Review Article

Unplanned Resection of Sarcoma

Nicholas S. Tedesco, DO
Robert M. Henshaw, MD
Abstract
Unplanned resection is a common problem in the management of
sarcoma. Because sarcomas are so rare, they may be misdiagnosed
initially as more common benign lesions. When the treating surgeon is
unaware of or does not adhere to proper surgical principles of
orthopaedic oncology, an intralesional procedure may be performed
without the requisite preoperative imaging, staging, or wide resection
margins for optimal management of sarcoma. Studies show that
oncologic outcomes after unplanned resections are mixed; however,
surgical outcomes drastically deteriorate. Failure to adhere to oncologic
principles accounts for increased morbidity and amputation rates with
re-resection. No diagnostic modality has been proven to accurately
predict residual disease in the resection bed following unplanned
resection. Thus, repeat surgery with or without adjuvant treatment is
usually offered to these patients, thereby adding considerable cost and
morbidity. Medical malpractice litigation associated with unplanned
sarcoma resection is common, with delayed diagnosis and unnecessary
amputation most often cited in cases decided in favor of the plaintiff.

U nplanned resection of osseous

From Medstar Washington Hospital
Center, Medstar Orthopedic Institute,
Georgetown University School of
Medicine, Washington, DC.
Dr. Henshaw or an immediate family
member has received research or
institutional support from Amgen and
Novartis Pharmaceuticals and serves
as a board member, owner, officer, or
committee member of the Mattie
Miracle Cancer Foundation and the
Musculoskeletal Tumor Society.
Neither Dr. Tedesco nor any
immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article.
J Am Acad Orthop Surg 2016;24:
150-159
http://dx.doi.org/10.5435/
JAAOS-D-15-00074
Copyright 2016 by the American
Academy of Orthopaedic Surgeons.
and soft-tissue sarcomas con-
tinues to be a major issue for muscu-
loskeletal oncologists. The term
“unplanned resection” was first pro-
posed by Giuliano and Eilber1 and
was later modified by Noria et al2 to
include any tumor surgically manipu-
lated without preoperative imaging or
regard for the necessity to resect the
tumor with a margin of normal tissue.
Unplanned resections have colloqui-
ally become known as “whoops” or
“oops” surgeries among practicing
orthopaedic surgeons because these
are the first words that come to mind
when the pathology report of the re-
sected, presumably benign, specimen
is returned with the word “sarcoma”
in the final diagnosis.
Epidemiology
Osseous and soft-tissue sarcomas are
exceedingly rare. Together, they
account for approximately 14,000
cases annually, which is ,1% of all
cancers diagnosed in the United
States.3 It is impossible to determine
the true incidence of benign osseous
and soft-tissue tumors because most
of these are never treated surgically.
Therefore, they are not reported in
series from which incidences are
usually extrapolated.4
Osseous malignancies with a non-
classic presentation are frequently mis-
diagnosed; therefore, they receive
inappropriate surgical management.5-9
In addition, benign soft-tissue tumors
have been estimated to occur 300
times more often than their malignant
counterparts.10,11 Because most soft-
tissue masses lack the classic pre-
sentation associated with soft-tissue
sarcoma, they are often clinically mis-
diagnosed as benign, and resection is
attempted without preoperative imag-
ing, biopsy, or proper adherence to
oncological surgical principles.1,2,10-27

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 Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD

Unplanned resection of osseous and Table 1

soft-tissue malignancies is common. Of
Percentage of Sarcoma Cases Referred After an Unplanned Resection
new patient referrals at major muscu-
loskeletal oncology tertiary care cen- Study Sarcoma Type Cases Referred (%)
ters, 5% to 31% were patients with Noria et al2 Soft tissue 25
osseous sarcoma who underwent a
Ayerza et al6 Osseous 7.7
prior unplanned resection or a pro-
Kim et al8 Osseous 5.5
cedure in which the presence of sar-
Wang et al9 Osseous 12
coma was missed at the time of surgery
Fiore et al10 Soft tissue 53
(eg, failure to recognize a pathologic
Davis et al12 Soft tissue 44
fracture).6,8,9,28 Similarly, several
Lewis et al13 Soft tissue 37
studies have reported that 18% to
66% of new patient referrals for soft- Wong et al14 Soft tissue 24
tissue sarcoma are for patients who Manoso et al16 Soft tissue 52
underwent a prior unplanned resec- Chui et al17 Pediatric soft tissue 81
tion.2,10,12-14,16,19,22,24-27,29-32 In some Rougraff et al18 Subcutaneous soft tissue 91
specific populations, such as pediatric Potter et al19 High-grade soft tissue 32
patients or patients with a sub- Rehders et al22 Soft tissue 35
cutaneous sarcoma, the number of Venkatesan et al24 Soft tissue 19
new patient referrals that involve Qureshi et al25 Soft tissue 64
unplanned resections is as high as 50% Alamanda et al26 Soft tissue 34
to 73%17,33 and 80%,18 respectively. Alamanda et al27 Soft tissue 37
These numbers have not changed Goodlad et al29 Soft tissue 40
appreciably over time, indicating a Zagars et al30 Soft tissue 54
failure of international educational Chandrasekar et al31 Soft tissue 18
efforts to change practice patterns with Sawamura et al32 Deep high-grade soft tissue 18
regard to diagnosis and management Sawamura et al33 Pediatric soft tissue 50
of soft-tissue sarcoma (Table 1).

Presentation of any abnormality on plain radi- reaming and intramedullary nail

Osseous Sarcoma
Presentation of malignant osseous
sarcoma varies widely, ranging from
undetectable on plain radiographs to
large, destructive tumors with exten-
sive periosteal reaction. The latter has
come to be known as the classic pre-
sentation of osseous sarcoma.34 Many
osseous sarcomas also exhibit age
predilections, with the accepted classic
age ranges of childhood and adoles-
cence for both osteosarcoma and
Ewing sarcoma,35 and middle-aged to
older adults for chondrosarcoma.36
Misdiagnosis and failure to recog-
nize an osseous lesion as malignant
are the most common reasons cited
for unplanned resection of osseous
sarcoma.7,9 The index of suspicion
should be high for an underlying
malignancy in the bone in the setting
ography or a low-energy fracture in
the absence of severe osteopenia.7,9
In addition, many histologic sub-
types of osseous sarcoma in older
patients can be purely lytic, which
may account for the diagnostic
confusion with simple cysts, giant
cell tumors of bone, or metastatic
disease.7 The third most common
reason for unplanned osseous sar-
coma resections is inappropriate
management of pathologic fracture.
In adults, lytic lesions are often
presumed to be carcinoma metasta-
ses.7,9 Also, many permeative sar-
comas can be missed on plain
radiography because the overlapping
fracture fragments obscure the
pathologic bone. When a pathologic
fracture occurs in the weight-bearing
long bones of a patient older than 40
years, treatment often consists of
fixation without biopsy or staging.7,9
On rare occasions, these lesions
represent primary sarcomas, and
inappropriate management can the-
oretically increase metastatic burden
by pushing tumor cells into the
bloodstream. In addition, tumor cells
spread throughout the entire limb
segment and may require massive
endoprosthetic replacement or a
high amputation as salvage proce-
dures (Figure 1).
The most commonly presumed
preoperative diagnoses in unplanned
osseous sarcoma resections are
osteomyelitis, giant cell tumor of
bone, bone cyst, osteonecrosis, and
metastatic disease.7,9 Unplanned
resection of an osseous sarcoma that
includes intralesional curettage for
presumed infection or a benign
osseous tumor or cyst can be

March 2016, Vol 24, No 3 151

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Unplanned Resection of Sarcoma

Figure 1 Figure 2

Axial T2-weighted fat-saturated

magnetic resonance image
demonstrating a massive, infected
sarcoma of the left thigh with
extensive intratumoral emphysema
and cutaneous fungation in a
A through D, Radiographs of the femur in a 17-year-old male who underwent 48-year-old woman who underwent
intramedullary nailing of a pathologic femur fracture with a missed sarcoma. .6 months of treatment, which
A, Magnified view of the femur demonstrating an acute fracture through the consisted of repeated aspirations
femoral diaphysis with a Codman triangle periosteal reaction and permeation of and surgical débridement for a
the bone that likely indicate an underlying disease process that was missed by presumed hematoma, at an outside
the treating surgeon. B, AP radiograph of the femur 9 months postoperatively institution. No advanced imaging or
demonstrating placement of an intramedullary nail through the pathologic lesion. biopsy was obtained before the
The fracture healed, but frank bone destruction is present. C, AP radiograph of patient presented at the authors’
the femur obtained 14 months after the index procedure that prompted referral to institution.
an orthopaedic oncologist. On biopsy, the lesion was diagnosed as Ewing
sarcoma. D, AP radiograph of the femur demonstrating total endoprosthetic
replacement of the femur, which was performed after en bloc resection of the
entire femur, intramedullary nail, and the prior surgical tracts. after mild trauma (eg, recreational
sports injury) are more likely to be
misdiagnosed and receive inadequate
problematic.5,7-9 Indeed, most refer- sarcomas who are referred for pri- treatment because of the more benign
rals for unplanned resection are for mary treatment at major referral presentation10,17,21,25-27 (Figure 3).
patients who lack the classic osseous centers have the classic soft-tissue Reported rates of residual sarcoma
sarcoma presentation or do not sarcoma presentation, and those in the re-resected specimen after
conform to the classic age ranges for referred for secondary treatment after unplanned resections are uniformly
specific types of osseous sarcoma.8,9 an unplanned resection are more likely high (Table 2). However, there appears
to have a sarcoma that is ,5 cm, to be no way to clinically predict
superficially located, and pain- residual disease. In several series in
Soft-tissue Sarcoma less.10,13,17-20,25-27,37 This is likely which unplanned resections under-
The classic presentation for soft-tissue because the latter is ostensibly re- went re-excision regardless of clinical
sarcoma is a large (.5 cm), firm, fixed garded as benign tumor presentation. scenario, residual tumor rates in the re-
mass that is deep-seated, enlarging, In the setting of unplanned resection resected specimens ranged from 24%
and either painless or newly painful yet of a soft-tissue sarcoma, the tumor is to 74%.1,2,10-13,18,19,23,29,38,39 In more
previously painless11,14,24 (Figure 2). most commonly misdiagnosed as a selective series in which strict criteria
However, up to one third of all soft- lipoma, cyst, hematoma, fibroma, were applied (eg, gross residual
tissue sarcomas arise superficial to the abscess, enlarged lymph node, or disease, positive margins, ability to
investing muscular fascia,18 and they other benign tumor.20,21 Further- preserve functional limb) to select re-
can range in size from a few millime- more, patients with rapidly growing excision candidates, the rates of
ters to several tens of centimeters. lesions are more likely to be referred tumor-positive specimens are virtu-
Indeed, several series have reported primarily, and those with slow- ally identical.20,30,31 For cases with
that most patients with soft-tissue growing tumors or tumors found confirmed residual disease in the

152 Journal of the American Academy of Orthopaedic Surgeons

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surgical bed, physical examination of
the surgical bed failed to detect
residual disease in 33% of cases.2 No
diagnostic modality has been shown
to accurately predict residual disease
in the tumor bed. MRI has been re-
ported to have a negative predictive
value of 66% to 75%, a sensitivity of
only 56%, and false-negative rates as
high as 25% to 33%.2,16 With regard
to pathology reports of unplanned
resections, the rate of inaccuracy in
terms of diagnosis and margin status
has been shown to be 37%21 and
50% to 82%,1,18,21 respectively.
Outcomes
Osseous Sarcoma
Oncologic outcomes following resec-
tion of osseous sarcoma are worse for
patients who have undergone an
unplanned resection. In the literature,
planned resections have better surgi-
cal outcomes and limb salvage rates.
Wang et al9 compared the outcomes
of 16 patients with osteosarcoma
who underwent unplanned resection
with those of 134 patients who had
planned primary resections of osteo-
sarcoma. The authors found that,
although patients with an unplanned
procedure had smaller mean tumor
volumes than did those with a planned
primary resection, the local recurrence
rate was higher, there was a shorter
mean time to local recurrence, and
there was a shorter mean time to
metastases. The limb salvage rate was
considerably lower in the unplanned
resection group.9 Ayerza et al6 re-
ported similar findings; compared
with planned resection, unplanned
resection of osteosarcoma was asso-
ciated with an increased risk of local
recurrence, decreased 10-year survival,
and increased rates of amputation.
Kim et al8 compared 55 patients
who had unplanned osteosarcoma
resections with 40 patients who had
planned resections. The authors re-
ported an increased rate of amputa-
March 2016, Vol 24, No 3
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Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD
Figure 3
Clinical photographs of the same patient shown in Figure 2 demonstrating a
fungating thigh wound (A) and purulent myonecrosis (B). The necrotic tissue
was removed in an attempt to eradicate the infection.
tion in the unplanned resection group,
but found no difference between the
two groups with regard to 5-year
event-free rates or overall survival
rates. Interestingly, the authors found
that, in 20 cases, the amount of tumor
left in the re-resected specimen was
too small to evaluate chemotherapy-
induced tumor necrosis. This results in
a treatment dilemma because assessing
tumor necrosis is important in deter-
mining subsequent chemotherapy and
prognosticating outcomes.
Picci et al5 studied risk factors for
local recurrence of osteosarcoma in
the extremities after limb salvage
resection in 23 cases. The authors re-
ported two recurrences at the site
of the unresected biopsy tract. Five
occurred secondary to unplanned
resection or inappropriate biopsy
techniques, which resulted in sub-
stantial tumor contamination of the
surrounding tissues. These findings
stress the importance of planning
biopsies such that they fall within the
planned plane of resection and are
performed by an experienced team
using appropriate techniques. In
addition, the authors noted that local
recurrence represents a risk factor
for amputation, further increasing
amputation rates following unplanned
resection.
Jeon et al7 reported similar findings
in a study of 25 cases of unplanned
resection of several types of osseous
sarcoma. They found that, with
unplanned resection, the local con-
trol rates were worse and the rates of
limb salvage were lower than those
associated with planned primary
resection. They found that oncologic
and surgical outcomes of unplanned
resection were as poor as those
of pathologic fracture through an
osseous sarcoma.
Soft-tissue Sarcoma
Increased morbidity and worse sur-
gical outcomes are associated with
unplanned resection of soft-tissue
sarcoma; however, the literature on
the oncologic outcomes of this type of
sarcoma is much more inconsistent
than the literature on outcomes of
osseous sarcoma (Figure 4). Noria
et al2 were the first to compare the
outcomes of a cohort of planned and
unplanned resections. They found
that local recurrence was consider-
ably higher in the unplanned resec-
tion group because of the increased
difficulty in obtaining wide surgical
margins in re-resections secondary to
extensive tumor contamination of
the prior surgical bed. Other studies
153
Unplanned Resection of Sarcoma

Table 2 Figure 4
Reported Rates of Residual Sarcoma Found Histologically in Re-resected
Specimens After Unplanned Resection of Soft-tissue Sarcoma
Number of
Unplanned Cases Tumor-positive
Resections Re-resected Re-resected
Study Referred (%) Specimens (%)

Giuliano and Eilber1 90 100 51.1

Noria et al2 65 100 35
Fiore et al10 318 100 23.6
Kang et al11 121 100 51.3
Davis et al12 104 100 40.4
Intraoperative photograph of the
Lewis et al13 407 100 39 same patient shown in Figures 2 and
Wong et al14 18 88.9 56.3 3 demonstrating resection of the
Manoso et al16 42 90.5 42 infected sarcoma and the entire
anterior thigh muscular compartment
Chui et al17 94 73.4 47.8
after serial débridement and
Rougraff et al18 75 100 65.3 systemic polyantimicrobial agents
Potter et al19 64 100 71.8 failed to clear the infection. The
Hoshi et al20 38 86.8 69.7 vessel loops surround the superficial
femoral artery and vein, and the
Rehders et al22 143 97.2 31 exposed femur can be seen deep to
Han et al23 104 100 51 the distal end of the tumor being
Venkatesan et al24 42 95.2 74 elevated by the surgeon.
Qureshi et al25 134 90.3 48
Goodlad et al29 95 100 58.9
Zagars et al30 666 44.3 46 group who underwent re-resection
Chandrasekar et al31 363 87 59.5 did so presumably because of local
Zornig et al38 67 100 45 recurrence, whereas re-resections in
Peiper et al39 110 100 39
patients who had unplanned resec-
tions were part of the standard
treatment for a potentially contami-
nated tumor bed. Thus, it may be
have also reported increased rates of increased metastatic rates and worse inferred that, overall, metastasis-free
local recurrence in patients who have relapse-free and overall survival rates and local recurrence-free survival
undergone an unplanned resec- in patients with residual disease rates for unplanned resection of soft-
tion.12,19,25 However, recent studies found in the re-resected specimens. tissue sarcoma are similar to those of
have found no markedly increased Qureshi et al25 found no overall local recurrence after a planned
local recurrence rates in patients who increase in metastases or decrease in resection—a potentially poor prog-
have undergone re-resection, possi- disease-specific survival. However, nostic indicator.5,18,25,30,32
bly because of improvements in once the tumors were stratified by In contrast, other authors have re-
treatment strategies over time and grade, high-grade tumors were asso- ported no significant effect on sur-
recognition of the need for very wide ciated with higher rates of metastases vival parameters associated with
margins in re-resections to capture and worse disease-specific survival in unplanned resection.16,20,31 Delays
any residual tumor.10,22,32 unplanned versus planned resections. of up to 120 days in definitive
In terms of survival and metastatic Arai et al37 compared the outcomes management after an unplanned
disease, the literature is mixed of patients who underwent planned resection were not associated with
(Figure 5). Fiore et al10 reported resections with those who underwent any substantial alterations in clinical
increased rates of distant metastases unplanned resections. They found outcome.10,23 Interestingly, Lewis
in patients with residual disease that, overall, metastasis-free and et al13 reported that, after correcting
found in the re-resected specimens, local recurrence-free survival rates for prognostic factors, patients who
but the trend toward worse survival were similar in the two groups. underwent unplanned resection had
in these patients was not statistically Although not specifically discussed, notably better 5-year disease-free
significant. Rehders et al22 reported patients in the planned resection survival rates than did those who

154 Journal of the American Academy of Orthopaedic Surgeons

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 Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD

Figure 5

Axial CT scans of the chest demonstrating the rapid progression of pulmonary metastatic disease at initial presentation to
the authors’ institution (A), 1 month later (B), and 2 months after initial presentation (C), in the patient shown in Figures 2
through 4. She ultimately succumbed to respiratory failure ,3 months after initial presentation to the authors’ institution.
Because of the refractory infection, the patient was never able to begin systemic chemotherapy and was not ambulatory after
the anterior compartment resection.

underwent planned resection (88%
versus 70%, respectively). These
spurious findings are likely attribut-
able to an unrecognized confounder
not accounted for in their study.
The treatment of choice for most
patients is wide re-resection of the
surgical bed, with the assumption
that residual tumor cells are present.
Some patients may also receive
radiotherapy and/or chemotherapy,
depending on the margin status
and tumor stage at the time of re-
resection.1,2,10-13,15,18,19,23,29,32,38,39
Kepka et al15 found that the use of
radiotherapy alone for local tumor
control in a patient who underwent
unplanned resection can lead to high
complication rates because of the
field size and the amount of radia-
tion required. Radiotherapy alone is
also less effective than repeat surgery
with adjuvant radiotherapy for local
control. Thus, radiotherapy alone
should be reserved for patients with
a surgical contraindication or an
unresectable tumor.15,30
Although the literature is mixed on
oncologic outcomes, the consensus is
that surgical outcomes are far worse in
unplanned resections than in planned
resections. Several studies have con-
firmed a greater need for flap cover-
age, worse functional scores, the
need for multiple surgeries to obtain
wide margins, increased wound com-
plications, or increased amputation
rates in patients who undergo re-
resection.14,16,19-22,24,25,37 In almost
all instances, the poorer outcomes are
caused by poor resection technique
during the unplanned procedure (eg,
transverse incisions, wide mattress
suture, hematoma formation, drains
placed not in line with incision,
adjacent compartment/joint or neu-
rovascular contamination), and not
by intrinsic properties of the pre-
senting tumor. Therefore, the poor
outcomes may have been obviated
by an initial appropriately planned
resection.
After an unplanned resection has
been performed, treatment recom-
mendations and expectations commu-
nicated to the patient before the referral
have been shown to be in concert with
the final orthopaedic oncologist’s rec-
ommendations only 45% of the time,
leading to considerable patient anxiety
and confusion.21 Thus, once the
decision has been made to refer a
patient after an unplanned resection,
treatment recommendations should be
deferred to the treating musculoskel-
etal oncologist.
Soft-tissue sarcoma in certain sub-
populations has been studied with
regard to unplanned resection. In
pediatric patients, local recurrence,
5-year event-free survival, and 5-year
overall survival rates appear to be no
different from those of patients who
undergo planned resection. How-
ever, the probability of obtaining
negative surgical margins in the
re-resected specimen decreases dras-
tically, often requiring larger or
multiple surgeries with considerably
more morbidity.17 In a study of
patients with superficial tumors,
Rougraff et al18 found that these
patients have the highest risk of
unplanned resection, and local
tumor control cannot be as reliably
obtained in this subset of patients
compared with those who undergo
planned resection. Furthermore, in
patients with tumors $4 cm, disease-
free survival rates are markedly
worse than those in matched patients
who underwent planned excision
(69% versus 88%, respectively).
Prevention
Although some authors recommend
referral to an orthopaedic oncologist
before intervention for any bone
lesion5 or soft-tissue mass $3 cm,18
this is not always practical or neces-
sarily indicated. Appropriate workup
and adherence to oncological surgical
principles can allow the community

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Unplanned Resection of Sarcoma
physician to address minimally sus-
picious lesions while obviating many
of the adverse outcomes associated
with unplanned resection.
Workup of any extremity mass
begins with an accurate history and
physical examination. Laboratory
tests can be ordered when indicated.
Standard orthogonal radiography
can be useful to rule out other causes
of swelling or pain, characterize in-
tralesional matrix or calcification,
and help determine bony involve-
ment.4,34 If any matrix is present or
suspected, CT is the test of choice to
characterize it further and to evalu-
ate bony structure and cortical
involvement/integrity.
The standard of care for evaluating
the extent of a lesion, characterizing
tumor properties when no matrix is
apparent on CT or radiography, and
denoting the presence or absence of
necrosis or hemorrhage within the
lesion or bone is MRI spin-echo
T1- and T2-weighted sequences, with
and without contrast, or CT with
intravenous contrast (when MRI is
contraindicated) of the entire bone or
extremity region. Tumor MRI pro-
tocol should avoid the use of non-
diagnostic gradient-echo sequences (eg,
proton density-weighted or BLADE
[Siemens Healthcare] sequences) often
used in the extremities. MRI can be
used to differentiate benign lipomas
and simple cysts from other tumors; the
former can be treated definitively
without further workup, and the latter
should be biopsied in the intended
plane of resection, or the patient should
be referred to an orthopaedic oncolo-
gist for further evaluation.1,2,12,18,24,25
However, findings from an MRI
that was not interpreted by a
musculoskeletal-trained radiologist
should be used with caution because
up to 76% of radiology reports of
unplanned resections do not include
sarcoma in the differential diagnosis.21
If the diagnosis is still in question
after advanced imaging is performed,
open or image-guided needle biopsy
156
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
in the plane of the planned definitive
resection is indicated to obtain tissue
for diagnosis before any treatment is
initiated. If the approach and resec-
tion plane are indeterminate, the
treating physician should consult a
musculoskeletal oncologist before
the biopsy is performed.
For a lesion that requires open
biopsy because needle biopsy is not
feasible or has been nondiagnostic, a
longitudinal incision should be made
along the long axis of the extremity.
Meticulous hemostasis should be ob-
tained with liberal use of cautery and
postoperative compressive dressings.
To minimize tissue contamination, the
clinician should avoid crossing multi-
ple compartments or exposing neu-
rovascular structures. A sample of the
lesion is obtained after a bony window
is made (for an osseous lesion) or the
pseudocapsule is entered (for a soft-
tissue lesion) and should be sent to
pathology for frozen-section analysis
before additional surgery is per-
formed. If the frozen section is con-
sistent with the suspected benign
pathology, curettage or excision can
be safely performed for a bone lesion
and a soft-tissue lesion, respectively. If
the frozen section is indeterminate or
consistent with malignancy, an addi-
tional portion of the lesion should be
sampled and sent for permanent sec-
tion. Then, any bone window made
should be plugged with polymethyl
methacrylate cement, and narrow
multilayer closure should be per-
formed. If the surgical field is large
enough to necessitate a drain, the
drain should exit the skin in line with
the incision such that it can be resected
en bloc with the biopsy tract at defin-
itive resection. Soft-tissue lesions ,3
cm that are superficial to the mus-
cular fascia can undergo excisional
biopsy with a wide cuff of normal
tissue using these same priniciples.18
Additional oncologic principles
should be kept in mind for fractures
when the underlying lesion was
missed or misdiagnosed, when the
Journal of the American Academy of Orthopaedic Surgeons
lesion has an invisible margin on plain
radiography, and in cases of joint ar-
throplasty when a missed lesion is
encountered intraoperatively. Using
the same principles outlined earlier, a
biopsy should be performed and the
tissue should be sent for analysis of the
frozen section to determine the diag-
nosis before proceeding with fixation
or device implantation. A potential
primary malignancy should never be
reamed, and tissue obtained from
reaming is often insufficient for diag-
nosis. Reaming spreads the tumor
throughout the entire bone and
introduces tumor cells into the
bloodstream, increasing metastatic
burden. If frozen-section analysis is
indeterminate or suggests malignancy,
a permanent specimen should be ob-
tained, and the wound should be
closed, thereby suspending any fur-
ther intervention until diagnosis is
definitive or the patient can be trans-
ferred to a facility with orthopaedic
oncology coverage. Traction or
extremity splints can be safely used for
interim management of the fracture or
a partially resected joint after an
aborted arthroplasty while definitive
diagnosis is pending.
Financial and Medicolegal
Considerations
To date, only one study has examined
the financial burden of unplanned
soft-tissue sarcoma resection in terms
of billable cost. Alamanda et al26
found that professional charges for
re-treating a patient who underwent
unplanned resection increased by
33%, and the overall cost increased
by 11%, compared with the cost of
treating a patient who underwent
a primary planned resection of a
sarcoma. In addition, when this cost
is added to the cost already accrued
in the primary unplanned resection,
the overall cost of treatment is nearly
double the cost of definitive treat-
ment with a planned resection.
 Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD

Figure 6

Bar graph demonstrating the average indemnity payments for general and sarcoma care provided by several specialties.
The blue bars represent the 2012 mean general indemnity payment within a designated specialty. The red bars represent
the mean sarcoma indemnity payment within the same specialty. (Adapted with permission from Mesko NW, Mesko JL,
Gaffney LM, Halpern JL, Schwartz HS, Holt GE: Medical malpractice and sarcoma care: A thirty-year review of case
resolutions, inciting factors, and at risk physician specialties surrounding a rare diagnosis. J Surg Oncol 2014;110[8]:919-
929.)

Although anecdotal reports of
medical malpractice claims against
physicians involved in unplanned
resection of sarcoma are abundant,
there is a paucity of literature that
directly addresses this topic. Insurance
coverage or distance from a tertiary
center with an orthopaedic oncologist
does not seem to be a factor in the type
or number of patients being referred
after unplanned sarcoma resection.27
However, rates of recurrence are
lower in patients referred from ter-
tiary centers after unplanned resec-
tion than in those referred from
nontertiary centers, despite the ten-
dency of tertiary referral centers to
refer patients with larger and higher-
grade tumors.11 This may be ex-
plained by the increased experience
with tumor resections at larger
medical centers, leading to a more
oncologically sound initial resection.
General surgeons account for the
largest percentage (up to 70%) of
unplanned resection referrals overall,
followed by orthopaedic surgeons,
plastic surgeons, urologists, podia-
trists, vascular surgeons, primary care
providers, and dermatologists.21,24
This highlights the importance of the
need for education on appropriate
extremity tumor workup and man-
agement in specialties other than
orthopaedics.
Mesko et al40 recently reviewed
216 medicolegal cases on sarcoma-
related medical malpractice from
1980 to 2012. Although one third of
the cases reviewed involved confi-
dential awards, two thirds were
disclosed publicly. Of those dis-
closed, 57% of cases favored the
plaintiff, with mean indemnity pay-
ments of $2.3 million (adjusted to
2012 US dollar amounts). The
average jury verdict award amount
($3.9 million) was almost triple that
of the average settlement amount
($1.4 million). The greatest numbers
of claims were filed against primary
care specialties (34%), orthopaedic
surgeons (23%), and radiologists
(12%). However, plaintiff awards
were $4.1 million in cases involving
a defendant who was an orthopaedic
surgeon compared with only
$1.5 million and $1.4 million for
general practitioners and radiolo-
gists, respectively. In fact, average
indemnity payments for sarcoma-
related medical malpractice were
higher than those for general claims
within all specialties, but these pay-
ments were 17.3 times higher for
orthopaedic surgeons, with a higher
prevalence of verdicts favoring
the plaintiff (Figure 6). Delay in
diagnosis (81%) and unnecessary
amputation (11%) accounted for the
most complaints, with wrongful
death cited in 39% of cases.

March 2016, Vol 24, No 3 157

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Unplanned Resection of Sarcoma
Summary
Reports show that 5% to 80% of
patients with osseous or soft-tissue sar-
comas experience an unplanned resec-
tion.2,6,8-10,12-14,16-19,22,24-27,29,30-33
Although most referrals for such
surgeries come from general sur-
geons, the orthopaedic community is
heavily involved in the care of these
patients and is cited in litigation
regarding unplanned resection of
sarcoma far more often than are
general surgeons.
It should be recognized that the
classic clinical presentation of sarcoma
represents a fraction of that for all sar-
comas. All suspicious fractures or
osseous lesions require additional
workup, including advanced imaging
and possibly biopsy and staging, before
undergoing any surgical intervention.
Thus, diligence with appropriate treat-
ment or referral is indicated in these
patients. In addition, any deep soft-
tissue mass or superficial mass $4 cm
should be evaluated with advanced
imaging and possibly percutaneous
biopsy before proceeding with surgical
intervention. If a biopsy is performed,
it should ideally involve the surgeon
who will be providing definitive
treatment and should fall within the
plane of definitive resection.
Other things to avoid when manag-
ing any extremity mass (benign or
malignant) include transverse inci-
sions, wide mattress suture closure,
placement of drains not in line with the
incision, adjacent compartment/joint
or neurovascular contamination, and
reaming of a potential primary osseous
sarcoma. If a suspicious lesion is
encountered intraoperatively, a sample
of the tumor should be obtained and
sent for frozen and permanent patho-
logical analysis before proceeding with
the case. If the findings of frozen-
section analysis are suspicious for
malignancy or indeterminate, meticu-
lous hemostasis should be obtained,
bony windows should be plugged with
158
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
polymethyl methacrylate cement, and
careful narrow closure should be done
with no further manipulation of the
tumor. If the surgical field is large
enough to necessitate a drain, it should
be placed in line proximal or distal to
the wound so that it can be excised en
bloc with the surgical/biopsy tract.
In addition to worse patient out-
comes, unplanned resection often
results in litigation against the treating
surgeon, which can result in millions
of dollars awarded to the plaintiff.
Prevention of unplanned resection
of sarcoma is best achieved through
education and clinical awareness to
avoid poor patient outcomes and liti-
gation against surgeons.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 3,
8-10, 12, 13, 18, 19, 26, 28, 32, 33,
35, and 40 are level II studies. Refer-
ences 2, 5, 6, 11, 16, 17, 21-23, 25, 27,
30, 31, 37, and 38 are level III studies.
References 1, 7, 14, 15, 20, 24, 29,
and 39 are level IV studies. Reference
36 is level V expert opinion.
References printed in bold type are
those published within the past
5 years.
1. Giuliano AE, Eilber FR: The rationale for
planned reoperation after unplanned total
excision of soft-tissue sarcomas. J Clin
Oncol 1985;3(10):1344-1348.
2. Noria S, Davis A, Kandel R, et al: Residual
disease following unplanned excision of
soft-tissue sarcoma of an extremity. J Bone
Joint Surg Am 1996;78(5):650-655.
3. Siegel R, Naishadham D, Jemal A: Cancer
statistics, 2013. CA Cancer J Clin 2013;
63(1):11-30.
4. Weiss SW, Goldblum JR, Enzinger FM:
General considerations, in Weiss SW,
Goldblum JR, eds: Enzinger and Weiss’s
Soft Tissue Tumors. Philadelphia, PA,
Mosby Elsevier, 2008, pp 1-14.
5. Picci P, Sangiorgi L, Bahamonde L, et al:
Risk factors for local recurrences after limb-
salvage surgery for high-grade
osteosarcoma of the extremities. Ann
Oncol 1997;8(9):899-903.
Journal of the American Academy of Orthopaedic Surgeons
6. Ayerza MA, Muscolo DL, Aponte-
Tinao LA, Farfalli G: Effect of erroneous
surgical procedures on recurrence and
survival rates for patients with
osteosarcoma. Clin Orthop Relat Res
2006;452:231-235.
7. Jeon DG, Lee SY, Kim JW: Bone primary
sarcomas undergone unplanned
intralesional procedures: The possibility of
limb salvage and their oncologic results.
J Surg Oncol 2006;94(7):592-598.
8. Kim MS, Lee SY, Cho WH, et al: Prognostic
effect of inadvertent curettage without
treatment delay in osteosarcoma. J Surg
Oncol 2009;100(6):484-487.
9. Wang TI, Wu PK, Chen CF, et al: The
prognosis of patients with primary
osteosarcoma who have undergone
unplanned therapy. Jpn J Clin Oncol 2011;
41(11):1244-1250.
10. Fiore M, Casali PG, Miceli R, et al:
Prognostic effect of re-excision in adult soft
tissue sarcoma of the extremity. Ann Surg
Oncol 2006;13(1):110-117.
11. Kang S, Han I, Lee SA, Cho HS, Kim HS:
Unplanned excision of soft tissue sarcoma:
The impact of the referring hospital. Surg
Oncol 2013;22(2):e17-e22.
12. Davis AM, Kandel RA, Wunder JS, et al:
The impact of residual disease on local
recurrence in patients treated by initial
unplanned resection for soft tissue sarcoma
of the extremity. J Surg Oncol 1997;66(2):
81-87.
13. Lewis JJ, Leung D, Espat J, Woodruff JM,
Brennan MF: Effect of reresection in
extremity soft tissue sarcoma. Ann Surg
2000;231(5):655-663.
14. Wong CK, Lam YL, So YC, Ngan KC,
Wong KY: Management of extremity soft
tissue sarcoma after unplanned incomplete
resection: Experience of a regional
musculoskeletal tumour centre. Hong Kong
Med J 2004;10(2):117-122.
15. Kepka L, Suit HD, Goldberg SI, et al:
Results of radiation therapy performed
after unplanned surgery (without re-
excision) for soft tissue sarcomas. J Surg
Oncol 2005;92(1):39-45.
16. Manoso MW, Frassica DA, Deune EG,
Frassica FJ: Outcomes of re-excision after
unplanned excisions of soft-tissue
sarcomas. J Surg Oncol 2005;91(3):
153-158.
17. Chui CH, Spunt SL, Liu T, et al: Is
reexcision in pediatric
nonrhabdomyosarcoma soft tissue sarcoma
necessary after an initial unplanned
resection? J Pediatr Surg 2002;37(10):
1424-1429.
18. Rougraff BT, Davis K, Cudahy T: The
impact of previous surgical manipulation of
subcutaneous sarcoma on oncologic
outcome. Clin Orthop Relat Res 2005;438
(438):85-91.

19. Potter BK, Adams SC, Pitcher JD Jr,
Temple HT: Local recurrence of disease
after unplanned excisions of high-grade soft
tissue sarcomas. Clin Orthop Relat Res
2008;466(12):3093-3100.
20. Hoshi M, Ieguchi M, Takami M, et al:
Clinical problems after initial unplanned
resection of sarcoma. Jpn J Clin Oncol
2008;38(10):701-709.
21. Siegel HJ, Brown O, Lopez-Ben R,
Siegal GP: Unplanned surgical excision of
extremity soft tissue sarcomas: Patient
profile and referral patterns. J Surg Orthop
Adv 2009;18(2):93-98.
22. Rehders A, Stoecklein NH, Poremba C,
Alexander A, Knoefel WT, Peiper M:
Reexcision of soft tissue sarcoma: Sufficient
local control but increased rate of
metastasis. World J Surg 2009;33(12):
2599-2605.
23. Han I, Kang HG, Kang SC, Choi JR,
Kim HS: Does delayed reexcision affect
outcome after unplanned excision for soft
tissue sarcoma? Clin Orthop Relat Res
2011;469(3):877-883.
24. Venkatesan M, Richards CJ,
McCulloch TA, et al: Inadvertent surgical
resection of soft tissue sarcomas. Eur J Surg
Oncol 2012;38(4):346-351.
25. Qureshi YA, Huddy JR, Miller JD,
Strauss DC, Thomas JM, Hayes AJ:
Unplanned excision of soft tissue sarcoma
results in increased rates of local
recurrence despite full further oncological
treatment. Ann Surg Oncol 2012;19(3):
871-877.
26. Alamanda VK, Delisca GO, Mathis SL,
et al: The financial burden of reexcising
incompletely excised soft tissue sarcomas:
March 2016, Vol 24, No 3
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Nicholas S. Tedesco, DO, and Robert M. Henshaw, MD
A cost analysis. Ann Surg Oncol 2013;20
(9):2808-2814.
27. Alamanda VK, Delisca GO, Archer KR,
Song Y, Schwartz HS, Holt GE: Incomplete
excisions of extremity soft tissue sarcomas
are unaffected by insurance status or
distance from a sarcoma center. J Surg
Oncol 2013;108(7):477-480.
28. Biau DJ, Weiss KR, Bhumbra RS, et al:
Monitoring the adequacy of surgical
margins after resection of bone and soft-
tissue sarcoma. Ann Surg Oncol 2013;20
(6):1858-1864.
29. Goodlad JR, Fletcher CD, Smith MA: Surgical
resection of primary soft-tissue sarcoma:
Incidence of residual tumour in 95 patients
needing re-excision after local resection. J
Bone Joint Surg Br 1996;78(4):658-661.
30. Zagars GK, Ballo MT, Pisters PW,
Pollock RE, Patel SR, Benjamin RS:
Surgical margins and reresection in the
management of patients with soft tissue
sarcoma using conservative surgery and
radiation therapy. Cancer 2003;97(10):
2544-2553.
31. Chandrasekar CR, Wafa H, Grimer RJ,
Carter SR, Tillman RM, Abudu A: The
effect of an unplanned excision of a soft-
tissue sarcoma on prognosis. J Bone Joint
Surg Br 2008;90(2):203-208.
32. Sawamura C, Matsumoto S, Shimoji T,
Tanizawa T, Ae K: What are risk factors
for local recurrence of deep high-grade soft-
tissue sarcomas? Clin Orthop Relat Res
2012;470(3):700-705.
33. Sawamura C, Springfield DS, Marcus KJ,
Perez-Atayde AR, Gebhardt MC: Factors
predicting local recurrence, metastasis, and
survival in pediatric soft tissue sarcoma in
extremities. Clin Orthop Relat Res 2010;
468(11):3019-3027.
34. Wodajo FM, Gannon F, Murphey MD:
Diagnostic features of bone tumors, in
Wodajo, Murphey F MGannon F, eds:
Visual Guide to Musculoskeletal Tumors:
A Clinical, Radiologic, Histologic
Approach. Philadelphia, PA, Saunders/
Elsevier, 2010, pp 3-18.
35. Miller BJ, Lynch CF, Buckwalter JA:
Conditional survival is greater than overall
survival at diagnosis in patients with
osteosarcoma and Ewing’s sarcoma. Clin
Orthop Relat Res 2013;471(11):
3398-3404.
36. Leddy LR, Holmes RE: Chondrosarcoma
of bone. Cancer Treat Res 2014;162:
117-130.
37. Arai E, Nishida Y, Tsukushi S, Wasa J,
Ishiguro N: Clinical and treatment outcomes
of planned and unplanned excisions of soft
tissue sarcomas. Clin Orthop Relat Res
2010;468(11):3028-3034.
38. Zornig C, Peiper M, Schröder S: Re-
excision of soft tissue sarcoma after
inadequate initial operation. Br J Surg
1995;82(2):278-279.
39. Peiper M, Knoefel WT, Izbicki JR: The
influence of residual tumor on local
recurrence after unplanned resection of soft
tissue sarcoma [German]. Dtsch Med
Wochenschr 2004;129(5):183-187.
40. Mesko NW, Mesko JL, Gaffney LM,
Halpern JL, Schwartz HS, Holt GE:
Medical malpractice and sarcoma care: A
thirty-three year review of case resolutions,
inciting factors, and at risk physician
specialties surrounding a rare diagnosis.
J Surg Oncol 2014;110(8):919-929.
159