision at 5, 10, and 15 years, and local recurrence-free survival was worse at 10 years (unplanned excision 67% [95% CI 47% to 81%] versus planned excision 69% [95% CI 57% to 79%]; p = 0.047) and 15 years (40% [95% CI 12% to 67%] versus 69% [95% CI 57% to 79%]; p = 0.01). On multivariable analysis, unplanned excisions independently were associated with worse overall survival (HR 1.77 [95% CI 1.06 to 2.97]; p = 0.03) and local recurrence-free survival (HR 1.74 [95% CI 1.10 to 2.75]; p = 0.02). CONCLUSION: Unplanned excision of soft tissue sarcoma is associated with worse long-term overall, local recurrence-free, and metastatic disease-free survival, with differences emerging after 10 years. These findings suggest a potential role for extended oncologic surveillance beyond 5 years, particularly in patients at high risk. Further prospective studies are needed to define appropriate surveillance strategies and determine whether earlier detection improves outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.