Unplanned Resection of Sarcoma.3
Unplanned Resection of Sarcoma.3
Unplanned Resection of Sarcoma.3
Abstract
Nicholas S. Tedesco, DO Unplanned resection is a common problem in the management of
Robert M. Henshaw, MD sarcoma. Because sarcomas are so rare, they may be misdiagnosed
initially as more common benign lesions. When the treating surgeon is
unaware of or does not adhere to proper surgical principles of
orthopaedic oncology, an intralesional procedure may be performed
without the requisite preoperative imaging, staging, or wide resection
margins for optimal management of sarcoma. Studies show that
oncologic outcomes after unplanned resections are mixed; however,
surgical outcomes drastically deteriorate. Failure to adhere to oncologic
principles accounts for increased morbidity and amputation rates with
re-resection. No diagnostic modality has been proven to accurately
predict residual disease in the resection bed following unplanned
resection. Thus, repeat surgery with or without adjuvant treatment is
usually offered to these patients, thereby adding considerable cost and
morbidity. Medical malpractice litigation associated with unplanned
sarcoma resection is common, with delayed diagnosis and unnecessary
amputation most often cited in cases decided in favor of the plaintiff.
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Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Unplanned Resection of Sarcoma
Figure 1 Figure 2
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Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD
Osseous Sarcoma tion in the unplanned resection group, Jeon et al7 reported similar findings
Oncologic outcomes following resec- but found no difference between the in a study of 25 cases of unplanned
tion of osseous sarcoma are worse for two groups with regard to 5-year resection of several types of osseous
patients who have undergone an event-free rates or overall survival sarcoma. They found that, with
unplanned resection. In the literature, rates. Interestingly, the authors found unplanned resection, the local con-
planned resections have better surgi- that, in 20 cases, the amount of tumor trol rates were worse and the rates of
cal outcomes and limb salvage rates. left in the re-resected specimen was limb salvage were lower than those
Wang et al9 compared the outcomes too small to evaluate chemotherapy- associated with planned primary
of 16 patients with osteosarcoma induced tumor necrosis. This results in resection. They found that oncologic
who underwent unplanned resection a treatment dilemma because assessing and surgical outcomes of unplanned
with those of 134 patients who had tumor necrosis is important in deter- resection were as poor as those
planned primary resections of osteo- mining subsequent chemotherapy and of pathologic fracture through an
sarcoma. The authors found that, prognosticating outcomes. osseous sarcoma.
although patients with an unplanned Picci et al5 studied risk factors for
procedure had smaller mean tumor local recurrence of osteosarcoma in
volumes than did those with a planned the extremities after limb salvage Soft-tissue Sarcoma
primary resection, the local recurrence resection in 23 cases. The authors re- Increased morbidity and worse sur-
rate was higher, there was a shorter ported two recurrences at the site gical outcomes are associated with
mean time to local recurrence, and of the unresected biopsy tract. Five unplanned resection of soft-tissue
there was a shorter mean time to occurred secondary to unplanned sarcoma; however, the literature on
metastases. The limb salvage rate was resection or inappropriate biopsy the oncologic outcomes of this type of
considerably lower in the unplanned techniques, which resulted in sub- sarcoma is much more inconsistent
resection group.9 Ayerza et al6 re- stantial tumor contamination of the than the literature on outcomes of
ported similar findings; compared surrounding tissues. These findings osseous sarcoma (Figure 4). Noria
with planned resection, unplanned stress the importance of planning et al2 were the first to compare the
resection of osteosarcoma was asso- biopsies such that they fall within the outcomes of a cohort of planned and
ciated with an increased risk of local planned plane of resection and are unplanned resections. They found
recurrence, decreased 10-year survival, performed by an experienced team that local recurrence was consider-
and increased rates of amputation. using appropriate techniques. In ably higher in the unplanned resec-
Kim et al8 compared 55 patients addition, the authors noted that local tion group because of the increased
who had unplanned osteosarcoma recurrence represents a risk factor difficulty in obtaining wide surgical
resections with 40 patients who had for amputation, further increasing margins in re-resections secondary to
planned resections. The authors re- amputation rates following unplanned extensive tumor contamination of
ported an increased rate of amputa- resection. the prior surgical bed. Other studies
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Unplanned Resection of Sarcoma
Table 2 Figure 4
Reported Rates of Residual Sarcoma Found Histologically in Re-resected
Specimens After Unplanned Resection of Soft-tissue Sarcoma
Number of
Unplanned Cases Tumor-positive
Resections Re-resected Re-resected
Study Referred (%) Specimens (%)
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Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD
Figure 5
Axial CT scans of the chest demonstrating the rapid progression of pulmonary metastatic disease at initial presentation to
the authors’ institution (A), 1 month later (B), and 2 months after initial presentation (C), in the patient shown in Figures 2
through 4. She ultimately succumbed to respiratory failure ,3 months after initial presentation to the authors’ institution.
Because of the refractory infection, the patient was never able to begin systemic chemotherapy and was not ambulatory after
the anterior compartment resection.
underwent planned resection (88% wide margins, increased wound com- 5-year event-free survival, and 5-year
versus 70%, respectively). These plications, or increased amputation overall survival rates appear to be no
spurious findings are likely attribut- rates in patients who undergo re- different from those of patients who
able to an unrecognized confounder resection.14,16,19-22,24,25,37 In almost undergo planned resection. How-
not accounted for in their study. all instances, the poorer outcomes are ever, the probability of obtaining
The treatment of choice for most caused by poor resection technique negative surgical margins in the
patients is wide re-resection of the during the unplanned procedure (eg, re-resected specimen decreases dras-
surgical bed, with the assumption transverse incisions, wide mattress tically, often requiring larger or
that residual tumor cells are present. suture, hematoma formation, drains multiple surgeries with considerably
Some patients may also receive placed not in line with incision, more morbidity.17 In a study of
radiotherapy and/or chemotherapy, adjacent compartment/joint or neu- patients with superficial tumors,
depending on the margin status rovascular contamination), and not Rougraff et al18 found that these
and tumor stage at the time of re- by intrinsic properties of the pre- patients have the highest risk of
resection.1,2,10-13,15,18,19,23,29,32,38,39 senting tumor. Therefore, the poor unplanned resection, and local
Kepka et al15 found that the use of outcomes may have been obviated tumor control cannot be as reliably
radiotherapy alone for local tumor by an initial appropriately planned obtained in this subset of patients
control in a patient who underwent resection. compared with those who undergo
unplanned resection can lead to high After an unplanned resection has planned resection. Furthermore, in
complication rates because of the been performed, treatment recom- patients with tumors $4 cm, disease-
field size and the amount of radia- mendations and expectations commu- free survival rates are markedly
tion required. Radiotherapy alone is nicated to the patient before the referral worse than those in matched patients
also less effective than repeat surgery have been shown to be in concert with who underwent planned excision
with adjuvant radiotherapy for local the final orthopaedic oncologist’s rec- (69% versus 88%, respectively).
control. Thus, radiotherapy alone ommendations only 45% of the time,
should be reserved for patients with leading to considerable patient anxiety
a surgical contraindication or an and confusion.21 Thus, once the Prevention
unresectable tumor.15,30 decision has been made to refer a
Although the literature is mixed on patient after an unplanned resection, Although some authors recommend
oncologic outcomes, the consensus is treatment recommendations should be referral to an orthopaedic oncologist
that surgical outcomes are far worse in deferred to the treating musculoskel- before intervention for any bone
unplanned resections than in planned etal oncologist. lesion5 or soft-tissue mass $3 cm,18
resections. Several studies have con- Soft-tissue sarcoma in certain sub- this is not always practical or neces-
firmed a greater need for flap cover- populations has been studied with sarily indicated. Appropriate workup
age, worse functional scores, the regard to unplanned resection. In and adherence to oncological surgical
need for multiple surgeries to obtain pediatric patients, local recurrence, principles can allow the community
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Unplanned Resection of Sarcoma
physician to address minimally sus- in the plane of the planned definitive lesion has an invisible margin on plain
picious lesions while obviating many resection is indicated to obtain tissue radiography, and in cases of joint ar-
of the adverse outcomes associated for diagnosis before any treatment is throplasty when a missed lesion is
with unplanned resection. initiated. If the approach and resec- encountered intraoperatively. Using
Workup of any extremity mass tion plane are indeterminate, the the same principles outlined earlier, a
begins with an accurate history and treating physician should consult a biopsy should be performed and the
physical examination. Laboratory musculoskeletal oncologist before tissue should be sent for analysis of the
tests can be ordered when indicated. the biopsy is performed. frozen section to determine the diag-
Standard orthogonal radiography For a lesion that requires open nosis before proceeding with fixation
can be useful to rule out other causes biopsy because needle biopsy is not or device implantation. A potential
of swelling or pain, characterize in- feasible or has been nondiagnostic, a primary malignancy should never be
tralesional matrix or calcification, longitudinal incision should be made reamed, and tissue obtained from
and help determine bony involve- along the long axis of the extremity. reaming is often insufficient for diag-
ment.4,34 If any matrix is present or Meticulous hemostasis should be ob- nosis. Reaming spreads the tumor
suspected, CT is the test of choice to tained with liberal use of cautery and throughout the entire bone and
characterize it further and to evalu- postoperative compressive dressings. introduces tumor cells into the
ate bony structure and cortical To minimize tissue contamination, the bloodstream, increasing metastatic
involvement/integrity. clinician should avoid crossing multi- burden. If frozen-section analysis is
The standard of care for evaluating ple compartments or exposing neu- indeterminate or suggests malignancy,
the extent of a lesion, characterizing rovascular structures. A sample of the a permanent specimen should be ob-
tumor properties when no matrix is lesion is obtained after a bony window tained, and the wound should be
apparent on CT or radiography, and is made (for an osseous lesion) or the closed, thereby suspending any fur-
denoting the presence or absence of pseudocapsule is entered (for a soft- ther intervention until diagnosis is
necrosis or hemorrhage within the tissue lesion) and should be sent to definitive or the patient can be trans-
lesion or bone is MRI spin-echo pathology for frozen-section analysis ferred to a facility with orthopaedic
T1- and T2-weighted sequences, with before additional surgery is per- oncology coverage. Traction or
and without contrast, or CT with formed. If the frozen section is con- extremity splints can be safely used for
intravenous contrast (when MRI is sistent with the suspected benign interim management of the fracture or
contraindicated) of the entire bone or pathology, curettage or excision can a partially resected joint after an
extremity region. Tumor MRI pro- be safely performed for a bone lesion aborted arthroplasty while definitive
tocol should avoid the use of non- and a soft-tissue lesion, respectively. If diagnosis is pending.
diagnostic gradient-echo sequences (eg, the frozen section is indeterminate or
proton density-weighted or BLADE consistent with malignancy, an addi-
[Siemens Healthcare] sequences) often tional portion of the lesion should be Financial and Medicolegal
used in the extremities. MRI can be sampled and sent for permanent sec- Considerations
used to differentiate benign lipomas tion. Then, any bone window made
and simple cysts from other tumors; the should be plugged with polymethyl To date, only one study has examined
former can be treated definitively methacrylate cement, and narrow the financial burden of unplanned
without further workup, and the latter multilayer closure should be per- soft-tissue sarcoma resection in terms
should be biopsied in the intended formed. If the surgical field is large of billable cost. Alamanda et al26
plane of resection, or the patient should enough to necessitate a drain, the found that professional charges for
be referred to an orthopaedic oncolo- drain should exit the skin in line with re-treating a patient who underwent
gist for further evaluation.1,2,12,18,24,25 the incision such that it can be resected unplanned resection increased by
However, findings from an MRI en bloc with the biopsy tract at defin- 33%, and the overall cost increased
that was not interpreted by a itive resection. Soft-tissue lesions ,3 by 11%, compared with the cost of
musculoskeletal-trained radiologist cm that are superficial to the mus- treating a patient who underwent
should be used with caution because cular fascia can undergo excisional a primary planned resection of a
up to 76% of radiology reports of biopsy with a wide cuff of normal sarcoma. In addition, when this cost
unplanned resections do not include tissue using these same priniciples.18 is added to the cost already accrued
sarcoma in the differential diagnosis.21 Additional oncologic principles in the primary unplanned resection,
If the diagnosis is still in question should be kept in mind for fractures the overall cost of treatment is nearly
after advanced imaging is performed, when the underlying lesion was double the cost of definitive treat-
open or image-guided needle biopsy missed or misdiagnosed, when the ment with a planned resection.
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD
Figure 6
Bar graph demonstrating the average indemnity payments for general and sarcoma care provided by several specialties.
The blue bars represent the 2012 mean general indemnity payment within a designated specialty. The red bars represent
the mean sarcoma indemnity payment within the same specialty. (Adapted with permission from Mesko NW, Mesko JL,
Gaffney LM, Halpern JL, Schwartz HS, Holt GE: Medical malpractice and sarcoma care: A thirty-year review of case
resolutions, inciting factors, and at risk physician specialties surrounding a rare diagnosis. J Surg Oncol 2014;110[8]:919-
929.)
Although anecdotal reports of largest percentage (up to 70%) of of the average settlement amount
medical malpractice claims against unplanned resection referrals overall, ($1.4 million). The greatest numbers
physicians involved in unplanned followed by orthopaedic surgeons, of claims were filed against primary
resection of sarcoma are abundant, plastic surgeons, urologists, podia- care specialties (34%), orthopaedic
there is a paucity of literature that trists, vascular surgeons, primary care surgeons (23%), and radiologists
directly addresses this topic. Insurance providers, and dermatologists.21,24 (12%). However, plaintiff awards
coverage or distance from a tertiary This highlights the importance of the were $4.1 million in cases involving
center with an orthopaedic oncologist need for education on appropriate a defendant who was an orthopaedic
does not seem to be a factor in the type extremity tumor workup and man- surgeon compared with only
or number of patients being referred agement in specialties other than $1.5 million and $1.4 million for
after unplanned sarcoma resection.27 orthopaedics. general practitioners and radiolo-
However, rates of recurrence are Mesko et al40 recently reviewed gists, respectively. In fact, average
lower in patients referred from ter- 216 medicolegal cases on sarcoma- indemnity payments for sarcoma-
tiary centers after unplanned resec- related medical malpractice from related medical malpractice were
tion than in those referred from 1980 to 2012. Although one third of higher than those for general claims
nontertiary centers, despite the ten- the cases reviewed involved confi- within all specialties, but these pay-
dency of tertiary referral centers to dential awards, two thirds were ments were 17.3 times higher for
refer patients with larger and higher- disclosed publicly. Of those dis- orthopaedic surgeons, with a higher
grade tumors.11 This may be ex- closed, 57% of cases favored the prevalence of verdicts favoring
plained by the increased experience plaintiff, with mean indemnity pay- the plaintiff (Figure 6). Delay in
with tumor resections at larger ments of $2.3 million (adjusted to diagnosis (81%) and unnecessary
medical centers, leading to a more 2012 US dollar amounts). The amputation (11%) accounted for the
oncologically sound initial resection. average jury verdict award amount most complaints, with wrongful
General surgeons account for the ($3.9 million) was almost triple that death cited in 39% of cases.
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Unplanned Resection of Sarcoma
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Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD
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