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Tesi di specializzazione (5 anni)
La radicalizzazione chirurgica dei sarcomi delle parti molli: revisione sistematica della letteratura e metanalisi.
RICERCA TRASLAZIONALE E DELLE NUOVE TECNOLOGIE IN MEDICINA E CHIRURGIA
Course of study
ORTOPEDIA E TRAUMATOLOGIA
relatore Prof. Capanna, Rodolfo
- Sarcomi delle parti molli
- Escissioni non adeguate
- Ortopedia oncologica
Graduation session start date
Background: In referral centres for the cure of soft tissue sarcomas, up to the 40% of the patients have already had an incomplete tumour resection in another hospital. In the majority of the re-resection specimen (35-90% of the cases), tumoral residual is detected; at the present time there is no way to predict before the procedure when residual tumour is very unlikely to be found. Patient who had residual tumour generally had worsen prognosis. Systematic surgical re-resection of the scar tissue area, is the gold standard of care. Recently, some authors suggested to postpone re-resections until the detection of a clinically evident local recurrence. Questions/purposes: This systematic review was conceived to answer the following questions: what are the oncological outcomes of patients treated with Re-resection compared to those ones initially treated with planned surgeries? What is the impact of residual tumour on mortality, local and distant relapses? What is the impact of a local recurrence on mortality and risk to develop a distant metastasis? Patients and Methods: a searching strategy was applied to two database as Pubmed-Central and Ovid Medline. Odds ratio (OR) to develop a local recurrence (LR), distant metastasis (MTS) or overall survival (OS) were calculated comparing patients who had tumour residual to people who hadn't. OR of local recurrences, distant metastasis and OS were calculated for patients in planned vs unplanned-excisions groups. OR to develop a metastasis and OS after a local recurrences were calculated. Results: Having residual tumour led to an OR to develop a LR of 3,56, OR of MTS was 3,42; OR of decreased OS was 3,42. Having a LR lead to a OR of 1,55 to develop MTS and to a OR of decreased OS of 2,32. Patients who underwent a re-excision compared to who had a planned surgery in sarcoma centres did not have an increased OR of LR and had an OR to develop a MTS of 0,56. Conclusions: the majority of the patients who underwent re-resection will have residual tumour in their specimens. This analysis confirmed the importance of residual tumour finding as a predictor of a worsened outcome. Since it is actually impossible to predict with enough precision and accuracy in which patients residual tumour will be very unlike to be found, systematic re-resection can be envisaged. Although some authors report that local control does not have a direct impact on survival, our data confirm that there is a strong relation between local recurrences, distant relapses and overall survival. Although there is a strong bias of selection in the groups since the U.E. group is composed by patients who had smaller and more superficial tumours than the P.S. group; this analysis highlights the optimal oncological outcome in patients who underwent re-resection. It seem that could be risky to postpone surgical re-excision to the moment of the development of local recurrence. The rationale for systematic re-resection after unplanned excision of soft tissue sarcomas is very strong and this treatment remains the gold standard of care in these patients.