Factors Influencing Factors Influencing Sarcoma Referral and Sarcoma Referral and

TreatmentTreatment William G. Ward, Matthew T. Cline, Fred J. William G. Ward, Matthew T. Cline, Fred J.

Dorey*Dorey*Wake Forest University Health Sciences, Winston-Wake Forest University Health Sciences, Winston-Salem, NC, *Department of Pediatrics, USC Keck Salem, NC, *Department of Pediatrics, USC Keck

School of Medicine, Los Angeles, CASchool of Medicine, Los Angeles, CA

What Is An Unplanned What Is An Unplanned Resection?Resection?

Lack of …Lack of …Preoperative imaging Preoperative imaging modalitiesmodalities

True wide resectionTrue wide resection

Unplanned ResectionsUnplanned Resections

Difficult reresection for Difficult reresection for oncologic surgeononcologic surgeon

Increased morbidity for Increased morbidity for sarcoma patientssarcoma patientsReresectionReresectionAdditional hospital stayAdditional hospital stayHigher rate of local Higher rate of local recurrencerecurrence

Primary QuestionPrimary Question

What factors influence treatment What factors influence treatment prior to referral?prior to referral?

Insurance statusInsurance status RaceRace AgeAge Tumor sizeTumor size Bone vs. Soft-tissueBone vs. Soft-tissue

HypothesisHypothesis

Patients with insurance Patients with insurance would be more likely to have would be more likely to have

undergone an unplanned undergone an unplanned resection prior to referralresection prior to referral

Demographic InformationDemographic Information 401 Sarcoma Patients401 Sarcoma Patients 172 Bone and 229 Soft Tissue Sarcomas172 Bone and 229 Soft Tissue Sarcomas 183 Females, 218 Males 183 Females, 218 Males Average age 48 (1 to 95)Average age 48 (1 to 95)

ResultsResults Local recurrence-free survivorship = 91.9% ± Local recurrence-free survivorship = 91.9% ±

1.65%1.65% Overall survivorship = 67% ± 2.4% at 5 years. Overall survivorship = 67% ± 2.4% at 5 years.

Diagnostic InformationDiagnostic InformationSarcoma Number

Osteosarcoma 74

Malignant Fibrous Histiocytoma 56

Liposarcoma 52

Chondrosarcoma 41

Myxofibrosarcoma 31

Synovial cell Sarcoma 24

Ewing's Sarcoma 22

Other 20

Leiomyosarcoma 17

Malignant Peripheral Nerve Sheath Tumor 14

Pleomorphic Sarcoma 14

Sarcoma (unspecified) 14

Fibrosarcoma 12

Rhabdomyosarcoma 6

Epithelioid Sarcoma 4

ResultsResults

Insurance Status and Insurance Status and Unplanned ResectionUnplanned Resection

Patients on Medicaid were Patients on Medicaid were less likely have an unplanned less likely have an unplanned

resection (p=0.14)resection (p=0.14)

Insurance and Unplanned Insurance and Unplanned Resections Prior to ReferralResections Prior to Referral

InsurancInsurance Typee Type PatienPatien

tsts

Patients with Patients with unplanned unplanned

resections, N (%)resections, N (%)

p = 0.14p = 0.14

MedicaidMedicaid 1818 1 (5%)1 (5%)

CommercCommercial ial

313313 76 (24%)76 (24%)

UninsureUninsuredd

3838 10 (26%)10 (26%)

MedicareMedicare 3232 11 (34%)11 (34%)

Race and Unplanned Race and Unplanned ResectionResection

African Americans were less African Americans were less likely to have an unplanned likely to have an unplanned

resection (p=0.05)resection (p=0.05)

African Americans were not African Americans were not more likely to be uninsured or more likely to be uninsured or

on Medicaid on Medicaid

Race and Treatment

RaceRace PatientsPatients

Patients with Patients with unplanned unplanned

resections, N resections, N (%)(%)

p = 0.05p = 0.05

African African AmericansAmericans

4242 5 (12%)5 (12%)

CaucasianCaucasian 351351 90 (26%)90 (26%)

OtherOther 88 3 (37%)3 (37%)

Age and Unplanned Age and Unplanned ResectionResection

Patients under the age of 18 Patients under the age of 18 were less likely to have an were less likely to have an

unplanned resection. unplanned resection. (p=0.004) (p=0.004)

Age and TreatmentAge and Treatment

Age, yearsAge, years Number of Number of patientspatients

Patients with Patients with unplanned unplanned

resections, N resections, N (%)(%)

p = 0.004p = 0.004

<18<18 5959 5 (8%)5 (8%)

1818 342342 93 (27%)93 (27%)

Tumor Size and Tumor Size and Unplanned ResectionUnplanned Resection

Patients with tumors Patients with tumors 5cm 5cm at initial resection were more at initial resection were more likely to have an unplanned likely to have an unplanned resection (p < 0.001)resection (p < 0.001)

Unplanned Resections Based on Tumor Size

ResectionResection Tumor Tumor size, size,

5cm N5cm N

Tumor Tumor size, size,

>5cm N>5cm N

UnplanneUnplannedd

3737 3030

No No UnplanneUnplanne

dd

3232 118118p < 0.001p < 0.001

Soft Tissue or Bone Tumor Soft Tissue or Bone Tumor and Unplanned Resectionand Unplanned Resection

Patient with bone tumors Patient with bone tumors were less likely to have an were less likely to have an unplanned resection (unplanned resection (p <

0.01)

Soft Tissue or Bone Tumor Soft Tissue or Bone Tumor and Unplanned Resectionand Unplanned Resection

Tumor Tumor LocationLocation

Unplanned Unplanned ResectionResection

Soft Soft TissueTissue

68/229 68/229 (30%)(30%)

BoneBone 30/172 30/172 (17%)(17%)

p < 0.01

Logistic Regression Analysis Logistic Regression Analysis of Local Recurrence of Local Recurrence

Following ReresectionFollowing Reresection

*Multi-variant analysis taking into account tumor size.

Dependent variable = local recurrenceIndependent variable = plan vs unplanned resection

Odds ratio = 3.027*

ResectionResectionLocal Local

recurrence N recurrence N (%)(%)

p = 0.012p = 0.012

UnplannedUnplanned 14/68 (21%)14/68 (21%)

No No UnplannedUnplanned

15/161 (9%)15/161 (9%)

DiscussionDiscussion

Our impression is that most Our impression is that most unplanned resection were performed unplanned resection were performed in situations where the diagnosis of in situations where the diagnosis of malignancy was not included in the malignancy was not included in the differential diagnosis.differential diagnosis.

Evidence…unplanned resections less Evidence…unplanned resections less likely to occur with larger tumors, likely to occur with larger tumors, patients under the age of 18, and patients under the age of 18, and bone tumors.bone tumors.

Teaching PointTeaching Point Whenever treating a “suspicious” mass Whenever treating a “suspicious” mass

always include malignancy in the always include malignancy in the differential diagnosis.differential diagnosis.

Avoid unplanned resections – consider Avoid unplanned resections – consider early referral to oncologic surgeon and/or early referral to oncologic surgeon and/or appropriate preoperative imaging.appropriate preoperative imaging.

Consider preoperative biopsyConsider preoperative biopsy FNA/aspirationFNA/aspiration Transilluminate all suspected ganglionsTransilluminate all suspected ganglions

Conclusion - SummaryConclusion - Summary Those Those less likelyless likely to undergo an unplanned to undergo an unplanned

resection...resection... Patients with larger lesions, p<0.001Patients with larger lesions, p<0.001 Patients under the age of 18, p=0.004Patients under the age of 18, p=0.004 Patients with bone tumors, p<0.01Patients with bone tumors, p<0.01 African Americans, p=0.05African Americans, p=0.05 Patients on Medicaid, p=0.14Patients on Medicaid, p=0.14

Patients subjected to unplanned resections Patients subjected to unplanned resections are are three timesthree times more likely to have a local more likely to have a local recurrence following definitive re-resection.recurrence following definitive re-resection.

Thank youThank you