Staged Resection with Temporizing VAC and Local Recurrence for Soft Tissue Sarcomas: A Multi-Institutional Review
by
, , , , , , , , and
Chloe Chose
1
,
Thomas Karadimas
1,
Lucy Hederick
2,
Anthony M. Griffin
3,
Veena Jajoo
1,
Caleb Cummings
1,
Joseph Connolly
2,
Thien Huong Huynh
1,
Erik T. Newman
2,
Kevin A. Raskin
2,
Peter C. Ferguson
3,
Jay S. Wunder
3,
David Joyce
4,
Odion Binitie
4,
Rahul Mhaskar
1,
Santiago A. Lozano-Calderon
2,
Kim Tsoi
3 and
Alexander L. Lazarides
4,* 1
Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA
2
Division of Orthopaedic Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
3
Division of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, ON M5G 1X5, Canada
4
Department of Sarcoma, Moffitt Cancer Center, Tampa, FL 33612, USA
*
Author to whom correspondence should be addressed.
Cancers 2026, 18(12), 1984; https://doi.org/10.3390/cancers18121984
Submission received: 28 May 2026
/
Revised: 13 June 2026
/
Accepted: 15 June 2026
/
Published: 18 June 2026
(This article belongs to the Special Issue Precision Medicine and Emerging Multidisciplinary Treatment Strategies for Bone and Soft Tissue Sarcomas)
Simple Summary
This multi-institutional retrospective cohort study evaluated whether staged resection with temporizing vacuum-assisted closure (VAC) is associated with local recurrence. A total of 314 patients were grade-matched across three tertiary care centers. Patients who underwent staged resection more frequently exhibited higher oncologic risk factors, including history of unplanned excision, recurrent disease, myxofibrosarcoma histology, and positive initial surgical margins. On multivariate analysis, temporizing VAC use remained independently associated with increased local recurrence rates. Overall, staged resection with VAC did not confer improved local control, but rather characterized a cohort of more aggressive tumor biology and complex presentations for which staged resection may not fully mitigate.
Abstract
Background/Objectives: Staged resection with temporizing vacuum-assisted closure (VAC) has been adopted to facilitate margin assessment and local control of soft tissue sarcomas (STS). Accordingly, the objective of this study is to compare rates of local recurrence (LR) among superficial STS patients treated with and without temporizing VAC therapy. Methods: We conducted a multi-institutional retrospective cohort study of superficial STS patients treated at three tertiary care centers. Patients were matched by grade, and descriptive statistics and multivariate binary logistic regression were performed. Results: After matching, 314 superficial STS patients were included in analysis. VAC patients were more likely to present with a history of prior unplanned excision (p = 0.024), with recurrent disease (p = 0.004), harbor a diagnosis of myxofibrosarcoma (p < 0.001), and have positive initial surgical margins (p < 0.001). After multivariate analysis, VAC use remained independently associated with increased LR rates (OR = 4.117; p = 0.003). Conclusions: In this multi-institutional analysis of superficial STS patients, staged resection with temporizing VAC was not associated with improved LR rates. Rather, the VAC cohort represented distinctly higher-risk tumor biology and complex oncologic presentations, in whom the risk of LR may not be fully mitigated by surgical staging alone.
1. Introduction
Soft tissue sarcomas (STS) are a heterogenous group of cancers marked by variability in biology, behavior, presenting features, and outcomes, which makes these tumors uniquely complex to manage [1]. Local recurrence (LR) remains a feared and clinically significant event in the disease course of STS, occurring at a median of 10.8 to 19 months after resection [2,3], with 80% recurring within the first 3 years [4]. LR is associated with higher rates of limb amputation and morbidity [5]. Studies also suggest an increased risk of distant metastasis and decreased overall survival with LR [6]. As such, local control is a central tenet in the treatment of these tumors, typically achieved by wide surgical resection with negative margins [7]. Positive surgical margins have been independently associated with worse overall survival and disease-specific survival [8]. Even after LR of a tumor, positive margins following re-resection yielded poorer re-recurrence and overall survival outcomes [9].
The gold standard for assessment of resection margins is postoperative pathologic assessment. However, this process can be time consuming, particularly in cases with complex anatomy or infiltrative growth patterns [10]. In response, staged resection with temporizing vacuum-assisted closure (VAC) has been adopted as a strategy to defer definitive soft tissue reconstruction until final margin status has been confirmed. Peri-operative VAC use in oncologic resection in general has been shown to be safe and harbor no increased risk of recurrence [11]. Its role in staged resection permits planned re-excision in cases of positive margins prior to definitive wound closure, with the intent of optimizing local control while minimizing reconstructive morbidity [12]. It has been described in management of malignant breast tumors [12] but has garnered special attention in the management of STS, particularly those complex reconstructive needs and high oncologic risk requiring careful margin assessment. Consistent with this approach, the National Comprehensive Cancer Network currently recommends the staging of infiltrative tumors, including myxofibrosarcoma and dermatofibrosarcoma protuberans (DFSP) [13]. Nevertheless, formal evidence-based guidelines defining the role of staged resection with VAC across the broader spectrum of STS remain lacking.
When compared with traditional single-stage excision for myxofibrosarcoma, VAC therapy was found to have lower LR rates (5.6% vs. 28.6%, p = 0.048) [14] and lower overall mortality (11.1% vs. 32%, p = 0.015) [15]. It also harbored an acceptable complication profile [16], similar cost profile [15], and similar patient-reported outcomes [17]. A separate study demonstrated that a staged approach, albeit without VAC therapy, obtained higher rates of negative final margins and resulted in significantly lower LR rates [18]. On the other hand, a separate institution found a 90% LR-free survival among superficial myxofibrosarcoma tumors treated with single-stage excision [19], revealing conflicting evidence as to the impact of VAC therapy on mitigating oncologic outcomes.
To date, the existing literature evaluating temporizing VAC therapy in STS largely focuses on individual histologic subtypes, notably myxofibrosarcoma, often within single-institution cohorts. Although these studies suggest potential benefits for local control in select tumors, their findings may not be generalizable across the heterogeneous population of superficial STS. Accordingly, the objective of this multi-institutional retrospective study is to compare rates of LR among patients with superficial STS treated with and without temporizing VAC therapy.
2. Materials and Methods
2.1. Patient Selection
We conducted a multi-institutional retrospective cohort study of patients treated surgically for STS at three tertiary referral centers between 2018 and 2024. Two of these institutions routinely employ staged resection with temporizing VAC when final margin status is uncertain, whereas the third institution does not and thus served as a comparison cohort. Patients in the VAC cohort were exclusively drawn from the two institutions that employ this strategy, while all patients from the third institution comprised the non-VAC comparison group.
Eligible patients included adults with pathologically confirmed STS who underwent surgical resection and had a minimum of one year of follow-up from the date of surgery. To avoid survivorship bias, patients who experienced LR or death within the first postoperative year were retained in the analysis. Deep-seated tumors involving the deep fascia were excluded to improve cohort homogeneity and limit confounding related to tumor depth, reconstructive complexity, and radiation exposure. Accordingly, the final analytic cohort was restricted to patients with superficial STS.
2.2. Data Collection
Demographics, tumor information, surgical and treatment-related variables, and outcomes were collected from electronic health record information. Pathology reports were reviewed for tumor grade and margin status. The primary outcome of interest was LR, defined as radiographic or clinical evidence of tumor recurrence at the operative site, confirmed either by imaging or by histopathologic analysis following re-excision. Due to limited sample size, race was recoded into two categories: White and non-White. Presenting status was categorized into primary tumor, locally recurrent tumor, and metastatic tumor to distant soft tissue site. Given low numbers of metastatic tumors (n = 3), locally recurrent and metastatic tumors were recoded as recurrent tumors for analysis.
2.3. Statistical Methods
Propensity score matching was attempted; however, adequate balance could not be achieved due to baseline differences between cohorts. Grade was then selected as the matching variable, because it is the most consistently identified independent predictor of LR across the broad heterogeneous STS histologic subtypes [20]. Matching on histologic subtype was not feasible due to the large number of subtypes with small cell sizes (Tables S1 and S2). After optimal manual matching of cases with randomized controls, the final analytic sample included an equal number of cases and controls.
Descriptive statistics were calculated for all variables. Continuous variables are presented as mean and standard deviation, while categorical variables are presented as frequencies and percentages. Because grade matching was used to construct comparable cohorts rather than establish analyzable matched pairs, observations were treated as independent in subsequent analyses. The primary variable of interest, temporizing VAC, and the dichotomous outcome variable, LR, were evaluated using Mann–Whitney U test for continuous variables using standard tie corrections. Pearson’s Chi-Square test or Fisher’s Exact test was used for categorical variables when expected cell counts were low. Univariate analyses were conducted to assess the association between each covariate and LR. Variables that were statistically significant in univariate analyses were subsequently included in a multivariate binary logistic regression model to identify independent associations of LR. Results are reported as odds ratios (OR) with 95% confidence intervals (CI). Finally, Kaplan–Meier analysis was performed to capture time-to-local recurrence, and survival curves were compared using log-rank tests. A p-value of <0.05 was considered statistically significant. All analyses were conducted using SPSS version 30.
3. Results
A total of 1242 patients with STS were identified across the three institutions. After applying inclusion criteria and excluding deep tumors, 519 patients with superficial STS were eligible for analysis. Manual 1:1 matching then resulted in a final matched cohort of 314 patients, with equal numbers among VAC and control groups.
3.1. Unmatched Cohort Analysis
The unmatched cohort analysis included 519 patients. Patients who received temporizing VAC were older on average (63.86 ± 15.62 vs. 59.92 ± 18.90 years, p = 0.020) and were more often female (48.4% vs. 39.0%, p = 0.037), White (86.3% vs. 69.8%, p < 0.001), and Hispanic/Latino (10.3% vs. 2.0%, p < 0.001). VAC patients more commonly presented with high-grade tumors (Grade 3: 64.7% vs. 32.6%, p < 0.001), advanced staged disease (Stage III/IV: 47.6% vs. 33.4%, p < 0.001), recurrent tumors (12.2% vs. 3.9%, p < 0.001), and with a history of unplanned excision (56.4% vs. 41.7%, p = 0.001). Tumor site varied (p = 0.007), with scalp tumors exclusively among VAC patients. Distribution of tumor size varied between groups, with the VAC group possessing proportionately less tumors smaller than 5 cm and less tumors greater than 10 cm (p = 0.033). Notably, tumor histology varied significantly between groups, with disproportionately more myxofibrosarcoma among VAC patients (48.4% vs. 25.4%, p < 0.001). VAC patients were more likely to receive radiation (67.6% vs. 34.2%, p < 0.001) and chemotherapy (15.4% vs. 3.6%, p < 0.001) and have shorter mean follow-up (38.99 ± 27.05 vs. 45.27 ± 25.35 months, p = 0.001). Reconstructive procedures were more common among VAC patients (flap reconstruction: 53.7% vs. 31.4%; skin graft: 31.9% vs. 20.5%, p = 0.001). Positive initial margins were more frequent in the VAC cohort (33.3% vs. 12.1%, p < 0.001), while negative final margins were more frequent among VAC patients, though not significantly (93.1% vs. 87.9%, p = 0.062). LR occurred in 16.0% of VAC patients compared to 4.8% of the comparison group (p < 0.001) (Table A1).
On univariate analysis, LR was associated with older age (69.09 ± 18.23 vs. 60.59 ± 17.67 years, p = 0.001), larger tumors (6.98 ± 5.17 vs. 5.40 ± 3.41 cm, p = 0.048), high-grade disease (Grade 3: 71.4% vs. 41.3%, p < 0.001), and a history of recurrent disease (19.6% vs. 5.5%, p = 0.002). Scalp (6.5% vs. 0.6%) and trunk tumors (15.2% vs. 10.2%) had high LR rates (p = 0.017), as did those requiring flap reconstruction (56.5% vs. 37.8%, p = 0.035) and those who received chemotherapy (19.6% vs. 6.8%, p = 0.006). Among LR patients, myxofibrosarcoma (43.5%) and undifferentiated pleomorphic sarcoma (UPS) (19.6%) were most frequent (p = 0.040). Additionally, advanced stage disease was more frequent among LR patients (Stage III/IV: 65.9% vs. 35.9%, p < 0.001). Tumor size was not associated with LR (p = 0.158). Positive initial margins were associated with LR (41.3% vs. 17.5%, p < 0.001), while final margin status (p = 0.12) and history of unplanned excision (p = 0.416) were not. Overall mortality (26.1% vs. 13.1%, p = 0.016) and metastasis (28.3% vs. 13.3%, p = 0.006) were higher among LR patients (Table A2).
After multivariate analysis, VAC use was associated with increased odds of LR (OR = 2.910; 95% CI, 1.408–6.014; p = 0.004). History of recurrent disease (OR = 3.080; 95% CI, 1.257–7.549; p = 0.014) and positive initial margin status (OR = 2.603; 95% CI, 1.287–5.265; p = 0.008) were also associated with LR odds. Radiation was protective, reducing odds of LR by about 50% (OR = 0.468; 95% CI 0.233–0.942; p = 0.033). Chemotherapy use (p = 0.136) and follow-up duration (p = 0.114) were not significantly associated (Table 1). Tumor grade was not included in multivariate analysis, because event frequencies were insufficient to support stable model estimation. No Grade 1 tumors experienced LR, and only twelve LR events occurred among Grade 2 tumors.
Among patients who developed LR, median LR-free survival was 20.9 months (95% CI, 11.2–23.8) for VAC patients and 12 months (95% CI, 5.0–16.0) for non-VAC patients. However, this difference was not statistically significant (p = 0.12) (Figure 1).
3.2. Matched Cohort Analysis
After manual 1:1 matching by tumor grade, the sample size included 314 superficial STS, with 157 patients treated with VAC and 157 treated without VAC. Residual differences between cohorts persisted after matching. VAC patients were more often White (86.8% vs. 64.9%, p < 0.001) and Hispanic/Latino (10.5% vs. 1.4%, p = 0.001). Additionally, VAC patients were more likely to present with a history of prior unplanned excision (54.1% vs. 41.4%, p = 0.024) and with recurrent disease (12.7% vs. 3.8%, p = 0.004). Tumor histology remained significantly different between groups, with myxofibrosarcoma predominating among VAC-treated tumors, followed by undifferentiated pleomorphic sarcoma (UPS) (p < 0.001). Tumor size varied, with proportionately less tumors smaller than 5 cm and less tumors greater than 10 cm among the VAC cohort (p = 0.041). Age (p = 0.278), gender (p = 0.173), stage (p = 0.172), and site (p = 0.141) were similarly distributed after matching (Table 2).
VAC patients were more likely to receive radiation (73.2% vs. 38.5%, p < 0.001) and chemotherapy (14.6% vs. 6.4%, p = 0.017) and undergo flap reconstruction (56.7% vs. 35.0%, p < 0.001). Initial margins were more often positive among VAC patients (33.1% vs. 10.2%, p < 0.001), but final margin status did not differ significantly (p = 0.428). LR (16.6% vs. 5.1%, p = 0.001) was higher and overall mortality was lower (12.1% vs. 24.8%, p = 0.004) among VAC patients (Table 3).
On univariate analysis, LR was associated with older age (68.47 ± 19.92 vs. 62.64 ± 16.45 years, p = 0.013) higher-grade tumors (Grade 3: 82.4% vs. 60.0%, p = 0.029), and recurrent disease (23.5% vs. 6.4%, p = 0.003). Trunk tumors (26.1%) and scalp tumors (66.7%) demonstrated higher rates of LR (p = 0.024). Tumor size was not associated with LR (p = 0.268). Positive initial margins were associated with LR (19.1% vs. 8.5%, p = 0.013), while final margin status was not (p = 0.428). Tumor size (p = 0.102), flap reconstruction (p = 0.723), chemotherapy (p = 0.068), stage (p = 0.051), metastasis (p = 0.272), and overall mortality (p = 0.723) were no longer associated with LR after matching, though some trended toward significance. Among LR patients, myxofibrosarcoma (41.2%) and undifferentiated pleomorphic sarcoma (UPS) (23.5%) remained the most frequent diagnoses (p = 0.003). In total 34 LR events occurred, with 76.5% of LR patients deriving from the VAC cohort (p = 0.001) (Table 4).
In multivariate analysis of the matched cohort, temporizing VAC remained independently associated with increased LR (OR = 4.117; 95% CI 1.593–10.640; p = 0.003). Radiation therapy demonstrated about a 75% reduction in odds of LR (OR = 0.256; 95% CI, 0.109–0.602; p = 0.002). Patients presenting with recurrent disease had approximately 4 times higher odds of LR (OR = 4.003; 95% CI, 1.458–10.989; p = 0.007). Neither chemotherapy (p = 0.244) nor follow-up duration (p = 0.137) were associated with LR. Notably initial margin status was not independently associated with LR following multivariable adjustment (p = 0.114) (Table 5).
Of the 34 LR patients, median LR-free survival was 20.9 months (95% CI, 11.2–23.8) for VAC patients and 11 months (95% CI, 2.0–16.0) for non-VAC patients. When time-to-event analyses were performed for the matched cohorts, the difference in median LR-free survival between the cohorts was statistically significant (p = 0.0276) (Figure 2).
4. Discussion
In this multi-institutional cohort, patients managed with staged resection and temporizing VAC represented a distinctly higher-risk clinical subgroup. Compared with patients treated without VAC, these individuals more frequently harbored high-grade tumors, advanced-staged disease, infiltrative histologies, and complex oncologic presentations. They were also more likely to have undergone prior unplanned excision or to present with recurrent disease. Furthermore, VAC patients tended to require more extensive soft-tissue reconstruction, reflecting both tumor- and treatment-related complexity. Collectively, these characteristics are well-established contributors to LR [20,21] and underscore the non-random clinical context in which staged resection with temporizing VAC is typically employed. Our analysis suggests that VAC use may be associated with increased time to LR; however, due to low event frequencies, we are likely underpowered to draw definitive conclusions.
Across both unmatched and grade-matched analyses, staged resection with temporizing VAC was not associated with improved LR rates. Although VAC use remained associated with higher LR rates after multivariable adjustment, this finding should not be interpreted as evidence that VAC therapy contributes causally to recurrence. Instead, VAC use appears to function as a marker of tumors with inherently aggressive biology, infiltrative growth patterns, and compromised oncologic margins: clinical scenarios in which the risk of LR may not be fully mitigated by surgical staging alone. With these limitations in mind, the intent of VAC therapy should be to facilitate margin assessment and staged reconstructive planning [22,23,24], not to alter tumor biology or compensate for biologically unfavorable disease.
Although tumor diameter did not differ between cohorts, the significantly higher rate of flap reconstruction among the VAC cohort likely reflects the combined influence of infiltrative histology (predominantly myxofibrosarcoma), higher rates of prior unplanned excision, and recurrent disease necessitating wider re-excision, greater use of preoperative radiation compromising primary closure, and institutional differences in reconstructive practice. This suggests that tumor diameter alone is an incomplete measure of surgical defect complexity, as tumor depth, volume, growth pattern, and the extent of the required re-excision field all contribute to reconstructive decision-making.
Notably, initial positive margin status was associated with LR in the unmatched analysis but not after grade-based matching, likely reflecting reduced statistical power and collinearity with tumor grade, histology, and presentation status. These further findings highlight the complex interplay between surgical margins and underlying tumor biology [25,26]. In certain cases, positive margins may reflect diffuse microscopic contamination or infiltrative tumor behavior rather than a technically correctable surgical error [27,28]. Although a central purpose of staged resection is to facilitate final negative margins, particularly for high-risk clinical scenarios such as myxofibrosarcoma or prior unplanned excision, we found that final margin status did not differ between cohorts and was not associated with LR in either analysis. This suggests VAC-facilitated re-excision may be insufficient to meaningfully alter recurrence risk, despite achieving negative margins.
Consistent with prior literature, radiation demonstrated a protective association against LR across multiple analyses [29,30]. Temporizing VAC may be able to facilitate adjuvant radiotherapy by better demarcating the tumor bed and reducing overall toxicity [31], particularly in highly infiltrative STS. Additionally, higher rates of metastasis and mortality were observed among patients who developed LR in the unmatched cohort, aligning with established associations linking local failure to systemic progression [5,6]. The attenuation of these associations after matching further suggests that adverse oncologic outcomes are driven predominantly by underlying tumor biology rather than LR alone [28].
Taken together, these findings reinforce that temporizing VAC should be viewed primarily as a reconstructive and logistical strategy rather than an oncologic intervention. While temporizing VAC may offer advantages in managing complex wounds and facilitating staged reconstruction, its use should not substitute for meticulous preoperative planning, careful assessment of tumor extent, and adherence to sound oncologic surgical principles.
Limitations
This study is limited by its retrospective design and relatively low event rates despite multi-institutional collaboration, which reduced statistical power and constrained multivariable analysis. Despite restricting the cohorts to superficial tumors, differences in tumor biology, presentation status, and institutional practices persisted between treatment groups, reflecting the non-random selection of patients for VAC therapy and introducing confounding by indication. Follow-up duration, while comparable to prior literature, may be insufficient to capture late recurrences and establish comparison of long-term recurrence rates. Limited recurrence events and small subgroups also precluded robust adjustment for tumor grade and histologic subtype (Tables S1 and S2). Notably, myxofibrosarcoma, which carries an inherently higher risk of LR, was disproportionately represented in the VAC cohort and may have confounded the observed association. Surgeon-specific decision-making, margin assessment techniques, and institutional differences in pathology turnaround time were not captured and may have influenced both the use of VAC and oncologic outcomes. Finally, the absence of standardized criteria for selecting patients for staged resection with VAC introduces variability that may limit generalizability. Prospective studies or consensus-driven guidelines are needed to better define which patients may derive the greatest benefit from this approach.
Despite these limitations, this multi-institutional study provides one of the broadest evaluations of temporizing VAC across the spectrum of superficial STS. Our findings suggest that VAC use may be most valuable in facilitating complex soft tissue reconstruction and radiation therapy rather than mitigating oncologic outcomes.
5. Conclusions
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- Staged resection with temporizing VAC was not associated with improved LR rates, with the VAC cohort possessing intrinsically higher-risk tumor biology and complex oncologic presentations.
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- LR risk in such complex patients may not be fully mitigated by surgical staging.
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- VAC use should be viewed as an adjunct for complex reconstructive planning and facilitation of radiation therapy.
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- Future efforts should focus on establishing standardized indications for staged resection in STS surgery.
Supplementary Materials
The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/cancers18121984/s1, Table S1: Full distribution of tumor histology, LR, and VAC treatment for unmatched analysis; Table S2: Full distribution of tumor histology, LR, and VAC treatment for matched analysis.
Author Contributions
Conceptualization, C.C. (Chloe Chose) and A.L.L.; methodology, V.J., R.M. and A.L.L.; formal analysis, V.J. and R.M.; investigation, C.C. (Chloe Chose), T.K., L.H., A.M.G., C.C. (Caleb Cummings), J.C. and T.H.H.; writing—original draft preparation, C.C. (Chloe Chose) and A.L.L.; writing—review and editing, E.T.N., K.A.R., P.C.F., J.S.W., D.J., O.B., R.M., S.A.L.-C., K.T. and A.L.L.; visualization, C.C. (Chloe Chose) and T.H.H.; supervision, E.T.N., K.A.R., P.C.F., J.S.W., D.J., O.B., S.A.L.-C., K.T. and A.L.L.; project administration, C.C. (Chloe Chose) and A.L.L. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Moffitt Cancer Center (MCC 16782) on 31 October 2024.
Informed Consent Statement
The study was granted a waiver for obtaining informed consent due to its retrospective design.
Data Availability Statement
The data is stored internally at Moffitt Cancer Center, Massachusetts General Hospital, and Mount Sinai Hospital. If there is interest in obtaining the data, please contact the study team.
Conflicts of Interest
The authors declare no conflicts of interest.
Abbreviations
The following abbreviations are used in this manuscript:
| VAC | Vacuum-assisted closure |
| STS | Soft tissue sarcoma |
| LR | Local recurrence |
| DFSP | Dermatofibrosarcoma protuberans |
| UPS | Undifferentiated pleomorphic sarcoma |
Appendix A
Table A1.
Demographics, tumor and treatment information, and outcomes of unmatched analysis.
| Non-VAC (n = 331) | VAC (n = 188) | |||
|---|---|---|---|---|
| Variable | n (%) or Mean ± SD | n (%) or Mean ± SD | p-Value | |
| Age (years) | 59.92 ± 18.90 | 63.86 ± 15.62 | 0.02 | |
| Gender | Male | 202 (61) | 97 (51.6) | 0.037 |
| Female | 129 (39) | 91 (48.4) | ||
| Race | White | 215 (69.8) | 157 (86.3) | <0.001 |
| Non-White | 93 (30.2) | 25 (13.7) | ||
| Ethnicity | Hispanic/Latino | 6 (2) | 19 (10.3) | <0.001 |
| Non-Hispanic/Latino | 298 (98) | 165 (89.7) | ||
| Tumor diameter (cm) | 5.46 ± 3.72 | 5.69 ± 3.48 | 0.226 | |
| Tumor diameter | Less than 5 cm | 178 (65.7) | 93 (50.5) | 0.033 |
| 5–10 cm | 90 (29.5) | 75 (40.8) | ||
| Greater than 10 cm | 37 (12.1) | 16 (8.7) | ||
| Grade | 1 | 71 (23.6) | 9 (5.4) | <0.001 |
| 2 | 132 (43.9) | 50 (29.9) | ||
| 3 | 98 (32.6) | 108 (64.7) | ||
| Stage | 1 | 65 (23.3) | 14 (8.4) | <0.001 |
| 2 | 121 (43.4) | 73 (44) | ||
| 3 | 90 (32.3) | 72 (43.4) | ||
| 4 | 3 (1.1) | 7 (4.2) | ||
| Presenting status | Primary | 318 (96.1) | 165 (87.8) | <0.001 |
| Recurrent | 13 (3.9) | 23 (12.2) | ||
| Site | Upper extremity | 106 (32) | 49 (26.2) | 0.007 |
| Lower extremity | 189 (57.1) | 114 (60.4) | ||
| Trunk | 36 (10.9) | 19 (10.2) | ||
| Scalp | 0 (0) | 6 (3.2) | ||
| Prior unplanned excision | No | 193 (58.3) | 82 (43.6) | 0.001 |
| Yes | 138 (41.7) | 106 (56.4) | ||
| Diagnosis | Myxofibrosarcoma | 84 (25.4) | 91 (48.4) | <0.001 |
| UPS | 34 (10.3) | 22 (11.7) | ||
| Leiomyosarcoma | 68 (20.5) | 9 (4.8) | ||
| Fibrosarcoma | 21 (6.3) | 1 (0.5) | ||
| Other STS | 124 (37.5) | 65 (34.6) | ||
| Initial margin status | Negative | 291 (87.9) | 126 (67) | <0.001 |
| Positive | 40 (12.1) | 62 (33) | ||
| Final margin status | Negative | 291 (87.9) | 175 (93.1) | 0.062 |
| Positive | 40 (12.1) | 13 (6.9) | ||
| Radiation | No | 218 (65.8) | 61 (32.4) | <0.001 |
| Yes | 113 (34.2) | 127 (67.6) | ||
| Chemotherapy | No | 319 (96.4) | 159 (84.6) | <0.001 |
| Yes | 12 (3.6) | 29 (15.4) | ||
| Soft tissue coverage | Primary closure | 159 (48) | 27 (14.4) | 0.001 |
| Skin graft | 68 (20.5) | 60 (31.9) | ||
| Flap reconstruction | 104 (31.4) | 101 (53.7) | ||
| Follow up | 45.27 ± 25.35 | 38.99 ± 27.05 | 0.001 | |
| LR | No | 315 (95.2) | 158 (84) | <0.001 |
| Yes | 16 (4.8) | 30 (16) | ||
| Metastasis | No | 284 (85.8) | 159 (84.6) | 0.704 |
| Yes | 47 (14.2) | 29 (15.4) | ||
| Time to metastasis (months) | 22.77 ± 27.58 | 17.07 ± 17.03 | 0.674 | |
| Overall survival | Alive | 278 (84) | 167 (88.8) | 0.129 |
| Dead | 53 (16) | 21 (11.2) | ||
Table A2.
Distribution and association of LR for unmatched analysis.
| No LR (n = 473) | LR (n = 46) | |||
|---|---|---|---|---|
| Variable | n (%) or Mean ± SD | n (%) or Mean ± SD | p-Value | |
| Age (years) | 60.59 ± 17.67 | 69.09 ± 18.23 | 0.001 | |
| Gender | Male | 267 (56.4) | 32 (69.6) | 0.086 |
| Female | 206 (43.6) | 14 (30.4) | ||
| Race | White | 337 (75.6) | 35 (79.5) | 0.555 |
| Non-White | 109 (24.4) | 9 (20.5) | ||
| Ethnicity | Hispanic/Latino | 21 (4.7) | 4 (9.3) | 0.263 |
| Non-Hispanic/Latino | 424 (95.3) | 39 (90.7) | ||
| Tumor diameter (cm) | 5.40 ± 3.41 | 6.98 ± 5.17 | 0.048 | |
| Tumor diameter | Less than 5 cm | 251 (56.5) | 20 (44.4) | 0.158 |
| 5–10 cm | 148 (33.3) | 17 (37.8) | ||
| Greater than 10 cm | 45 (10.1) | 8 (17.8) | ||
| Grade | 1 | 80 (18.8) | 0 (0) | <0.001 |
| 2 | 170 (39.9) | 12 (28.6) | ||
| 3 | 176 (41.3) | 30 (71.4) | ||
| Stage | 1 | 78 (19.3) | 1 (2.4) | <0.001 |
| 2 | 181 (44.8) | 13 (31.7) | ||
| 3 | 137 (33.9) | 25 (61) | ||
| 4 | 8 (2) | 2 (4.9) | ||
| Presenting status | Primary | 446 (94.3) | 37 (80.4) | 0.002 |
| Recurrent | 26 (5.7) | 9 (19.6) | ||
| Site | Upper extremity | 144 (30.5) | 11 (23.9) | 0.017 |
| Lower extremity | 277 (58.7) | 25 (54.3) | ||
| Trunk | 48 (10.2) | 7 (15.2) | ||
| Scalp | 3 (0.6) | 3 (6.5) | ||
| Prior unplanned excision | No | 248 (52.4) | 27 (58.7) | 0.416 |
| Yes | 225 (47.6) | 19 (41.3) | ||
| Diagnosis | Myxofibrosarcoma | 155 (32.8) | 20 (43.5) | 0.040 |
| UPS | 47 (9.9) | 9 (19.6) | ||
| Leiomyosarcoma | 75 (15.9) | 2 (4.3) | ||
| Fibrosarcoma | 21 (4.4) | 1 (2.2) | ||
| Other STS | 175 (37) | 14 (30.4) | ||
| Initial margin status | Negative | 390 (82.5) | 27 (58.7) | <0.001 |
| Positive | 83 (17.5) | 19 (41.3) | ||
| Final margin status | Negative | 428 (90.5) | 38 (82.6) | 0.12 |
| Positive | 45 (9.5) | 8 (17.4) | ||
| Radiation | No | 252 (53.4) | 26 (56.5) | 0.684 |
| Yes | 220 (46.6) | 20 (43.5) | ||
| Chemotherapy | No | 441 (93.2) | 37 (80.4) | 0.006 |
| Yes | 32 (6.8) | 9 (19.6) | ||
| Soft tissue coverage | Primary closure | 176 (37.2) | 10 (21.7) | 0.035 |
| Skin graft | 118 (24.9) | 10 (21.7) | ||
| Flap reconstruction | 179 (37.8) | 26 (56.5) | ||
| Follow up | 43.96 ± 26.18 | 33.04 ± 23.64 | 0.003 | |
| VAC | No | 315 (66.6) | 16 (34.8) | <0.001 |
| Yes | 158 (33.4) | 30 (65.2) | ||
| Metastasis | No | 410 (86.7) | 33 (71.7) | 0.006 |
| Yes | 63 (13.3) | 13 (28.3) | ||
| Time to metastasis (months) | 20.24 ± 24.92 | 23.03 ± 21.56 | 0.359 | |
| Overall survival | Alive | 411 (86.9) | 34 (73.9) | 0.016 |
| Dead | 62 (13.1) | 12 (26.1) | ||
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Figure 1.
Kaplan–Meier analysis of LR-free survival, unmatched analysis.
Figure 2.
Kaplan–Meier analysis of LR-free survival, matched analysis.
Table 1.
Association of LR after Univariate and Multivariate Analysis for unmatched analysis.
| Univariate Analysis | Multivariate Analysis | ||
|---|---|---|---|
| Variable | OR (95% CI) | OR (95% CI) | p-Value |
| Temporizing VAC | 3.738 (1.979, 7.062) | 2.910 (1.408, 6.014) | 0.004 |
| Presenting Status | 4.018 (1.760, 9.174) | 3.080 (1.257, 7.549) | 0.014 |
| Chemotherapy | 3.352 (1.488, 7.551) | 1.954 (0.810, 4.717) | 0.136 |
| Radiation | 0.881 (0.479, 1.622) | 0.468 (0.233, 0.942) | 0.033 |
| Follow Up | 0.981 (0.967, 0.995) | 0.988 (0.974, 1.003) | 0.114 |
| Initial Margin | 3.307 (1.756, 6.227) | 2.603 (1.287, 5.265) | 0.008 |
Table 2.
Demographics and tumor information of matched analysis.
| Non-VAC (n = 157) | VAC (n = 157) | |||
|---|---|---|---|---|
| Variable | n (%) or Mean ± SD | n (%) or Mean ± SD | p-Value | |
| Age (years) | 62.4 ± 18.35 | 64.50 ± 15.31 | 0.278 | |
| Gender | Male | 93 (59.2) | 81 (51.6) | 0.173 |
| Female | 64 (40.8) | 76 (48.4) | ||
| Race | White | 96 (64.9) | 131 (86.8) | <0.001 |
| Non-White | 52 (35.1) | 20 (13.2) | ||
| Ethnicity | Hispanic/Latino | 2 (1.4) | 16 (10.5) | 0.001 |
| Non-Hispanic/Latino | 137 (98.6) | 137 (89.5) | ||
| Tumor diameter (cm) | 6.02 ± 4.04 | 6.03 ± 3.52 | 0.551 | |
| Tumor diameter | Less than 5 cm | 80 (54.4) | 71 (46.1) | 0.041 |
| 5–10 cm | 45 (30.6) | 68 (44.2) | ||
| Greater than 10 cm | 22 (15.0) | 15 (9.7) | ||
| Grade | 1 | 9 (5.7) | 9 (5.7) | 1 |
| 2 | 50 (31.8) | 50 (31.8) | ||
| 3 | 98 (62.4) | 98 (62.4) | ||
| Stage | 1 | 8 (5.4) | 14 (9) | 0.172 |
| 2 | 76 (51.7) | 67 (42.9) | ||
| 3 | 61 (41.5) | 68 (43.6) | ||
| 4 | 2 (1.4) | 7 (4.5) | ||
| Presenting status | Primary | 151 (96.2) | 137 (87.3) | 0.004 |
| Recurrent | 6 (3.8) | 20 (12.7) | ||
| Site | Upper extremity | 50 (31.8) | 38 (24.2) | 0.141 |
| Lower extremity | 91 (58) | 102 (65) | ||
| Trunk | 16 (10.2) | 13 (8.3) | ||
| Scalp | 0 (0) | 3 (1.9) | ||
| Prior unplanned excision | No | 92 (58.6) | 72 (45.9) | 0.024 |
| Yes | 65 (41.4) | 85 (54.1) | ||
| Diagnosis | Myxofibrosarcoma | 43 (27.4) | 85 (54.1) | <0.001 |
| UPS | 23 (14.6) | 19 (12.1) | ||
| Leiomyosarcoma | 28 (17.8) | 9 (5.7) | ||
| Fibrosarcoma | 7 (4.5) | 1 (0.6) | ||
| Other STS | 56 (35.7) | 43 (27.4) | ||
Table 3.
Treatment information and outcomes of matched analysis.
| Non-VAC (n = 157) | VAC (n = 157) | |||
|---|---|---|---|---|
| Variable | n (%) or Mean ± SD | n (%) or Mean ± SD | p-Value | |
| Initial margin status | Negative | 141 (89.8) | 105 (66.9) | <0.001 |
| Positive | 16 (10.2) | 52 (33.1) | ||
| Final margin status | Negative | 141 (89.8) | 145 (92.4) | 0.428 |
| Positive | 16 (10.2) | 12 (7.6) | ||
| Radiation | No | 96 (61.5) | 42 (26.8) | <0.001 |
| Yes | 60 (38.5) | 115 (73.2) | ||
| Chemotherapy | No | 147 (93.6) | 134 (85.4) | 0.017 |
| Yes | 10 (6.4) | 23 (14.6) | ||
| Soft tissue coverage | Primary closure | 65 (41.4) | 20 (12.7) | <0.001 |
| Skin graft | 37 (23.6) | 48 (30.6) | ||
| Flap reconstruction | 55 (35) | 89 (56.7) | ||
| Follow up | 42.94 ± 25.66 | 40.60 ± 27.99 | 0.165 | |
| LR | No | 149 (94.9) | 131 (83.4) | 0.001 |
| Yes | 8 (5.1) | 26 (16.6) | ||
| Metastasis | No | 123 (78.3) | 130 (82.8) | 0.318 |
| Yes | 34 (21.7) | 27 (17.2) | ||
| Time to metastasis (months) | 20.06 ± 26.55 | 17.00 ± 17.70 | 0.89 | |
| Overall survival | Alive | 118 (75.2) | 138 (87.9) | 0.004 |
| Dead | 39 (24.8) | 19 (12.1) | ||
Table 4.
Distribution and associations of LR for matched analysis.
| No LR (n = 280) | LR (n = 34) | |||
|---|---|---|---|---|
| Variable | n (%) or Mean ± SD | n (%) or Mean ± SD | p-Value | |
| Age (years) | 62.64 ± 16.45 | 68.47 ± 19.92 | 0.013 | |
| Gender | Male | 151 (53.9) | 23 (67.6) | 0.129 |
| Female | 129 (46.1) | 11 (32.4) | ||
| Race | White | 199 (74.8) | 28 (84.8) | 0.203 |
| Non-White | 67 (25.2) | 5 (15.2) | ||
| Ethnicity | Hispanic/Latino | 14 (5.4) | 4 (12.5) | 0.12 |
| Non-Hispanic/Latino | 246 (94.6) | 28 (84.8) | ||
| Tumor diameter (cm) | 5.84 ± 3.44 | 7.51 ± 5.71 | 0.189 | |
| Tumor diameter | Less than 5 cm | 137 (51.1) | 14 (42.4) | 0.268 |
| 5–10 cm | 101 (37.7) | 12 (36.4) | ||
| Greater than 10 cm | 30 (11.2) | 7 (21.2) | ||
| Grade | 1 | 18 (6.4) | 0 (0) | 0.029 |
| 2 | 94 (33.6) | 6 (17.6) | ||
| 3 | 168 (60) | 28 (82.4) | ||
| Stage | 1 | 21 (7.8) | 1 (3) | 0.051 |
| 2 | 133 (49.3) | 10 (30.3) | ||
| 3 | 109 (40.4) | 20 (60.6) | ||
| 4 | 7 (2.6) | 2 (6.1) | ||
| Presenting status | Primary | 262 (93.6) | 26 (76.5) | 0.003 |
| Recurrent | 18 (6.4) | 8 (23.5) | ||
| Site | Upper extremity | 81 (28.9) | 7 (20.6) | 0.024 |
| Lower extremity | 174 (62.1) | 19 (55.9) | ||
| Trunk | 23 (8.2) | 6 (17.6) | ||
| Scalp | 1 (0.4) | 2 (5.9) | ||
| Prior unplanned excision | No | 143 (51.1) | 21 (61.8) | 0.238 |
| Yes | 137 (48.9) | 13 (38.2) | ||
| Diagnosis | Myxofibrosarcoma | 114 (40.7) | 14 (41.2) | 0.003 |
| UPS | 34 (12.1) | 8 (23.5) | ||
| Leiomyosarcoma | 35 (12.5) | 2 (5.9) | ||
| Fibrosarcoma | 7 (2.5) | 1 (2.9) | ||
| Other STS | 90 (32.1) | 9 (26.5) | ||
| Initial margin status | Negative | 225 (80.4) | 21 (61.8) | 0.013 |
| Positive | 55 (19.6) | 13 (38.2) | ||
| Final margin status | Negative | 257 (91.8) | 29 (85.3) | 0.206 |
| Positive | 24 (8.2) | 5 (14.7) | ||
| Radiation | No | 118 (42.3) | 20 (58.8) | 0.067 |
| Yes | 161 (57.7) | 14 (41.2) | ||
| Chemotherapy | No | 254 (90.7) | 27 (79.4) | 0.068 |
| Yes | 26 (9.3) | 7 (20.6) | ||
| Soft tissue coverage | Primary closure | 78 (27.9) | 7 (20.6) | 0.275 |
| Skin graft | 78 (27.9) | 7 (20.6) | ||
| Flap reconstruction | 124 (44.3) | 20 (58.8) | ||
| Follow up | 43.02 ± 26.95 | 31.48 ± 23.77 | 0.009 | |
| VAC | No | 149 (53.2) | 8 (23.5) | 0.001 |
| Yes | 131 (46.8) | 26 (76.5) | ||
| Metastasis | No | 228 (81.4) | 25 (73.5) | 0.272 |
| Yes | 52 (18.6) | 9 (26.5) | ||
| Time to metastasis (months) | 17.89 ± 22.83 | 24.31 ± 25.54 | 0.542 | |
| Overall survival | Alive | 231 (82.5) | 25 (73.5) | 0.203 |
| Dead | 49 (17.5) | 9 (26.5) | ||
Table 5.
Association of LR after Univariate and Multivariate Analysis for matched analysis.
| Univariate Analysis | Multivariate Analysis | ||
|---|---|---|---|
| Variable | OR (95% CI) | OR (95% CI) | p-Value |
| Temporizing VAC | 3.697 (1.618, 8.447) | 4.117 (1.593, 10.640) | 0.003 |
| Radiation | 0.513 (0.249, 1.057) | 0.256 (0.109, 0.602) | 0.002 |
| Initial Margin | 2.532 (1.194, 5.371) | 1.995 (0.848, 4.695) | 0.114 |
| Chemotherapy | 2.533 (1.005, 6.381) | 1.819 (0.665, 4.972) | 0.244 |
| Follow Up | 0.980 (0.964, 0.997) | 0.986 (0.969, 1.004) | 0.137 |
| Presenting Status | 4.479 (1.776, 11.297) | 4.003 (1.458, 10.989) | 0.007 |
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Chose, C.; Karadimas, T.; Hederick, L.; Griffin, A.M.; Jajoo, V.; Cummings, C.; Connolly, J.; Huynh, T.H.; Newman, E.T.; Raskin, K.A.; et al. Staged Resection with Temporizing VAC and Local Recurrence for Soft Tissue Sarcomas: A Multi-Institutional Review. Cancers 2026, 18, 1984. https://doi.org/10.3390/cancers18121984
AMA Style
Chose C, Karadimas T, Hederick L, Griffin AM, Jajoo V, Cummings C, Connolly J, Huynh TH, Newman ET, Raskin KA, et al. Staged Resection with Temporizing VAC and Local Recurrence for Soft Tissue Sarcomas: A Multi-Institutional Review. Cancers. 2026; 18(12):1984. https://doi.org/10.3390/cancers18121984
Chicago/Turabian StyleChose, Chloe, Thomas Karadimas, Lucy Hederick, Anthony M. Griffin, Veena Jajoo, Caleb Cummings, Joseph Connolly, Thien Huong Huynh, Erik T. Newman, Kevin A. Raskin, and et al. 2026. "Staged Resection with Temporizing VAC and Local Recurrence for Soft Tissue Sarcomas: A Multi-Institutional Review" Cancers 18, no. 12: 1984. https://doi.org/10.3390/cancers18121984
APA StyleChose, C., Karadimas, T., Hederick, L., Griffin, A. M., Jajoo, V., Cummings, C., Connolly, J., Huynh, T. H., Newman, E. T., Raskin, K. A., Ferguson, P. C., Wunder, J. S., Joyce, D., Binitie, O., Mhaskar, R., Lozano-Calderon, S. A., Tsoi, K., & Lazarides, A. L. (2026). Staged Resection with Temporizing VAC and Local Recurrence for Soft Tissue Sarcomas: A Multi-Institutional Review. Cancers, 18(12), 1984. https://doi.org/10.3390/cancers18121984
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