Background: This study aims to assess the oncologic outcomes of unplanned versus planned excision in patients with high-grade soft tissue sarcoma.

Methods: A retrospective review was conducted, including 147 patients surgically treated for non-metastatic high-grade soft tissue sarcoma at a single institution between 2010 and 2021. Perioperative, clinical, and surveillance data were collected. Outcomes were compared between patients with unplanned (n = 53) and planned (n = 94) excisions. Multivariate analyses controlled for tumor characteristics and adjuvant therapies.

Results: The cohort included 53 patients treated with unplanned excision and 94 patients with planned excision, with a mean follow-up of 65.3 months postoperatively. Demographic variables, tumor size, type, histological grade, and margin status were statistically comparable between the planned and unplanned excision groups based on univariate analysis. Unplanned excisions were associated with significantly higher rates of local recurrence (39.6% vs 7.4%, p < 0.001) and metastasis (18.9% vs 5.3%, p = 0.009) compared to planned excisions. On multivariate analysis, planned excision conferred a decreased risk for local recurrence (HR 0.12, 95% CI 0.05-0.31, p < 0.001) and metastasis (OR 0.22, 95% CI 0.05-1.02, p = 0.05). Final positive margins were strongly associated with local recurrence (HR 18.26, 95% CI 6.80-48.99, p < 0.001). Over 90% of re-excision specimens after unplanned excision contained residual disease. Patients with microscopic or macroscopic disease identified in the re-excision specimen had a 42% and 44% risk of local recurrence, respectively, in comparison to those patients with no residual disease identified as having no incidence of local recurrence.

Conclusion: This study highlights the importance of a proper primary excision by an orthopedic oncologist for patients with high-grade soft tissue sarcoma. Unplanned excisions often result in tumor beds with either gross or residual microscopic disease and have a significantly increased risk of local recurrence, distant metastasis, and shortened survival.