AI Versus MD: Evaluating the surgical decision-making accuracy of ChatGPT-4.

BACKGROUND: ChatGPT-4 is a large language model with possible applications to surgery education The aim of this study was to investigate the accuracy of ChatGPT-4's surgical decision-making compared with general surgery residents and attending surgeons. METHODS: Five clinical scenarios were created from actual patient data based on common general surgery diagnoses. Scripts were developed to sequentially provide clinical information and ask decision-making questions. Responses to the prompts were scored based on a standardized rubric for a total of 50 points. Each clinical scenario was run through Chat GPT-4 and sent electronically to all general surgery residents and attendings at a single institution. Scores were compared using Wilcoxon rank sum tests. RESULTS: On average, ChatGPT-4 scored 39.6 points (79.2%, standard deviation ± 0.89 points). A total of five junior residents, 12 senior residents, and five attendings completed the clinical scenarios (resident response rate = 15.9%; attending response rate = 13.8%). On average, the junior residents scored a total of 33.4 (66.8%, standard deviation ± 3.29), senior residents 38.0 (76.0%, standard deviation ± 4.75), and attendings 38.8 (77.6%, standard deviation ± 5.45). ChatGPT-4 scored significantly better than junior residents (P = .009) but was not significantly different from senior residents or attendings. ChatGPT-4 was significantly better than junior residents at identifying the correct operation to perform (P = .0182) and recommending additional workup for postoperative complications (P = .012). CONCLUSION: ChatGPT-4 performed superior to junior residents and equivalent to senior residents and attendings when faced with surgical patient scenarios. Large language models, such as ChatGPT, may have the potential to be an educational resource for junior residents to develop surgical decision-making skills.

Utility of LEF1 to differentiate desmoid fibromatosis from its histologic mimics.

Diagnosis of desmoid-type fibromatosis (DF) may be challenging on biopsy due to morphologic overlap with reactive fibrosis (scar) and other uniform spindle cell neoplasms. Evaluation of nuclear ß-catenin, a surrogate of Wnt pathway activation, is often difficult in DF due to weak nuclear expression and high background membranous/cytoplasmic staining. Lymphoid enhancer-factor 1 (LEF1) is a recently characterized effector partner of ß-catenin which activates the transcription of target genes. We investigated the performance of LEF1 and ß-catenin immunohistochemistry in a retrospective series of 156 soft tissue tumors, including 35 DF, 3 superficial fibromatosis, and 121 histologic mimics (19 soft tissue perineurioma, 8 colorectal perineurioma, 4 intraneural perineurioma, 26 scars, 23 nodular fasciitis, 6 low-grade fibromyxoid sarcomas, 6 angioleiomyomas, 5 neurofibromas, 5 dermatofibrosarcoma protuberans, 3 low-grade myofibroblastic sarcomas, 3 synovial sarcomas, 3 inflammatory myofibroblastic tumors, 2 schwannomas, and 1 each of Gardner-associated fibroma, radiation-associated spindle cell sarcoma, sclerotic fibroma, dermatofibroma, and glomus tumor). LEF1 expression was not only seen in 33/35 (94%) of DF but also observed in 19/23 (82%) nodular fasciitis, 7/19 (37%) soft tissue perineurioma, 2/3 (66%) synovial sarcoma, and 6/26 (23%) scar, as well as in 1 radiation-associated spindle cell sarcoma. The sensitivity and specificity of LEF1 IHC for diagnosis of DF were 94% and 70%, respectively. By comparison, ß-catenin offered similar sensitivity, 94%, but 88% specificity. Positivity for LEF1 and ß-catenin in combination showed sensitivity of 89%, lower than the sensitivity of ß-catenin alone (94%); however, the combination of both LEF1 and ß-catenin improved specificity (96%) compared to the specificity of ß-catenin alone (88%). Although LEF1 has imperfect specificity in isolation, this stain has diagnostic utility when used in combination with ß-catenin.

Top Gastric Cancer Articles from 2022 and 2023 to Inform Your Cancer Practice.

BACKGROUND: The multimodality management of patients with gastroesophageal cancers is rapidly evolving, with the introduction of new therapies against potential molecular targets paving the way to personalized medicine for patients with both resectable and metastatic disease. Over the past 2 years, several important studies evaluating these new targeted therapies, as well as minimally invasive surgical approaches to gastric cancer, have been published. METHODS: This review article summarizes the top studies published in gastric cancer over the past 2 years that are fundamentally changing our practice approach to gastric cancer patients. RESULTS: First, the long-term safety and efficacy of laparoscopic distal gastrectomy as compared with open gastrectomy for locally advanced gastric cancer was confirmed with the publication of the 5-year outcomes of the CLASS-01 and KLASS-02 randomized clinical trials. In addition, several important studies of perioperative immunotherapy for patients with resectable gastric or gastroesophageal junction cancers are ongoing, and in 2022, an interim analysis of the DANTE trial and the final results of the GERCOR NEONIPIGA study were reported. Lastly, the KEYNOTE-859 and SPOTLIGHT trials address an unmet need for additional targeted therapies for patients with previously untreated, human epidermal growth factor receptor-2 (HER2)-negative, unresectable or metastatic gastroesophageal cancers, incorporating immune checkpoint inhibitors and targeting Claudin-18 isoform 2 (CLDN18.2) with the monoclonal antibody zolbetuximab, respectively. CONCLUSIONS: This article summarizes the findings and implications of several important studies published over the past 2 years that are fundamentally changing the way we treat patients with gastroesophageal cancer.

Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial.

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

Reusable scrub caps are cost-effective and help reduce the climate footprint of surgery.

BACKGROUND: As the US healthcare sector contributes to 5-10% of national CO2 emissions, with a substantial contribution from surgical services, a collective effort is important to minimize the climate footprint of surgery. Solid plastic waste generated from single-use items in operating rooms is a major contributor to greenhouse gas emissions. To address this problem, we implemented a pilot study to replace single-use scrub caps with reusable caps. METHODS: Ninety-two surgical trainees at the Massachusetts General Hospital, Boston, were provided reusable personalized scrub caps. Over 6 months, their use of the reusable cap was compared with corresponding use of disposable single-use caps. We then used the cost of raw materials, fabric and cap manufacturing, transportation, and end-of-life/waste treatment to perform an economic and environmental burden analysis. RESULTS: After 6 months of reusable scrub cap use, 33 participants (51.6%) reported that due to their use of a reusable scrub cap, their utilization of disposable bouffant or caps had decreased by 76-100%. This was associated with a significant reduction in the use of single-use caps after adjusting for surgical case volume. The carbon footprint of single-use scrub caps was significantly higher than reusable caps during the study period. Reusable scrub cap usage also strongly correlated with substantial reductions in energy consumption and freshwater toxicity. CONCLUSIONS: Reusable personalized cloth scrub caps are cost-effective and can help reduce surgery's carbon footprint by reducing waste generated from disposable scrub cap use. More programs should consider replacing single-use polypropylene caps with reusable scrub caps for their operating room staff.

Personalized Scrub Caps for Identification of Surgical Trainees.

This survey study investigates whether personalized scrub caps for surgical trainees can help decrease role and name misidentification, microaggressions, and miscommunication-related delays in patient care.

Impact of supraphysiologic MDM2 expression on chromatin networks and therapeutic responses in sarcoma.

Amplification of MDM2 on supernumerary chromosomes is a common mechanism of P53 inactivation across tumors. Here, we investigated the impact of MDM2 overexpression on chromatin, gene expression, and cellular phenotypes in liposarcoma. Three independent regulatory circuits predominate in aggressive, dedifferentiated tumors. RUNX and AP-1 family transcription factors bind mesenchymal gene enhancers. P53 and MDM2 co-occupy enhancers and promoters associated with P53 signaling. When highly expressed, MDM2 also binds thousands of P53-independent growth and stress response genes, whose promoters engage in multi-way topological interactions. Overexpressed MDM2 concentrates within nuclear foci that co-localize with PML and YY1 and could also contribute to P53-independent phenotypes associated with supraphysiologic MDM2. Importantly, we observe striking cell-to-cell variability in MDM2 copy number and expression in tumors and models. Whereas liposarcoma cells are generally sensitive to MDM2 inhibitors and their combination with pro-apoptotic drugs, MDM2-high cells tolerate them and may underlie the poor clinical efficacy of these agents.

Implementation, Feasibility, and Perception of Facilitated Process Groups in Surgical Residency.

OBJECTIVE: Recent studies have demonstrated burnout in surgeons, with trainees affected at alarming levels. However, few studies have focused on specific wellbeing initiatives in surgical residency. We implemented facilitated process groups at our residency program and aimed to understand the feasibility and perception of this program. DESIGN: We recruited a psychologist to conduct weekly process groups. Each postgraduate year (PGY) class was scheduled for a rotating 1-hour session every 6 weeks during protected didactic time. A presurvey was conducted shortly following program commencement for PGY1-5 residents (11/2020-1/2021) and a postsurvey conducted after 9 to 10 months of implementation for PGY2-5 residents. Surveys included demographics, a 2-item Maslach Burnout Inventory, and questions about stress, lifestyle, and perception of the process groups, including qualitative feedback. SETTING: The study took place at within the General Surgery Residency at Massachusetts General Hospital, a tertiary-care institution in Boston, Massachusetts. PARTICIPANTS: Participants in process groups were all General Surgery residents during the timeframe of the study. Participation in the presurvey and postsurvey was voluntary for residents. RESULTS: A total of 32 and 35 residents completed the presurveys and postsurveys, respectively. Groups were similar with regards to gender and race. A total of 97% and 57% of postsurvey respondents attended ≥1 and ≥3 process groups, respectively, with 95% citing clinical/other obligations as the cause of missing sessions. Perception of process groups was highly positive and persisted across both surveys. There were no significant differences in perception or burnout questions, except for a slight decrease in "I think process groups might help me process personal challenges" on postsurvey. Of 15 qualitative postsurvey responses, 73% were positive and the remainder were neutral. CONCLUSIONS: Based on current measures, it is feasible to implement facilitated process groups for surgical residents. Resident perception of these groups was persistently positive.

Dissection of gastric homeostasis in vivo facilitates permanent capture of isthmus-like stem cells in vitro.

The glandular stomach is composed of two regenerative compartments termed corpus and antrum, and our understanding of the transcriptional networks that maintain these tissues is incomplete. Here we show that cell types with equivalent functional roles in the corpus and antrum share similar transcriptional states including the poorly characterized stem cells of the isthmus region. To further study the isthmus, we developed a monolayer two-dimensional (2D) culture system that is continually maintained by Wnt-responsive isthmus-like cells capable of differentiating into several gastric cell types. Importantly, 2D cultures can be converted into conventional three-dimensional organoids, modelling the plasticity of gastric epithelial cells in vivo. Finally, we utilized the 2D culture system to show that Sox2 is both necessary and sufficient to generate enterochromaffin cells. Together, our data provide important insights into gastric homeostasis, establish a tractable culture system to capture isthmus cells and uncover a role for Sox2 in enterochromaffin cells.

Inpatient Satisfaction With Surgical Resident Care After Elective General and Oncologic Surgery.

OBJECTIVE: To investigate inpatient satisfaction with surgical resident care. BACKGROUND: Surgical trainees are often the primary providers of care to surgical inpatients, yet patient satisfaction with surgical resident care is not well characterized or routinely assessed. METHODS: English-speaking, general surgery inpatients recovering from elective gastrointestinal and oncologic surgery were invited to complete a survey addressing their satisfaction with surgical resident care. Patients positively identified photos of surgical senior residents and interns before completing a modified version of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey (S-CAHPS). Adapted S-CAHPS items were scored using the "top-box" method. RESULTS: Ninety percent of recruited patients agreed to participate (324/359, mean age=62.2, 50.3% male). Patients were able to correctly identify their seniors and interns 85% and 83% of the time, respectively ( P =0.14). On a 10-point scale, seniors had a mean rating of 9.23±1.27 and interns had a mean rating of 9.01±1.49 ( P =0.14). Ninety-nine percent of patients agreed it was important to help in the education of future surgeons. CONCLUSIONS: Surgical inpatients were able to recognize their resident physicians with high frequency and rated resident care highly overall, suggesting that they may serve as a willing source of feedback regarding residents' development of core competencies such as interpersonal skills, communication, professionalism, and patient care. Future work should investigate how to best incorporate patient evaluation of surgical resident care routinely into trainee assessment to support resident development.

Assessing the Safety and Utility of Wound VAC Temporization of the Sarcoma or Benign Aggressive Tumor Bed Until Final Margins Are Achieved.

BACKGROUND: Local recurrence of microinvasive sarcoma or benign aggressive pathologies can be limb- and life-threatening. Although frozen pathology is reliable, tumor microinvasion can be subtle or missed, having an impact on surgical margins and postoperative radiation planning. The authors' service has begun to temporize the tumor bed after primary tumor excision with a wound vacuum-assisted closure (VAC) pending formal margin analysis, with coverage performed in the setting of final negative margins. METHODS: This retrospective analysis included all patients managed at a tertiary referral cancer center with VAC temporization after soft tissue sarcoma or benign aggressive tumor excision from 1 January 2000 to 1 January 2019 and at least 2 years of oncologic follow-up evaluation. The primary outcome was local recurrence. The secondary outcomes were distant recurrence, unplanned return to the operating room for wound/infectious indications, thromboembolic events, and tumor-related deaths. RESULTS: For 62 patients, VAC temporization was performed. The mean age of the patients was 62.2 ± 22.3 years (median 66.5 years; 95% confidence interval [CI] 61.7-72.5 years), and the mean age-adjusted Charlson Comorbidity Index was 5.3 ± 1.9. The most common tumor histology was myxofibrosarcoma (51.6%, 32/62). The mean volume was 124.8 ± 324.1 cm3, and 35.5% (22/62) of the cases were subfascial. Local recurrences occurred for 8.1% (5/62) of the patients. Three of these five patients had planned positive margins, and 17.7% (11/62) of the patients had an unplanned return to the operating room. No demographic or tumor factors were associated with unplanned surgery. CONCLUSIONS: The findings showed that VAC-temporized management of microinvasive sarcoma and benign aggressive pathologies yields favorable local recurrence and unplanned operating room rates suggestive of oncologic and technical safety. These findings will need validation in a future randomized controlled trial.

Perceived Discrimination Among Surgical Residents at Academic Medical Centers.

BACKGROUND: Residents of color experience microaggressions in the work environment, are less likely to feel that they fit into their training programs, and feel less comfortable asking for help. Discrimination has been documented among surgical residents, but has not been extensively studied and largely remains unaddressed. We sought to determine the extent of perceived discrimination among general surgery residents. MATERIALS AND METHODS: Residents who were enrolled in a randomized controlled trial investigating a cultural dexterity curriculum completed baseline assessments prior to randomization that included demographic information and the Everyday Discrimination Scale (EDS). Data from the baseline assessments were analyzed for associations of EDS scores with race, ethnicity, sex, socioeconomic level, language ability, and training level. RESULTS: Of 266 residents across seven residency programs, 145 (55%) were men. Racial breakdown was 157 (59%) White, 45 (17%) Asian, 30 (11%) Black, and 12 (5%) Multiracial. The median EDS score was seven (range: 0-36); 58 (22%) fell into the High EDS score group. Resident race, fluency in a language other than English, and median household income were significantly associated with EDS scores. When controlling for other sociodemographic factors, Black residents were 4.2 (95% CI 1.62-11.01, P = 0.003) times as likely to have High EDS scores than their White counterparts. CONCLUSIONS: Black surgical residents experience high levels of perceived discrimination on a daily basis. Institutional leaders should be aware of these findings as they seek to cultivate a diverse surgical training environment.

Neoadjuvant versus Postoperative Chemoradiotherapy is Associated with Improved Survival for Patients with Resectable Gastric and Gastroesophageal Cancer.

BACKGROUND: The optimal timing of chemoradiotherapy (CRT) for patients with localized gastric cancer remains unclear. This study aimed to compare the survival outcomes between neoadjuvant and postoperative CRT for patients with gastric and gastroesophageal junction (GEJ) cancer. METHODS: This retrospective study analyzed 152 patients with gastric (42%) or GEJ (58%) adenocarcinoma who underwent definitive surgical resection and received either neoadjuvant or postoperative CRT between 2005 and 2017 at the authors' institution. The primary end point of the study was overall survival (OS). RESULTS: The median follow-up period was 37.5 months. Neoadjuvant CRT was performed for 102 patients (67%) and postoperative CRT for 50 patients (33%). The patients who received neoadjuvant CRT were more likely to be male and to have a GEJ tumor, positive lymph nodes, and a higher clinical stage. The median radiotherapy (RT) dose was 50.4 Gy for neoadjuvant RT and 45.0 Gy for postoperative RT (p < 0.001). The neoadjuvant CRT group had a pathologic complete response (pCR) rate of 26% and a greater rate of R0 resection than the postoperative CRT group (95% vs. 76%; p = 0.002). Neoadjuvant versus postoperative CRT was associated with a lower rate of any grade 3+ toxicity (10% vs. 54%; p < 0.001). The multivariable analysis of OS showed lower hazards of death to be independently associated neoadjuvant versus postoperative CRT (hazard ratio [HR] 0.57; 95% confidence interval [CI] 0.36-0.91; p = 0.020) and R0 resection (HR 0.50; 95% CI 0.27-0.90; p = 0.021). CONCLUSIONS: Neoadjuvant CRT was associated with a longer OS, a higher rate of R0 resection, and a lower treatment-related toxicity than postoperative CRT. The findings suggest that neoadjuvant CRT is superior to postoperative CRT in the treatment of gastric and GEJ cancer.

Which Patient Do I Attend to First? Night-float Simulation to Assess Surgical Intern's Clinical Prioritization Skills.

OBJECTIVE: Night-float rotations require general surgery interns to prioritize multiple competing patients' needs efficiently and accurately. Research is lacking on whether these skills can be taught and to what degree the prioritizations taught match overall attending surgeon expectations. DESIGN: A night-float situation was developed to simulate the experience of surgical interns responding to multiple patients' needs. Participants were instructed to rank order 10 patient paper-case scenarios with a variety of clinical urgencies. After completing their first ranking, the interns participated in a faculty-facilitated peer discussion (intervention) and were then instructed to re-rank their priorities. Their performance was compared pre- and post-intervention, and to the ranking of 16 surgery faculty attendings. SETTING: Massachusetts General Hospital, Department of Surgery, Boston, MA. PARTICIPANTS: Post-graduate year (PGY) 1 surgical residents. RESULTS: Two classes of general surgery interns (n = 25) completed the prioritization training simulation in the middle of their internship year, one class in 2018 and one in 2020. Agreement between interns regarding patient prioritization ranking increased after the facilitated peer discussion (pre-intervention mean standard deviation = 1.8 versus 0.9 post-intervention; p = 0.03). In the post-intervention mean rank, four cases moved by one position (p < 0.05). The facilitated discussion resulted in increased absolute agreement between individual interns and attendings' ranks (mean agreement 38 ± 17% pre-intervention Vesus mean 50 ± 20% post-intervention, p = 0.02). The scenarios with highest agreement between interns and attendings concerned patients with the most urgent conditions. Scenarios with the lowest agreement were those ranked with medium-to-low urgency. CONCLUSION: A faculty-led facilitated discussion appears to increase clinical prioritization consistency among surgical interns and better align their prioritizations with expectations of local attending surgeons.

Results and Molecular Correlates from a Pilot Study of Neoadjuvant Induction FOLFIRINOX Followed by Chemoradiation and Surgery for Gastroesophageal Adenocarcinomas.

PURPOSE: We performed a NCI-sponsored, prospective study of neoadjuvant FOLFIRINOX followed by chemoradiation with carboplatin/paclitaxel followed by surgery in patients with locally advanced gastric or gastroesophageal cancer. PATIENTS AND METHODS: The primary objective was to determine completion rate of neoadjuvant FOLFIRINOX × 8 followed by chemoradiation. Secondary endpoints were toxicity and pathologic complete response (pCR) rate. Exploratory analysis was performed of circulating tumor DNA (ctDNA) to treatment response. RESULTS: From October 2017 to June 2018, 25 patients were enrolled. All patients started FOLFIRINOX, 92% completed all eight planned cycles, and 88% completed chemoradiation. Twenty (80%) patients underwent surgical resection, and 7 had a pCR (35% in resected cohort, 28% intention to treat). Tumor-specific mutations were identified in 21 (84%) patients, of whom 4 and 17 patients had undetectable and detectable ctDNA at baseline, respectively. Presence of detectable post-chemoradiation ctDNA (P = 0.004) and/or postoperative ctDNA (P = 0.045) were associated with disease recurrence. CONCLUSIONS: Here we show neoadjuvant FOLFIRINOX followed by chemoradiation for locally advanced gastroesophageal cancer is feasible and yields a high rate of pCR. ctDNA appears to be a promising predictor of postoperative recurrence.See related commentary by Catenacci, p. 6281.

The Resident-Run Minor Surgery Clinic: A Four-Year Analysis of Patient Outcomes, Satisfaction, and Resident Education.

OBJECTIVE: A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence. DESIGN: Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks. SETTING: Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program. PARTICIPANTS: Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation. RESULTS: 1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05). CONCLUSION: Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.

Temporizing Wound VAC Dressing Until Final Negative Margins are Achieved Reduces Myxofibrosarcoma Local Recurrence.

BACKGROUND: The microinvasive nature of suprafascial myxofibrosarcoma reduces the accuracy of intraoperative margin assessment, and tumor bed resections after soft-tissue reconstruction are unreliable. In 2017, we began temporizing the excised tumor bed with a wound VAC, delaying soft-tissue coverage until final negative margins were achieved. We compare the oncologic/surgical outcomes of suprafascial myxofibrosarcomas managed with VAC temporization (VT) with single-stage excision/reconstruction (SS). METHODS: We retrospectively studied suprafascial myxofibrosarcomas managed from January 1, 2000 to January 1, 2019 for patients who received neoadjuvant or adjuvant radiation and had at least 2 years of oncologic follow-up at a tertiary referral cancer center. Our primary outcome was local recurrence. Comparisons were performed by using Fisher's exact test or Student's t test. A p value < 0.05 was considered significant. RESULTS: Fifty-three patients (18 VAC temporized, 35 single stage) were included. While VT patients were older (74.9 ± 10.2 vs. 63.9 ± 13.6, p = 0.003), treatment groups did not significantly differ with respect to comorbidity, tumor volume, stage and grade. VT patients had significantly fewer local recurrences (5.6% vs. 28.6% after SS, p = 0.048) and R1 resections that required an unplanned readmission for tumor bed reexcision (0% vs. 37.1% after SS, p = 0.002). VT required more total surgeries (2.8 ± 0.9 vs. 1.8 ± 0.9 for SS, p = 0.0002). Postoperative infectious and wound complications were equivalent. CONCLUSIONS: Our VAC temporization strategy had a significantly lower LR than SS treatment. While high quality multi-institutional validation is required, VT may represent a paradigm shift in the management of myxofibrosarcoma.