the financial burden of reexcising incompletely excised soft tissue sarcomas: a cost analysis

ORIGINAL ARTICLE – HEALTHCARE POLICY AND OUTCOMES

The Financial Burden of Reexcising Incompletely Excised SoftTissue Sarcomas: A Cost Analysis

Vignesh K. Alamanda, BS1, Gadini O. Delisca, BS1, Shannon L. Mathis, PhD1, Kristin R. Archer, PhD, DPT1,

Jesse M. Ehrenfeld, MD, MPH2, Mark W. Miller, MHSA, MS1, Kelly C. Homlar, MD3, Jennifer L. Halpern, MD1,

Herbert S. Schwartz, MD1, and Ginger E. Holt, MD1

1Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN; 2Department of

Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; 3Department of Orthopaedic Oncology, Medical

College of Georgia, Augusta, GA

ABSTRACT

Background. Although survival outcomes have been

evaluated between those undergoing a planned primary

excision and those undergoing a reexcision following an

unplanned resection, the financial implications associated

with a reexcision have yet to be elucidated.

Methods. A query for financial data (professional, tech-

nical, indirect charges) for soft tissue sarcoma excisions

from 2005 to 2008 was performed. A total of 304 patients

(200 primary excisions and 104 reexcisions) were identi-

fied. Wilcoxon rank sum tests and v2 or Fisher’s exact tests

were used to compare differences in demographics and

tumor characteristics. Multivariable linear regression

analyses were performed with bootstrapping techniques.

Results. The average professional charge for a primary

excision was $9,694 and $12,896 for a reexcision (p \ .001).

After adjusting for tumor size, American Society of Anes-

thesiologists status, grade, and site, patients undergoing

reexcision saw an increase of $3,699 in professional charges

more than those with a primary excision (p \ .001).

Although every 1-cm increase in size of the tumor results in

an increase of $148 for a primary excision (p = .006), size

was not an independent factor in affecting reexcision char-

ges. The grade of the tumor was positively associated with

professional charges of both groups such that higher-grade

tumors resulted in higher charges compared to lower-grade

tumors (p \ .05).

Conclusions. Reexcision of an incompletely excised sar-

coma results in significantly higher professional charges

when compared to a single, planned complete excision.

Additionally, when the cost of the primary unplanned

surgery is considered, the financial burden nearly doubles.

Soft tissue sarcomas (STS) are rare, with an incidence of

about 1 in 100,000.1,2 As such, soft tissue masses are

commonly assumed to be benign and are excised without

any preoperative imaging or biopsy. When pathology

unexpectedly reveals sarcoma, the result is often incomplete

excision. Additionally, these procedures may be performed

using local anesthetic, nonextensile incisions and without

meticulous hemostasis, resulting in not only residual tumor,

but also a large area of potential contamination.3,4 Thus,

reexcision requires a much larger resection in order to

obtain adequate margins. This often necessitates complex

closure or flap coverage, requiring the services of a plastic

surgeon. Studies have also shown that patients requiring

reexcision experience a higher incidence of wound com-

plications and longer recovery times.5–7 Thus, although

evidence has shown no difference in overall survival after

reexcision, there is certainly additional morbidity over and

above the known increased rate of local recurrence.

In addition to undergoing a second procedure, the added

complexity of the reexcision translates into increased cost to

the patient. However, the precise financial implications that

the definitive surgery of a reexcision result in as compared to

a primary, planned excision has yet to be determined. In this

study, we sought to determine those financial implications

and additionally to report the various tumor-related elements

that influence the charges billed for performing a definitive

surgery for both a planned excision and for a reexcision.

� Society of Surgical Oncology 2013

First Received: 7 March 2013;

Published Online: 30 April 2013

G. E. Holt, MD

e-mail: [email protected]

Ann Surg Oncol (2013) 20:2808–2814

DOI 10.1245/s10434-013-2995-5

METHODS

We conducted a retrospective cohort study at a major sar-

coma center to evaluate the financial implications related to

reexcision of incompletely excised sarcomas as compared to

single, planned complete excisions. After receipt of institu-

tional review board approval, all patients who underwent

surgical resection of extremity STS at our center between June

2006 and December 2008 (n = 304) were identified and

considered for the study. Patients were excluded if they were

younger than 18 years of age, lacked adequate medical

records, or had a histologic subtype considered to be a bor-

derline malignancy (dermatofibrosarcoma protuberans).8 Of

these 304 patients, 200 underwent a primary excision, and the

remaining 104 underwent a reexcision.

Patient demographics and tumor characteristics were

collected from a retrospective review of medical records.

Financial data including provider charges (charges billed

by surgeons), technical charges (supplies, intraoperative

imaging, and operative staff charges), and indirect charges

(other miscellaneous charges) for both primary excisions

and reexcisions were obtained from the hospital’s billing

department. These three charge categories were selected

because they are the most direct representation of fee for

service. Other categories had too many bundled variables

and less accurately depicted actual charges.

These charges accounted for both the charges of the

definitive surgery and related surgical procedures, includ-

ing such charges pertaining to open biopsies, charges billed

by other services (i.e., plastic surgery), and wound

debridement issues related to the definitive surgery. Patient

age at the time of surgery, sex, type of insurance, and race

were recorded, as were tumor characteristics, including site

(upper or lower extremity), histologic grade (low, inter-

mediate, or high), size, depth (superficial or deep), and

histologic subtype. Patients were staged according to the

guidelines recommended by the American Joint Committee

on Cancer.9 Additional characteristics such as American

Society of Anesthesiologist (ASA) class at the time of

surgery and number of postoperative clinic visits were

collected for both groups. During this study period, Current

Procedural Terminology (CPT) codes did not distinguish

between tumors of various sizes. In 2010, after the end of

this study period (2008), CPT codes were revised allowing

distinction on the basis of size: less than or more than

1.5 cm in the upper extremity, and less than or more than

5 cm in the lower extremity.

Wilcoxon rank sum and v2 or Fisher’s exact tests were used

to compare patient demographics and clinical characteristics

of the primary excision versus reexcision groups. Separate

Wilcoxon rank sum tests were used to compare differences

between type of excision and indirect, professional, and

technical charges. Bivariate differences that were significant

at p \ .05 were further analyzed by multivariable linear

regression analyses with bootstrapping techniques. Demo-

graphic and clinical characteristics that were significantly

associated with charges at p \ .10 in bivariate analyses were

also entered into the multivariable linear regression models.

Stata statistical software, version 11.0 (StataCorp, College

Station, TX, USA) was used to analyze the data. The signifi-

cance level was set at p \ .05.

RESULTS

A total of 304 patients met our study criteria with 200

undergoing a single complete excision and 104 a reexci-

sion. Patient demographics and tumor characteristics for

each of the two groups are summarized in Table 1. Sig-

nificant differences between the two groups included

gender (larger percentage of men in the single excision

group, p = .04), tumor grade (larger percentage of high-

grade tumors in the single excision group, p = .001),

tumor size (average size 13.1 cm in the single excision

group compared to 7.1 cm in the reexcision group,

p \ .001), tumor depth (larger percentage of deep tumors

in the single excision group, p \ .001), stage (larger per-

centage of higher-stage tumors in the single excision group,

p \ .001), histology type (p = .01), and the number of

intraoperative consults made for each group (higher num-

ber of consults in the reexcision group, p \ .001).

Reexcision Incurs Increased Charges Compared to

Primary Excisions

Three charge categories were analyzed and compared

between the two groups: professional, technical, and indirect

charges. A significant difference was found in professional

charges (p \ .001). Patients, on average, were charged

$9,694 for a primary excision and $12,896 for a reexcision.

This results in a difference of $3,202, translating to a 33 %

increase in professional charges for a reexcision (Table 2).

There were no significant differences in technical and

indirect charges between the two groups. On average,

patients undergoing a primary excision were charged

$22,596 and $7,942 in technical and indirect charges,

respectively. Similarly, patients undergoing a reexcision

were charged $23,071 and $8,803, respectively. All of

these values represent charges associated with the defini-

tive surgery for both groups (i.e., the initial costs of the

incomplete resection of patients undergoing reexcision

were not considered).

Combining the professional, technical, and indirect

charges reveals that on average, patients undergoing primary

excision were charged $40,231 and those undergoing reex-

cision were charged $44,770. This represents a difference of

Increased Cost of Reexcision of STS 2809

TABLE 1 Demographics and tumor characteristics of 304 patients undergoing primary excision versus reexcision

Characteristic Primary excision (n = 200) Reexcision (n = 104) p

Age, years 55.9 ± 16.4 57.4 ± 17.2 .30

Sex .04*

Male 111 (55.5) 45 (43.3)

Female 89 (44.5) 59 (56.7)

Race .25

White 179 (89.5) 98 (94.2)

African American 10 (5.0) 2 (1.9)

Other 11 (5.5) 4 (3.9)

Insurance .44

Commercial 50 (48.1) 107 (53.5)

Medicare 42 (40.4) 53 (26.5)

TN care 4 (3.9) 7 (3.5)

Out-of-state medicaid 0 2 (1.0)

Self-pay 1 (1.0) 16 (8.0)

Commercial managed care 7 (6.7) 15 (7.0)

ASA .29

1 5 (2.5) 7 (6.7)

2 128 (64.0) 55 (52.9)

3 61 (30.5) 40 (38.5)

4 6 (3.0) 2 (1.9)

Excision site .49

Upper extremity 43 (21.5) 26 (25.0)

Lower extremity 157 (78.5) 78 (75.0)

Tumor grade .001*

Low grade 41 (20.5) 14 (13.5)

Intermediate grade 13 (6.5) 22 (21.2)

High grade 146 (73.0) 68 (65.4)

Tumor size, cm 13.1 ± 6.9 7.1 ± 4.9 \.001*

Depth \.001*

Superficial 16 (8.0) 39 (37.5)

Deep 184 (92.0) 65 (62.5)

Stage \.001*

I 42 (21.0) 25 (24.0)

II 15 (7.5) 32 (30.8)

III 70 (35.2) 19 (18.3)

IV 73 (36.5) 28 (26.9)

Histology type .01*

Fibrosarcoma 7 (3.5) 6 (5.8)

Leiomyosarcoma 20 (10.0) 12 (11.5)

Liposarcoma 67 (33.5) 7 (6.7)

MPNST 5 (2.5) 3 (2.9)

MFH 71 (35.5) 46 (44.2)

Synovial sarcoma 11 (5.5) 13 (12.5)

Vascular sarcoma 4 (2.0) 5 (4.8)

Rhabdomyosarcoma 2 (1.0) 0 (0)

Surgical consults \.001*

Total 5 14

Plastic surgery 4 13

2810 V. K. Alamanda et al.

$4,539, or an 11.3 % charge increase in total charges for a

reexcision.

Large, High-Grade, and Lower Extremity Tumors are

Associated with an Increase in Professional Charges

Bivariate linear regression with bootstrapping was used

to analyze the association between patient demographics,

clinical characteristics, and professional cost. Statistically

significant variables at p \ .10 were entered into a multi-

variable linear regression analysis with bootstrapping

(Table 3). Excision type, size, grade, and site remained

significantly associated with professional charges. When

compared to the primary excision, a reexcision costs

$3,699 more in professional charges (p \ .001). As tumor

sizes increases by 1 cm, professional charges increase by

$119 (p = .001). When compared to a low/intermediate

grade tumor, a high-grade tumor results in $2,381 more in

professional charges (p = .001). When compared to an

upper extremity tumor, excision of a lower extremity tumor

results in $2,111 more in professional charges (p = .001).

Multivariable linear regression analyses of patient and

tumor characteristics and professional charges were per-

formed separately for primary excision (Table 4) and

reexcision (Table 5). For primary excision, as size

increased by 1 cm, professional charges increased by $148.

Size was not a factor in influencing professional charges of

reexcisions. Primary excision of high-grade tumors results

in $1,654 increase in professional charges compared to

low/intermediate-grade tumors (p = .04), whereas reexci-

sion of a high-grade tumor results in $3,262 increase in

professional charges when compared to low/intermediate-

grade tumors (p = .03). Whereas site was not noted to

affect professional charges in primary excisions, reexcision

of a lower extremity sarcoma results in $3,240 increase in

professional charges when compared to upper extremity

sarcomas (p = .002).

DISCUSSION

Given the rarity of STSs, they are frequently assumed to

be benign and are excised without appropriate preoperative

TABLE 2 Bivariate differences in charges between primary and reexcision

Charge Primary excision (n = 200) Secondary excision (n = 104) p

Indirect 7,942.00 (6,367.30) 8,803.40 (7,376.20) .24

Professional 9,693.70 (7,311.50) 12,895.60 (10,443.30) \.001*

Technical 22,595.50 (15,546.40) 23,070.90 (22,113.00) .28

Results for charge variables are shown as median (interquartile range). Data were analyzed by the Wilcoxon rank sum test

* Statistically significant at .05

TABLE 3 Multivariable analysis of professional charges for selected variables

Characteristic B p

Excision: secondary versus primary (ref.) 3,699.30 \.001

Size 119.10 .001

ASA: 3, 4 versus 1, 2 (ref.) 1,172.70 .05

Grade: high versus low/intermediate (ref.) 2,381.40 .001

Site: lower versus upper (ref.) 2,111.10 .001

Size describes the incremental charge per centimeter increase in tumor size

ASA American Society of Anesthesiologists, ref reference

TABLE 1 continued

Characteristic Primary excision (n = 200) Reexcision (n = 104) p

Vascular surgery 1 1

Results for continuous variables are shown as mean ± SD and were analyzed by the Wilcoxon rank sum text. Results for categorical variables

are shown as n (%); comparisons were performed by v2 or Fisher’s exact tests

ASA American Society of Anesthesiologists, MPNST malignant peripheral nerve sheath tumor, MFH malignant fibrous histiocytoma



imaging or biopsy, often resulting in an incomplete exci-

sion. Approximately a third of the patients in this study

(104 of 304) presented for treatment after an incomplete

excision was performed elsewhere. This is similar to pre-

viously reported experiences at other institutions, with

percentages of sarcoma patients presenting with an

incompletely excised lesion ranging from 14 to

53 %.1,10–14 The standard of care after incomplete excision

has been to reexcise the tumor bed in order to obtain

negative margins. Recent studies have shown no difference

in overall survival between patients undergoing a single,

planned complete excision and those undergoing reexci-

sion of an incompletely excised STS.1,7,13,14 However,

reexcision does not come without morbidity.

Reexcision results in increased rates of local recurrence,

increased soft tissue loss, increased need for complex

closure/flap coverage, and longer time required for reha-

bilitation.15–17 In addition, as this study shows, reexcision

has significant financial implications. As a result of the

complexity of care, patients requiring reexcision see a

33 % increase in professional charges and an 11 %

increase in total charges compared to patients undergoing a

single planned excision, even with controlling for factors

such as tumor size, grade, site, and ASA class before sur-

gery. Additionally, when the cost of the primary unplanned

surgery is considered, the financial burden nearly doubles.

The increase in professional charges in the setting of

reexcision can be explained by the added complexity of the

resection. In addition to the increased charge billed by the

primary surgeon, the involvement of other services, such as

plastic surgery for tissue coverage or vascular surgery for

vascular bypass, drives up the cost.5,6 When all patients

were pooled together to seek out variables that have a

significant effect on the charge, three variables in addition

to excision status were identified: tumor size, grade, and

site. However, when the same multivariable analysis was

performed with patients separated into the two study

groups, differences emerged. Grade continued to be a

significant factor in influencing professional charges in

both groups. Higher-grade tumors were typically more

invasive, and as a result the surgical resection was more

complex. This subsequently led to higher professional

charges billed.

Size was only a factor in affecting charges in the pri-

mary excision group. Thus, in the case of a primary

excision as the tumor size increases, the charge for excising

the mass increased proportionally. However, in the case of

a reexcision, the charge that the patient is billed is not

affected by the size of the tumor when accounting for other

factors such as tumor grade and site. The initial unplanned

excision often leaves residual disease, and as a conse-

quence, wide margins have to be obtained during the repeat

excision regardless of the initial tumor size.14,18,19 For

example, a 3-cm-deep mass of the thigh that is mistakenly

and incompletely excised would have to undergo a repeat

excision that has to encompass the initial tumor bed and the

new contaminated tumor bed to obtain negative margins.

Thus, in a repeat excision, the 3-cm incomplete excision at

least doubles to become a 6-cm excision—at best. This is

especially important with changes in coding that now

delineate a different charge for excisions above 5 cm for

the lower extremity and 1.5 cm for the upper extremity. A

TABLE 4 Multivariable linear regression analysis of professional charges for primary excisions

Characteristic B p

Size 148.20 .006

ASA: 3, 4 versus 1, 2 (ref.) 902.40 .26

Grade: high versus low/intermediate (ref.) 1,654.40 .04




TABLE 5 Multivariable linear regression analysis of professional charges for reexcisions

Characteristic B p

Size -30.70 .83

ASA: 3, 4 versus 1, 2 (ref.) 1,540.70 .17

Grade: high vs. low/intermediate (ref.) 3,262.40 .03*






quick calculation of relative value units (RVUs) reveals

that the patient described above would incur over 89.09 in

RVUs: 13.84 (CPT 27328—initial resection of \5-cm

mass) ? 40.62 (CPT 27364—radical resection of now 6-

cm tumor bed) ? 22.81 (CPT 15750—rotational flap (i.e.,

neurovascular pedicle) ? 11.82 (CPT 64708—neurolysis),

compared to just 26.12 (CPT 27329—radical resection of

3 m neoplasm) if the tumor was resected appropriately

initially at a sarcoma center. This translates to over 241 %

increase in RVUs billed.

Interestingly, tumor site was not a significant variable in

affecting the charge of primary excisions; however, in the

case of reexcisions, patients with tumors in the lower

extremity were charged $3,240 more than those with

tumors in the upper extremity. Nonetheless, when all the

patients were analyzed as a single cohort, we found that

site still has a significant effect on affecting professional

charges even after controlling for excision status, tumor

size, and grade. This is explained, in part, when we note

that all intraoperative consults made to other surgical

specialties such as plastic and vascular surgery for creation

of flaps and vascular access were for tumors involving the

lower extremity. Additionally, significantly fewer consults

were made for the primary excision group, explaining why

the significance of site seen in reexcisions drops in the

primary excision group.

In addition to the direct charges evaluated in this study,

there are further costs, financial and otherwise, related to

having undergone a reexcision of an incompletely excised

sarcoma. Significant inconvenience in the form of time and

travel is commonly required if multiple surgeons are

involved in the reexcision. Prolonged recovery periods and

increased time spent in rehabilitation may be a reflection of

the larger resection and soft tissue loss associated with

reexcision as well as the need for higher dose and larger

field radiation resulting in fibrosis and functional compro-

mise.6,17,20,21 Other unaccountable costs in the form of

significant emotional toil are also experienced by patients

as they undergo reexcision of an inappropriately excised

STS.22

An argument could be made that the initial resection

acts as a biopsy and aids in obtaining a diagnosis for the

patient. Thus, diagnosis of their malignancy is established

and billed for during the initial incomplete excision.

However, patients undergoing primary excisions often

undergo a fine needle aspiration (FNA) or core biopsy in

clinic before their definitive excision. At our center, the

average professional charges billed for an FNA are as

follows: FNA without imaging guidance (CPT code—

10021) is $375 and with image guidance (CPT code 10022)

is $363. Performing a FNA in clinic before definitive

excision is thus a much safer and cheaper option ($375 vs.

$3,699) than having the patient undergo an unplanned

resection with possible contamination of the tumor bed and

spares the patient of an unsuccessful surgery.

Though studies have shown no differences in overall

survival between patients undergoing a single planned

complete excision and those undergoing reexcision of an

incompletely excised sarcoma, reexcision does commonly

result in increased morbidity. Reexcision results in

increased rates of local recurrence, increased soft tissue

loss, increased need for complex closure/flap coverage, and

longer time required for rehabilitation.15–17 In addition, as

this study shows, reexcision has significant financial

implications. As a result of the complexity of care, patients

requiring reexcision see a 33 % increase in professional

charges and an 11 % increase in total charges compared to

patients undergoing a single planned excision, even after

controlling for factors such as tumor size, grade, site, and

ASA class before surgery. Additionally, when the cost of

the primary unplanned surgery is considered, the financial

burden nearly doubles. This study again highlights the

importance of education and awareness of sarcoma as a

disease entity as well as early referral of suspicious lesions

to comprehensive sarcoma centers.10,23–25

A limitation of this study is because the specific finan-

cial figures quoted in this study are charges billed by a

single leading sarcoma center, the absolute difference in

cost may not be generalizable, as various centers may bill

differently. However, the relationships and conclusions

postulated remain highly plausible.

Conflict of interest The authors declare they have no conflict of

interest.

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the financial burden of reexcising incompletely excised soft tissue sarcomas: a cost analysis

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