What is it about?

Soft tissue sarcomas are rare malignant tumours where complete surgical removal provides the primary opportunity for cure. In approximately 15% to 30% of surgeries, microscopic cancer cells are left behind at the edge of the removed specimen-known as a microscopically positive margin (R1 resection). This review outlines an evidence-based roadmap to help clinicians manage positive surgical margins. Rather than using a one-size-fits-all protocol, optimal treatment depends on tumour location, histologic subtype, cancer grade, and whether the positive margin was deliberately planned to preserve essential blood vessels, nerves, or organs. The available strategies include repeat surgery (re-excision), targeted radiotherapy, risk-stratified chemotherapy, or structured active surveillance.

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Why is it important?

A positive margin substantially elevates the risk of local recurrence and impairs overall survival, yet clinical management has historically remained controversial. This work synthesises landmark trials and international guidelines from ESMO, NCCN, and the UK into a unified clinical framework. It demonstrates that planned positive margins on vital organs or major vessels achieve local control rates comparable to clear margins and do not require mutilating repeat operations. Conversely, inadvertent positive margins resulting from non-specialist or unplanned excisions carry recurrence rates exceeding 35% and strongly benefit from early specialist re-excision. Furthermore, the review clarifies the selective role of adjuvant chemotherapy using validated nomograms like Sarculator, empowering multidisciplinary teams to maximise oncological control while preserving patient limb function and overall quality of life.

Perspectives

Sarcoma surgery must balance oncological safety with long-term quality of life. The single most impactful intervention to prevent positive margins is referring patients to a dedicated multidisciplinary sarcoma centre before the initial biopsy or excision. When an R1 margin occurs, decision-making should be individualized: we must avoid both under-treating aggressive tumours and performing unnecessarily mutilating re-operations when radiation or structured surveillance is the safer choice.

Piotr Remiszewski
Maria Sklodowska - Curie National Research Institute of Oncology Poland

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This page is a summary of: Optimising Clinical Outcomes Following R1 Resection in Soft Tissue Sarcoma: An Evidence-Based Approach, Current Treatment Options in Oncology, August 2026, Springer Science + Business Media,
DOI: 10.1007/s11864-026-01410-3.
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