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Original Article
Analysis of results of soft tissue sarcoma margins revision surgery
Análisis de resultados en cirugía de revisión de márgenes de sarcomas de partes blandas
A. García-Jiméneza,
Corresponding author
agarciaji@santpau.cat

Corresponding author.
, L. Trullols-Tarragób, A. Peiró-Ibáñezb, I. Gracia-Alegríab
a Servicio de Cirugía Ortopédica y Traumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
b Unidad de Cirugía Oncológica Ortopédica, Servicio de Cirugía Ortopédica y Traumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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It is calculated that centres specialising in sarcomas receive from 19&#37; to 53&#37; of patients referred from other hospitals after unplanned surgery&#46; The risk of residual disease after unplanned resection stands at 24&#8211;60&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> Tumour relapse is 2&#46;2 times more common in these patients than it is in those who had received appropriate study prior to surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To manage these patients the specialised centre has to gather the maximum amount of information about the case&#46; The data supplied by the patient as well as the surgeon who first operated are therefore highly important&#46; These include the results of any preoperative or postoperative study and the details of the surgery&#46; It is also important to revise the histological samples from the tumour&#44; not only to confirm the diagnosis&#44; but also to discover the surgical margins&#44; given that these are predictors of the risk of local relapse&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> The therapeutic options implemented in the reference centre often run from abstaining from therapy with regular checks on the patient&#44; to revision surgery of the margins &#40;&#8220;second-look surgery&#8221;&#41;&#44; as well as the isolated or concomitant use of adjuvant therapies &#40;radiotherapy and&#47;or chemotherapy&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This study aims to describe the oncological evolution of a group of patients who were subjected to revision surgery of soft tissue sarcoma margins after they had previously been subjected to unplanned surgery for the resection of the same&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We carried out a descriptive longitudinal observational and retrospective study of the relevant data in our database of patients with muscle or bone tumours&#46; We included all of the patients aged 18 years old or above who had been sent to the orthopaedic oncology unit in our hospital after resection with positive margins of a soft tissue sarcoma located in the upper or lower limbs&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Firstly we gathered patient epidemiological data as well as data relating to certain aspects of the disease&#44; such as location or the first symptom&#46; We also recorded information about the first operation&#44; such as additional testing beforehand &#40;MRI&#44; computerised tomography &#91;CT&#93;&#44; ultrasound scans and biopsies&#44; etc&#46;&#41;&#44; the diagnosis of suspicion prior to surgery&#44; the time lapse until surgery&#44; the type of surgery &#40;broad surgery or simple resection&#41; and the result of the pathologic study of the samples obtained during the same&#46; For the margins revision or second-look surgery we collected similar data&#44; including the pathological diagnosis of the revision in our hospital of the histological sections from the first operation&#44; imaging studies prior to the revision surgery&#44; the time elapsed between the first and revision operations&#44; and the classification of the residual disease based on the classification of the American Joint Commission on Cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> Finally&#44; we gathered information about adjuvant treatment and the clinical evolution of patients&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">From November 2001 to July 2013 35 patients who had been subjected to an unplanned resection of a soft tissue sarcoma were treated in our unit&#46; They all fulfilled the inclusion criteria described&#46; 18 of these patients were women &#40;51&#46;4&#37;&#41; and 17 were men &#40;48&#46;6&#37;&#41;&#46; Their average age was 48 years old &#40;range from 17 to 29&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The most common location of the disease was the thigh &#40;42&#46;9&#37; of cases&#44; 15 cases&#41;&#44; followed by the foot &#40;14&#46;3&#37;&#44; 5 cases&#41;&#44; the leg &#40;8&#46;6&#37;&#44; 3 cases&#41;&#44; the groin &#40;8&#46;6&#37;&#44; 3 cases&#41;&#44; at shoulder blade level &#40;5&#46;7&#37;&#44; 2 cases&#41; and the knee &#40;5&#46;7&#37;&#44; 2 cases&#41;&#46; The other cases were in the arm&#44; elbow&#44; hand&#44; pelvic waist and the ankle &#40;with one case in each location&#44; 2&#46;9&#37;&#41;&#59; 14 cases &#40;40&#37;&#41; were in the right side and 21 cases &#40;60&#37;&#41; were in the left side&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The average duration of patient follow-up was 52 months &#40;range from 5 to 128 months&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The first symptom described by patients was the appearance of a painless swelling &#40;85&#46;7&#37;&#44; 30 cases&#41;&#44; followed by a painful swelling &#40;11&#46;4&#37;&#44; 4 cases&#41;&#46; Only one case &#40;2&#46;9&#37;&#41; presented isolated pain&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">97&#46;1&#37; of the patients &#40;34 cases&#41; were referred to the oncological orthopaedic unit from another centre&#46; The remaining 2&#46;9&#37; &#40;one case&#41; were referred from the General Surgery department of our hospital with the definitive diagnosis of leiomyosarcoma in what had originally been suspected to be a groin adenopathy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">76&#46;4&#37; &#40;26 cases&#41; of the patients from other centres were referred following a surprise diagnosis in the analysis of the intraoperative pathological samples obtained&#44; which is known as &#8220;whoops surgery&#8221;&#46; 17&#46;6&#37; &#40;6 cases&#41; were referred after positive tumour margins were found&#46; The remaining 5&#46;9&#37; &#40;2 cases&#41; were referred when the tumour was found to persist by complementary imaging tests after surgery&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">54&#46;3&#37; of lesions were at the level of the fascia &#40;19 patients&#41;&#44; while in 45&#46;7&#37; &#40;16 patients&#41; they were superficial&#46; The resected tumour was less than 8<span class="elsevierStyleHsp" style=""></span>cm in size in 91&#46;4&#37; of the patients &#40;32 cases&#41;&#44; i&#46;e&#46;&#44; T1 according to the American Joint Commission on Cancer &#40;AJCC&#41; staging system &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The 3 remaining cases &#40;8&#46;6&#37;&#41; correspond to T2 tumours according to the same staging system&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Only one case &#40;2&#46;9&#37;&#41; presented close tumoral adenopathies&#44; while only one case &#40;2&#46;9&#37;&#41; presented pulmonary metastasis in the diagnosis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The most common degree of tumour according to the AJCC classification was therefore II-A in 22 patients &#40;62&#46;9&#37;&#41;&#44; followed by II-B &#40;5 cases&#44; 14&#46;3&#37; of cases&#41;&#44; I-B &#40;2 cases&#44; 5&#46;7&#37; of cases&#41; and II-B&#44; IV-A and IV-B &#40;with one case each&#44; 2&#46;9&#37; of cases each&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The initial surgery had taken place without complementary tests in 10 cases &#40;28&#46;6&#37;&#41;&#44; while in 16 cases &#40;45&#46;7&#37;&#41; only one complementary test had been performed&#46; Only 5 patients &#40;14&#46;3&#37;&#41; were subjected to biopsy beforehand&#44; and 2 patients &#40;5&#46;7&#37;&#41; received fine needle aspiration biopsy &#40;FNAB&#41;&#46; A MRI technique was performed in 45&#46;7&#37; of cases &#40;16 cases&#41;&#46; Other imaging tests used were ultrasound scans &#40;20&#37;&#44; 7 cases&#41;&#44; CT &#40;11&#46;4&#37;&#44; 4 cases&#41; and simple X-ray &#40;5&#46;7&#37;&#44; 2 cases&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">For the majority of patients &#40;82&#46;9&#37; of cases&#44; 29 patients&#41; the samples obtained in the first operation were revised again by pathologists in our hospital with experience in tumours of this type&#46; Samples were not revised in the other cases because of bureaucratic difficulties in obtaining the pathological sample sections&#46; It may therefore be concluded that the most common diagnosis is synovial sarcoma &#40;37&#46;9&#37;&#44; 11 patients&#41;&#44; followed by malign fibrohistiocytoma&#44; high grade liposarcoma&#44; extraskeletal condrosarcoma and malign schwannoma &#40;6&#46;9&#37;&#44; 2 patients each&#41;&#46; Other diagnoses were pleomorphic sarcoma&#44; extraskeletal osteosarcoma&#44; leiomyosarcoma&#44; fibrosarcoma&#44; mesenchymal sarcoma&#44; clear cell sarcoma and atypical fusocellular proliferation &#40;3&#46;4&#37; and one patient each&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">When patients arrived at our hospital a new MRI test was performed before revision surgery in 91&#46;4&#37; of cases &#40;32 patients&#41;&#46; 53&#46;1&#37; of these patients presented a residual tumour according to this complementary test &#40;17 patients&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Second look surgery was undertaken from 1 to 9 months after the first operation &#40;with an average of 3 months&#41;&#46; The most common diagnosis found was synovial sarcoma&#44; in 25&#46;7&#37; of the patients &#40;9 patients&#41;&#46; In 31&#46;4&#37; of the patients &#40;11 cases&#41; no evidence of malignity was found&#46; A total of 8 patients &#40;22&#46;8&#37;&#41; had positive tumour margins after resection &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">More than half of the patients &#40;51&#46;4&#37;&#44; 18 patients&#41; also received adjuvant chemotherapy and radiotherapy&#46; 25&#46;7&#37; &#40;9 patients&#41; only received radiotherapy after revision of the margins&#44; while 8&#46;6&#37; &#40;3 patients&#41; only received adjuvant chemotherapy prior to the second look&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">At the end of follow-up a total of 4 patients &#40;11&#46;4&#37;&#41; had a local relapse&#46; Two of them had positive margins in revision surgery histology&#46; 4 other patients &#40;11&#46;4&#37;&#41; had systemic dissemination&#46; One patient &#40;2&#46;9&#37;&#41; died due to pulmonary progression&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">The concept of the complete unplanned resection of soft tissue sarcomas was introduced for the first time by Giuliano and Eilber&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> It refers to the situation in which no previous type of diagnosis has taken place prior to surgery&#44; which is performed without the intention of achieving free tumour margins&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Given that there are a higher proportion of benign tumours in the soft tissues than malign ones&#44; sometimes malign tumours may be resected in unplanned surgery&#46; Several series in the literature show a significant number of patients were operated for tumours which unexpectedly proved to be malign&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;6&#8211;16</span></a> This may be due to a lack of knowledge about the management of soft tissue sarcomas and this may be problematic if their potential malignity is not considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">To prevent the unplanned resection of soft tissue sarcomas a number of signs which may indicate malignity have to be taken into account&#46; These include indurate consistency&#44; a tumour size &#62;5<span class="elsevierStyleHsp" style=""></span>cm&#44; a rapid increase in size&#44; the presence of the mass at the depth of the fascia&#44; pain and recurrent swelling&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14&#44;16</span></a> If there is a suspicion of malignity the relevant tests must be performed prior to the operation&#44; including biopsy and imaging studies&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> In our series the initial surgery took place without previous complementary tests in 28&#46;6&#37; of cases&#46; A biopsy was taken beforehand in only 14&#46;3&#37; of cases&#44; while a MRI study was performed in 45&#46;7&#37; of cases&#46; We found no similar data in the literature with which our results could be compared&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Synovial sarcoma was the tumour found the most often in unplanned surgery &#40;37&#46;9&#37;&#41; in our series&#46; This agrees with the results obtained by Chandrasekar et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> although in their case this type of tumour represents 17&#37; of the cases in their series&#46; The most common tumour types found by Lewis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> in their series were malign fibrohistiocytoma &#40;MFH&#41; and liposarcoma &#40;LPS&#41;&#44; at 28&#37; and 26&#37;&#44; respectively&#46; In the series of Fiore et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> they found the most common malign tumour to be liposarcoma&#44; in 36&#37; of cases&#46; In our study malign fibrohistiocytoma and high grade liposarcoma are in second place&#44; each with 6&#46;9&#37; of cases&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The typical lesion found in our series would therefore be a synovial sarcoma smaller than 8<span class="elsevierStyleHsp" style=""></span>cm and located in the thigh&#46; The typical patient&#44; without adenopathies or metastasis&#44; would be in AJCC stage II-A&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">As was observed in previous studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;6&#8211;10&#44;12&#44;13</span></a> the unplanned resection of a soft tissue sarcoma involves the incomplete cutting out of the same in the majority of cases &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The incidence of residual tumour being found in revision margins surgery is similar to that in series such as that of Chandrasekar et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> which stands at 60&#37;&#46; In our series we found residual tumour in 68&#46;6&#37; of patients &#40;24 cases&#41;&#44; although the actual figure is probably slightly higher&#44; given that one patient &#40;2&#46;9&#37;&#41; without the finding of residual tumour in revision margin surgery went on to suffer a local relapse&#46; We can therefore estimate that&#44; in our series 71&#46;4&#37; of the patients subjected to an unplanned operation had residual tumour in the surgical site&#46; It is due to this high number of patients with residual tumour after the unplanned resection of a soft tissue sarcoma that in our centre we routinely perform revision surgery of the margins in such cases&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Revision surgery has to include broader margins than those which would have been included in planned surgery for the resection of a soft tissue sarcoma&#46; Imaging studies &#40;CT or MRI&#41; may be negative as they emphasise postoperative changes that prevent the correct visualisation of residual disease&#44; while habitually unsuitable surgical incisions and approaches compromise and contaminate compartments adjacent to the tumour&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;17</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The value of adjuvant therapies following sarcoma margin revision surgery is unclear&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Chemotherapy&#44; which was used alone in 8&#46;6&#37; of our patients and in 51&#46;4&#37; together with radiotherapy&#44; plays a complementary role to margin revision surgery&#46; Radiotherapy&#44; which was used alone in 25&#46;7&#37; of our patients&#44; is indicated routinely in many hospitals following the resection of a tumour&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10&#44;13</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">According to the literature&#44; local relapse and metastasis are greater in patients who receive second look surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;10&#44;14&#44;18</span></a> The incidence of local relapse in our series was 11&#46;4&#37;&#46; This is comparable to the rates observed in other series&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;6&#8211;10&#44;12&#44;13</span></a> in which the incidence stands at from 7&#37; to 26&#37;&#46; In 50&#37; of the patients who presented a relapse &#40;2 patients&#44; 5&#46;7&#37; of the total&#41; margin positivity had been observed in the histology of the samples obtained during revision surgery in our hospital&#46; 11&#46;4&#37; of the patients presented remote dissemination&#44; a lower figure than that found in other series&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The overall survival rate of the patients in our series was 97&#46;1&#37; at the end of follow-up&#46; This survival rate is higher than those in other series&#44; which stand at 77&#8211;88&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;10&#44;13</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">The results obtained in our series show no major differences from those of other published series in hospitals in other countries&#46; We can conclude that the high rate of residual tumour identified in our series makes it recommendable to resect any soft tissue tumour in a sarcoma reference hospital&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">19&#44;20</span></a> In those cases in which the tumour was resected in an unplanned operation in another hospital&#44; it is recommendable to refer the case to a reference hospital where a new revision of histology and MRI studies will be undertaken to detect residual disease&#44; together with revision surgery of the tumour bed&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">This is why in our unit we currently systematically recommend broad revision of the surgical site following the unplanned resection of a sarcoma&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Level of evidence</span><p id="par0170" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">iii</span>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of persons and animals</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that no experiments in human beings or animals were performed for this research&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Data confidentiality</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they followed the protocols of their centre of work governing the publication of patient data&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that this paper contains no patient data&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patients from other centres where they have had an unplanned surgical resection of a soft tissue sarcoma are often referred to hospitals specialised in sarcomas&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A study was conducted on 35 patients who required this type of surgery were referred to our centre between November 2001 and July 2013&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Surgery had been performed on 29&#37; of the patients without any complementary tests being done&#46; In 75&#37; of cases&#44; the sarcoma diagnosis was discovered in the post-surgical histological study&#46; Synovial sarcoma was the most common&#44; affecting 38&#37; of the patients&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A surgical revision of the margins was performed on all of them&#44; and adjuvant treatment was performed on 86&#37; of them&#46; The histopathology study found that 69&#37; of the patients had residual disease&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">At the end of follow-up&#44; 12&#37; had a local recurrence&#44; another 12&#37; distant metastases&#44; and 3&#37; had died&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Given the results&#44; it is concluded that any tumour of the soft tissues in which malignancy is suspected has to be resected in a reference centre&#46; If an unplanned esection was performed in another centre&#44; it should be referred immediately in order to perform an imaging study&#44; revision surgery&#44; and if required&#44; adjuvant treatment&#46;</p></span>"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En ocasiones&#44; a los hospitales especializados en sarcomas son derivados pacientes desde otros centros donde se les ha realizado una cirug&#237;a no planeada de resecci&#243;n de sarcoma de partes blandas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Entre noviembre del 2001 y julio del 2013&#44; 35 pacientes de este tipo fueron derivados a nuestro centro&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El 29&#37; de los pacientes hab&#237;a sido intervenido sin pruebas complementarias previas&#46; En el 76&#37; el diagn&#243;stico de sarcoma se descubri&#243; en el estudio histol&#243;gico postoperatorio&#46; El sarcoma sinovial fue el m&#225;s com&#250;n encontrado&#44; afectando el 38&#37; de los pacientes&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A todos ellos se les realiz&#243; cirug&#237;a de revisi&#243;n de m&#225;rgenes y en el 86&#37; se realiz&#243; terapia adyuvante&#46; El 69&#37; de los pacientes ten&#237;an enfermedad residual hallada en la anatom&#237;a patol&#243;gica&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Al final del seguimiento&#44; el 12&#37; hab&#237;a presentado recidiva local&#44; otro 12&#37; diseminaci&#243;n a distancia y el 3&#37; hab&#237;a fallecido&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Dados los resultados&#44; concluimos que cualquier tumoraci&#243;n de partes blandas de la que se sospeche malignidad ha de ser resecada en un centro de referencia&#44; y si se ha producido una resecci&#243;n no planeada en otro centro tiene que ser derivado inmediatamente para la realizaci&#243;n reglada de un estudio de imagen&#44; cirug&#237;a de revisi&#243;n y&#44; si precisa&#44; tratamiento adyuvante&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-Jim&#233;nez A&#44; Trullols-Tarrag&#243; L&#44; Peir&#243;-Ib&#225;&#241;ez A&#44; Gracia-Alegr&#237;a I&#46; An&#225;lisis de resultados en cirug&#237;a de revisi&#243;n de m&#225;rgenes de sarcomas de partes blandas&#46; Rev Esp Cir Ortop Traumatol&#46; 2016&#59;60&#58;366&#8211;371&#46;</p>"
      ]
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Diagnostic findings in the revision of histological sample sections from the first operation by experienced pathologists in our hospital&#46; CS&#58; condrosarcoma&#59; MFH&#58; malign fibrohistiocytoma&#59; LPS&#58; liposarcoma&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Diagnostic findings in the histology of margin revision surgery&#46; MFH&#58; malign fibrohistiocytoma&#46;</p>"
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        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Taken from the American Cancer Association&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a>"
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Grades&#58; I-A&#58; T1&#44; N0&#44; M0&#44; G1-2&#59; I-B&#58; T2-3&#44; N0&#44; M0&#44; G1-2&#59; II-A&#58; T1&#44; N0&#44; M0&#44; G3-4&#59; II-B&#58; T2&#44; N0&#44; M0&#44; G3-4&#59; III&#58; T3&#44; N0&#44; M0&#44; G3-4&#59; IV-A&#58; T1-3&#44; N0&#44; M1a&#44; G0-3&#59; IV-B&#58; T1-3&#44; N1&#44; M0-1&#44; G0-3&#47;T1-3&#44; N0-1&#44; M1b&#44; G0-3&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No evidence of primary tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tumour &#60;8<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tumour &#62;8<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Skip metastases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No regional adenopathies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">With regional adenopathies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No metastasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">a&#58; only pulmonary<br>b&#58; extrapulmonary dissemination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">G&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">Low grade</td><td class="td" title="table-entry  " colspan="2" align="center" valign="top">High grade</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">RMS&#58; revision margin surgery&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Noria et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Siebenrock et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Fiore et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Chandrasekar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Venkatesan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Umer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Garc&#237;a-Jim&#233;nez et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">597&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">363&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RMS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#44;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Residual tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:20 [
            0 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                        0 => array:2 [
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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            ]
            1 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Post-treatment complications of soft tissue tumours"
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                        0 => array:2 [
                          "etal" => true
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                            1 => "P&#46;J&#46;L&#46; de Visschere"
                            2 => "K&#46;L&#46; Verstraete"
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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            ]
            2 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of unplanned excision on prognosis of patients with extremity soft tissue sarcoma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "H&#46;M&#46; Umer"
                            1 => "M&#46; Umer"
                            2 => "I&#46; Qadir"
                            3 => "N&#46; Abbasi"
                            4 => "N&#46; Masood"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1155/2013/498604"
                      "Revista" => array:5 [
                        "tituloSerie" => "Sarcoma"
                        "fecha" => "2013"
                        "volumen" => "2013"
                        "paginaInicial" => "498604"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23737702"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Classification of positive margins after resection of extremity soft tissue sarcoma predicts the risk of local recurrence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;H&#46; Gerrand"
                            1 => "J&#46;S&#46; Wunder"
                            2 => "R&#46;A&#46; Kandel"
                            3 => "B&#46; O&#39;Sullivan"
                            4 => "C&#46;N&#46; Catton"
                            5 => "R&#46;S&#46; Bell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Bone Joint Surg Br"
                        "fecha" => "2001"
                        "volumen" => "83-B"
                        "paginaInicial" => "1149"
                        "paginaFinal" => "1155"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:1 [
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:3 [
                        "titulo" => "AJCC cancer staging manual"
                        "edicion" => "7th ed&#46;"
                        "serieFecha" => "2010"
                      ]
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                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "6"
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