Factors Influencing Factors Influencing Sarcoma Referral and Sarcoma Referral and Treatment Treatment William G. Ward, Matthew T. Cline, Fred J. William G. Ward, Matthew T. Cline, Fred J. Dorey* Dorey* Wake Forest University Health Sciences, Wake Forest University Health Sciences, Winston-Salem, NC, *Department of Winston-Salem, NC, *Department of Pediatrics, USC Keck School of Medicine, Pediatrics, USC Keck School of Medicine, Los Angeles, CA Los Angeles, CA
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Factors Influencing Sarcoma Referral and Treatment William G. Ward, Matthew T. Cline, Fred J. Dorey* Wake Forest University Health Sciences, Winston-Salem,
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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
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.