Impact of Surgical Margin on Survival in Extremity Soft Tissue Sarcoma: A Systematic Review and Meta-analysis

Abstract

Introduction: A correct understanding of the prognostic effect of the surgical margin is essential in extremity soft tissue sarcoma (STS). If the status of surgical margin has by itself a significant impact on survival, wider surgical margins would be needed, and larger functional sequelae justified. However, if the status of surgical margin does not affect survival, closer surgical margins with a lower loss of function may be advantageous. The impact of surgical margin status on survival in extremity STS remains to be clearly defined. Therefore, a systematic review and meta-analysis were conducted to determine the impact of SM status on survival in extremity STS. Methods: A literature search of the National Library of Medicine and National Institutes of Health (PubMed), EMBASE, and Cochrane Controlled Trials Register (CENTRAL) electronic database and by hand searching reference lists of original studies was performed. We searched the studies with the following text words and/or Medical Subject Heading (MeSH) terms: neoplasm or sarcoma or connective tissue or soft tissue and extremity and margin. The quality of each study was assessed using the Newcastle–Ottawa Scale (NOS). A pooled HR was analyzed using an inverse variance weighting method and the random effects model or fixed effect model was selected according to heterogeneity. For identifying publication bias, Beggs test was used. Results: A total of 6 studies were included in the meta-analysis. All six studies were conducted at a single institution and were of high quality (NOS ≥ 7). Meta-analysis of all 6 studies showed that a positive SM predicted poor 5-year survival compared to patients with negative surgical margin in a random-effects model with moderate heterogeneity among studies (SHRs = 1.56, 95 % CI 1.12–2.17

test for heterogeneity p<0.002, I² = 64.18%). Formal evaluation using Beggs test revealed no evidence for significant publication bias in the 5-year survival (p = 0.086). Conclusion: This meta-analysis supports the hypothesis that positive surgical margin is a poor prognostic factor for survival in extremity STS. Our study provides guidance for surgeons undertaking limb salvage surgery in deciding the extent of the SM and its effect in terms of survival.