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Nitta S, Kandori S, Takahashi R, Suzuki S, Hamada K, Tanuma K, Shiga M, Kojo K, Sakka S, Nagumo Y, Hoshi A, Mathis BJ, Negoro H, Okuyama A, Higashi T, Nishiyama H. Retroperitoneal sarcoma: a 10-year follow-up analysis using hospital-based cancer registry data in Japan. Jpn J Clin Oncol 2024; 54:716-721. [PMID: 38411262 DOI: 10.1093/jjco/hyae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/03/2024] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVES We sought clinical characteristics, survival outcomes, and prognostic factors for overall survival of retroperitoneal sarcoma in Japan. METHODS A Japanese hospital-based cancer registry database with a pivotal 10-year follow-up was used to identify and enroll patients, registered from 106 institutions, diagnosed with retroperitoneal sarcoma in 2008-2009. Treating hospitals were divided by hospital care volume; high-volume hospitals and low-volume hospitals were defined as ≥ 4 and < 4 cases/year, respectively. RESULTS A total of 91 men and 97 women were included, with a median age of 64 years. The most common histological type was liposarcoma in 101 patients, followed by leiomyosarcoma in 38 patients. The 5-year and 10-year overall survival rates were 44.1 and 28.3%. The majority of patients (n = 152, 80.9%) were treated at low-volume hospitals. High-volume hospital patients had higher 10-year overall survival rates than low-volume hospital patients (51.2% vs 23.2%, P = 0.026). Multivariate analysis revealed age over 60 years, treatment in low-volume hospitals and chemotherapy were independent predictors of unfavorable survival while treatment with surgery was an independent predictor of favorable survival. CONCLUSIONS The possibility of surgical removal was suggested to be the most important prognostic factor for retroperitoneal sarcoma. Better survival was shown in patients treated at high-volume hospitals in our series.
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Affiliation(s)
- Satoshi Nitta
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Shuya Kandori
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Reo Takahashi
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Shuhei Suzuki
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Kazuki Hamada
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Kozaburo Tanuma
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Masanobu Shiga
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Kosuke Kojo
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Shotaro Sakka
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Yoshiyuki Nagumo
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Akio Hoshi
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Bryan J Mathis
- International Medical Center, University of Tsukuba Affiliated Hospital, Ibaraki
| | - Hiromitsu Negoro
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
| | - Ayako Okuyama
- Graduate School of Nursing, St Luke's International University, Tokyo
- Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Takahiro Higashi
- Institute for Cancer Control, National Cancer Center Japan, Tokyo, Japan
| | - Hiroyuki Nishiyama
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki
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Callegaro D, Barretta F, Raut CP, Johnston W, Strauss DC, Honoré C, Bonvalot S, Fairweather M, Rutkowski P, van Houdt WJ, Gladdy RA, Tirotta F, Tzanis D, Skoczylas J, Haas RL, Miceli R, Swallow CJ, Gronchi A. New Sarculator Prognostic Nomograms for Patients With Primary Retroperitoneal Sarcoma: Case Volume Does Matter. Ann Surg 2024; 279:857-865. [PMID: 37753660 DOI: 10.1097/sla.0000000000006098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE To update the current Sarculator retroperitoneal sarcoma (RPS) prognostic nomograms considering the improvement in patient prognosis and the case volume effect. BACKGROUND Survival of patients with primary RPS has been increasing over time, and the volume-outcome relationship has been well recognized. Nevertheless, the specific impact on prognostic nomograms is unknown. METHODS All consecutive adult patients with primary localized RPS treated at 8 European and North American sarcoma reference centers between 2010 and 2017 were included. Patients were divided into 2 groups: high-volume centers (HVC, ≥13 cases/year) and low-volume centers (LVC, <13 cases/year). Primary end points were overall survival (OS) and disease-free survival (DFS). Multivariable analyses for OS and DFS were performed. The nomograms were updated by recalibration. Nomograms performance was assessed in terms of discrimination (Harrell C index) and calibration (calibration plot). RESULTS The HVC and LVC groups comprised 857 and 244 patients, respectively. The median annual primary RPS case volume (interquartile range) was 24.0 in HVC (15.0-41.3) and 9.0 in LVC (1.8-10.3). Five-year OS was 71.4% (95% CI: 68.3%-74.7%) in the HVC cohort and 63.3% (56.8%-70.5%) in the LVC cohort ( P =0.012). Case volume was associated with both OS (LVC vs. HVC hazard ratio 1.40, 95% CI: 1.08-1.82, P =0.011) and DFS (hazard ratio 1.93, 95% CI: 1.57-2.37, P <0.001) at multivariable analyses. When applied to the study cohorts, the Sarculator nomograms showed good discrimination (Harrell C index between 0.68 and 0.73). The recalibrated nomograms showed good calibration in the HVC group, whereas the original nomograms showed good calibration in the LVC group. CONCLUSIONS New nomograms for patients with primary RPS treated with surgery at high-volume versus low-volume sarcoma reference centers are available in the Sarculator app.
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Affiliation(s)
- Dario Callegaro
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesco Barretta
- Department of Biostatistics for Clinical Research, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Chandrajit P Raut
- Department of Surgery, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Wendy Johnston
- Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Dirk C Strauss
- Sarcoma Unit, Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charles Honoré
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
| | | | - Mark Fairweather
- Department of Surgery, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Winan J van Houdt
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Rebecca A Gladdy
- Department of Surgical Oncology, Princess Margaret Cancer Centre, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Fabio Tirotta
- Sarcoma Unit, Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London, United Kingdom
- Department of Sarcoma and General Surgery, Midlands Abdominal and Retroperitoneal Sarcoma Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Jacek Skoczylas
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Rick L Haas
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Rosalba Miceli
- Department of Biostatistics for Clinical Research, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Carol J Swallow
- Department of Surgical Oncology, Princess Margaret Cancer Centre, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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3
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Garcia-Ortega DY, Ortega Jiménez JA, Melendez-Fernandez AP, Álvarez-Cano A, Caro-Sanchez CHS, Vargas-Lara AK, Luna-Ortiz K. Does compartmental resection really impact retroperitoneal soft tissue sarcomas? A retrospective analysis from a Single Referral Center. Surg Oncol 2023; 51:101997. [PMID: 37832278 DOI: 10.1016/j.suronc.2023.101997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/03/2023] [Accepted: 09/17/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND The treatment of choice for retroperitoneal soft tissue sarcomas (RPS) is surgical resection; the outcomes with more radical surgeries, notably compartmental resection, remains a subject of debate. Arguments against it, include the complexity of the technique and high morbidity. MATERIALS AND METHODS A retrospective analysis of cases treated in a single center from January 2010 to December 2019 is presented. Two time periods were evaluated: 2010-2015 and 2016-2019, corresponding to before and after the implementation of routine compartmentectomy. We evaluated the short- and long-term outcomes of compartmental resection compared to limited surgeries through a multivariate analysis of prognostic factors. RESULTS A total of 176 cases were included, of which 102 met the inclusion criteria. The sex distribution was similar. The average age was 52.9 years, and the average tumor size was 24.5 cm. The most frequent histology was liposarcoma (65.7%), followed by leiomyosarcoma (12.7%), and malignant peripheral nerve sheath tumor (8.8%). The median follow-up period was 40 months. We found a lower local recurrence in the group treated in the recent period (compartmentectomy) 42.3% vs 20% p = 0.007. The median overall survival (OS) was 38.7 months, and there was no difference in distant recurrence between the two time periods. Postoperative morbidity was higher in the recent period (25% vs 10% p 0.041), with no difference in 30-day mortality. CONCLUSIONS The implementation of extensive surgery, specifically compartmentectomy, for retroperitoneal sarcomas has been linked to reduced local recurrence. We recommend considering this surgical approach for RPS in alignment with current expert consensus guidelines, as highlighted by the updated TARPSWG consensus.
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Affiliation(s)
- Dorian Yarih Garcia-Ortega
- Surgical Oncology, Skin, Soft Tissue & Bone Tumors Department, National Cancer Institute, Mexico City, Mexico.
| | | | | | - Alethia Álvarez-Cano
- Surgical Oncology, Christus Muguerza Alta Especialidad, Monterrey, Nuevo Leon, Mexico
| | | | | | - Kuauhyama Luna-Ortiz
- Surgical Oncology Department of Head and Neck Surgery Department, National Cancer Institute, Mexico City, Mexico
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Hong AM, Sundaram A, Perianayagam G, Lo H, Lawless A, Zhou D, McDonough J, Thompson SR, Maclean F, Connolly EA, Coker D, Mar J, Lazarakis S, Johnston A. Surgery at specialised sarcoma centres improves patient outcomes - A systematic review by the Australia and New Zealand sarcoma association clinical practice guidelines working party. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106951. [PMID: 37301636 DOI: 10.1016/j.ejso.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Optimal management of sarcoma requires multidisciplinary team input throughout the process of diagnosis, treatment and follow up. This systematic review aimed to evaluate the impact of surgery performed at specialised sarcoma centres on outcomes. METHODS A systematic review was conducted using the population, intervention, comparison and outcome (PICO) model. Medline, Embase, Cochrane Central databases were queried for publications that evaluated the local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival in patients undergoing surgery in a specialist sarcoma centre compared with non-specialist centre. Each study was screened by two independent reviewers for suitability. A qualitative synthesis of the results was performed. RESULTS Sixty-six studies were identified. The majority of studies were Level III-3 as assessed by the NHMRC Evidence Hierarchy, whilst just over half of the studies were of good quality. Definitive surgery performed at specialised sarcoma centres was associated with improved local control as defined by lower rate of local relapse, higher rate of negative surgical margins, improved local recurrence free survival and higher limb conservation rate. Available evidences show a favourable pattern of lower 30-day and 90-day mortality rates, and greater overall survival when surgery was performed in specialist sarcoma centres compared with non-specialised centres. CONCLUSIONS Evidences support better oncological outcomes when surgery is performed at specialised sarcoma centre. Patients with suspected sarcoma should be referred early to a specialised sarcoma centre for multidisciplinary management, which includes planned biopsy and definitive surgery.
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Affiliation(s)
- Angela M Hong
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia; Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia.
| | - Abay Sundaram
- Department of Orthopaedic Surgery, Sir Charles Gardiner Hospital, Nedlands, WA, 6009, Australia
| | - Ganaps Perianayagam
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Helen Lo
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia; Mid North Coast Cancer Institute, Port Macquarie, NSW, 2444, Australia
| | - Anna Lawless
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia; Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia
| | - Deborah Zhou
- NHMRC Clinical Trials Centre, The University of Sydney, NSW, 2006, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia
| | | | - Stephen R Thompson
- Faculty of Medicine, University of New South Wales, Randwick, NSW, 2131, Australia; Department of Radiation Oncology, Prince of Wales Hospital, Randwick, NSW, 2132, Australia
| | - Fiona Maclean
- Douglass Hanly Moir Pathology, North Ryde, NSW, 2113, Australia
| | - Elizabeth A Connolly
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia
| | - David Coker
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia; Department of Melanoma and Surgical Oncology, and Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Jasmine Mar
- Australia and New Zealand Sarcoma Association, Parkville, Victoria, 3010, Australia
| | - Smaro Lazarakis
- Health Sciences Library, Royal Melbourne Hospital, Parkville, Victoria, 3010, Australia
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5
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Tirotta F, Bacon A, Collins S, Desai A, Liu H, Paley L, Strauss D, Strauss SJ. Primary retroperitoneal sarcoma: A comparison of survival outcomes in specialist and non-specialist sarcoma centres. Eur J Cancer 2023; 188:20-28. [PMID: 37178646 DOI: 10.1016/j.ejca.2023.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Consensus guidelines outline that patients with primary retroperitoneal sarcoma (RPS) should be managed within specialist sarcoma centres (SSC). There is, however, a paucity of population-based data detailing incidence and outcomes in these patients. Hence, we aimed to evaluate patterns of care among RPS patients in England and compare outcomes for those undergoing surgery in high-volume specialist sarcoma centres (HV-SSC), low-volume SSC (LV-SSC), and non-SSC (N-SSC). METHODS Data on patients diagnosed with primary RPS between 2013 and 2018 were extracted from NHS Digital's National Cancer Registration and Analysis Service using the national cancer registration dataset. Diagnostic pathways, treatment, and survival outcomes were compared between HV-SSC, LV-SSC, and N-SSC. Uni- and multivariate analyses were calculated. RESULTS Of 1878 patients diagnosed with RPS, 1120 (60%) underwent surgery within 12 months of diagnosis, with 847 (76%) operated on at SSC; of these, 432 patients (51%) were operated on in HV-SSC, and 415 (49%) in LV-SSC. One- and 5-year estimated overall survival (OS) rates for patients undergoing surgery in N-SSC were 70.6% (95% confidence interval [CI]: 64.8-75.7) and 42.0% (CI: 35.9-47.9), compared to 85.0% (CI: 81.1-88.1) and 51.7% (CI: 46.6-56.6) in LV-SSC (p < 0.01), and 87.4% (CI: 83.9-90.2) and 62.8% (CI: 57.9-67.4) in HV-SSC, (p < 0.01). After adjusting for patient- and treatment-related factors, patients treated in HV-SSC were found to have significantly longer OS than those treated at LV-SSC, with an adjusted hazard ratio of 0.78 (CI: 0.62-0.96, p < 0.05). CONCLUSION Patients with RPS undergoing surgery in HV-SSC have significantly better survival outcomes than those treated in N-SSC and L-SSC.
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Affiliation(s)
- Fabio Tirotta
- Department of Sarcoma and General Surgery, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Andrew Bacon
- National Cancer Registration and Analysis Service, NHS Digital, Wellington Place, Leeds LS1 4AP, UK
| | - Shane Collins
- National Cancer Registration and Analysis Service, NHS Digital, Wellington Place, Leeds LS1 4AP, UK; Research Department of Oncology, University College London Cancer Institute, London, UK
| | - Anant Desai
- Department of Sarcoma and General Surgery, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hanhua Liu
- National Cancer Registration and Analysis Service, NHS Digital, Wellington Place, Leeds LS1 4AP, UK
| | - Lizz Paley
- National Cancer Registration and Analysis Service, NHS Digital, Wellington Place, Leeds LS1 4AP, UK
| | - Dirk Strauss
- Sarcoma Unit, Department of Academic Surgery, The Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
| | - Sandra J Strauss
- National Cancer Registration and Analysis Service, NHS Digital, Wellington Place, Leeds LS1 4AP, UK; Research Department of Oncology, University College London Cancer Institute, London, UK.
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Álvarez Álvarez R, Manzano A, Agra Pujol C, Artigas Raventós V, Correa R, Cruz Jurado J, Fernandez JA, Garcia Del Muro X, Gonzalez JA, Hindi N, Lozano Lominchar P, Martínez-Trufero J, Méndez R, Muñoz M, Muñoz Casares C, Orbis Castellanos F, Orellana Fernandez R, Paniagua González M, Redondo A, Valverde Morales C, Asencio JM. Updated Review and Clinical Recommendations for the Diagnosis and Treatment of Patients with Retroperitoneal Sarcoma by the Spanish Sarcoma Research Group (GEIS). Cancers (Basel) 2023; 15:3194. [PMID: 37370803 DOI: 10.3390/cancers15123194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Soft tissue sarcomas (STS) are an uncommon and biologically heterogeneous group of tumors arising from mesenchymal cells. The incidence is estimated at five cases per 100,000 people per year. Retroperitoneal sarcomas (RPS) account for 10-15% of all STS, and their management depends on their anatomical characteristics and histotype. Due to their very low incidence, it is recommended that RPS be treated in reference centers and evaluated by an experienced multidisciplinary team (MDT). In Spain, the Spanish Group for Research in Sarcomas (GEIS) brings together experts from various specialties to promote research on sarcomas and improve treatment results. This paper summarizes the GEIS recommendations for the diagnosis, treatment, and follow-up of patients with RPS.
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Affiliation(s)
- Rosa Álvarez Álvarez
- Medical Oncology Department, Instituto de Investigacion Sanitaria Gregorio Marañon, Hospital Universitario Gregorio Marañon, 28007 Madrid, Spain
| | - Aránzazu Manzano
- Medical Oncology Department, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain
| | - Carolina Agra Pujol
- Pathology Department, Hospital Universitario Gregorio Marañon, Complutense University, 28007 Madrid, Spain
| | - Vicente Artigas Raventós
- Surgery Department, Hospital Universitario Sant Pau, Universidad Autonoma de Barcelona, 08035 Barcelona, Spain
| | - Raquel Correa
- Radiation Oncology Department, Hospital Virgen de la Victoria, 29010 Malaga, Spain
| | - Josefina Cruz Jurado
- Medical Oncology Department, Hospital Universitario Canarias, 38320 Santa Cruz de Tenerife, Spain
| | - Juan Angel Fernandez
- Sarcoma Multidisciplinary Unit, Surgery Department, Hospital Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Xavier Garcia Del Muro
- Sarcoma Multidisciplinary Unit, Medical Oncology Department, Idibell, Instituto Catalan Oncología Hospitalet, 08908 Barcelona, Spain
| | - Jose Antonio Gonzalez
- Surgery Department, Hospital Universitario Sant Pau, Universidad Autonoma de Barcelona, 08035 Barcelona, Spain
| | - Nadia Hindi
- Medical Oncology Department, Fundacion Jimenez Diaz University Hospital, 28040 Madrid, Spain
- Medical Oncology Department, Hospital General de Villalba, 28400 Madrid, Spain
- Health Research Institute-Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), 28040 Madrid, Spain
| | - Pablo Lozano Lominchar
- Surgery Department, Hospital Universitario Gregorio Marañon, Complutense University, 28040 Madrid, Spain
| | | | - Ramiro Méndez
- Radiology Department, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain
| | - Mercedes Muñoz
- Radiation Oncology Department, Hospital Universitario Gregorio Marañon, Complutense University, 28007 Madrid, Spain
| | | | - Francisco Orbis Castellanos
- Sarcoma Multidisciplinary Unit, Surgery Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | | | - Miguel Paniagua González
- Radiology Department, Hospital Universitario Gregorio Marañon, Complutense University, 28007 Madrid, Spain
| | - Andres Redondo
- Medical Oncology Department, Hospital Universitario La Paz-IdiPAZ, 28046 Madrid, Spain
| | | | - Jose Manuel Asencio
- Surgery Department, Hospital Universitario Gregorio Marañon, Complutense University, 28040 Madrid, Spain
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7
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Baia M, Ford SJ, Dumitra S, Samà L, Naumann DN, Spolverato G, Callegaro D. Follow-up of patients with retroperitoneal sarcoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:1125-1132. [PMID: 35277304 DOI: 10.1016/j.ejso.2022.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/14/2022] [Indexed: 12/16/2022]
Abstract
Retroperitoneal sarcomas (RPS) are rare malignancies that are potentially curable by complete surgical resection. A regular surveillance program is normally commenced following surgery due to the risk of local recurrence (LR), especially in low-intermediate grade disease, and distant metastases (DM), especially in high-grade RPS. Consensus guidelines usually advocate for more frequent imaging during the first 2-3 years and less intensive imaging over a prolonged period thereafter, reflecting the incidence pattern of LR and DM. Definitive evidence for the most effective imaging schedule has never been provided, and retrospective studies have not shown an association between follow-up intensity and survival. Improvement in the prediction of recurrence patterns has been sustained by prognostic dynamic nomograms, which are now capable of forecasting disease behaviour in each patient according to specific features. Incorporation of such tools in clinical practice may help to stratify patients and tailor ongoing surveillance to the risk of recurrence. This may help to relieve patients' anxiety while awaiting results of surveillance investigations, and also reduce the economic and environmental burden of repeated imaging. A randomized controlled study (SARveillance Trial) is proposed to shed light on this controversial topic, allowing clinicians to harmonize the follow-up protocol of patients undergoing surgery for RPS.
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Affiliation(s)
- Marco Baia
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital Birmingham, UK
| | - Samuel J Ford
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital Birmingham, UK
| | | | - Laura Samà
- Surgical Oncology Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy
| | - David N Naumann
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital Birmingham, UK
| | - Gaya Spolverato
- Department of Surgical, Oncological and Gastroenterological Sciences, Section of Surgery, University of Padova, Padova, Italy
| | - Dario Callegaro
- Sarcoma Service, Department of Surgery, IRCCS Fondazione Istituto Nazionale Dei Tumori di Milano, Milan, Italy.
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8
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Janes LA, Angeles CV. The Role of Surgery in Oligometastatic Retroperitoneal Sarcoma. Curr Oncol 2023; 30:5240-5250. [PMID: 37366881 DOI: 10.3390/curroncol30060398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Retroperitoneal sarcomas are extremely rare, comprising <15% of primary sarcomas. Distant metastasis occurs in about 20% of cases, with pulmonary and hepatic metastasis as the most common sites of hematogenous spread. Although surgical resection is well established as the main treatment of localized primary disease, there are limited guidelines for the surgical treatment of intra-abdominal and distant metastases. There are inadequate systemic treatment options for patients with metastatic sarcoma, thereby necessitating the consideration of surgical options in carefully selected patients. Key points to consider include tumor biology, patient fitness and co-morbidities, overall prognosis, and goals of care. Multidisciplinary sarcoma tumor board discussion for each case is an essential practice in order to deliver the best care to these patients. The purpose of this review is to summarize the published literature on the past and present role of surgery in the treatment of oligometastatic retroperitoneal sarcoma in order to inform the management of this difficult disease.
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Affiliation(s)
- Lindsay A Janes
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Christina V Angeles
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
- Rogel Cancer Center, University of Michigan, 1500 E. Medical Center Drive, 6219 Cancer Center Ann Arbor, Ann Arbor, MI 48109, USA
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9
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Osterloh J, Ludolph I, Grützmann R, Meyer A, Lang W, Horch RE, Fechner K, Arkudas A. Interdisciplinary Surgical Therapy of Extremity Soft-Tissue Sarcomas: A Personalized Resection and Reconstruction Algorithm. J Pers Med 2023; 13:262. [PMID: 36836496 PMCID: PMC9965817 DOI: 10.3390/jpm13020262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Soft-tissue sarcomas (STS) are rare, but potentially life-threatening malignancies. STS can occur anywhere in the human body with the limbs being the most common site. Referral to a specialized sarcoma center is crucial to guarantee prompt and appropriate treatment. STS treatment strategies should be discussed in an interdisciplinary tumor board to involve expertise from all available resources, including an experienced reconstructive surgeon for an optimal outcome. In many cases, extensive resection is needed to achieve R0 resection, resulting in large defects after surgery. Hence, an evaluation of whether plastic reconstruction might be required is mandatory to avoid complications due to insufficient primary wound closure. In this retrospective observational study, we present data of patients with extremity STS treated at the Sarcoma Center, University Hospital Erlangen, in 2021. We found that complications were more frequent in patients who received secondary flap reconstruction after insufficient primary wound closure compared to patients who received primary flap reconstruction. Additionally, we propose an algorithm for an interdisciplinary surgical therapy of soft-tissue sarcomas regarding resection and reconstruction and present two problematic cases to emphasize the complexity of surgical sarcoma therapy.
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Affiliation(s)
- Justus Osterloh
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Bavaria, Germany
| | - Ingo Ludolph
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Bavaria, Germany
| | - Robert Grützmann
- Department of Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Bavaria, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Bavaria, Germany
| | - Werner Lang
- Department of Vascular Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Bavaria, Germany
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Bavaria, Germany
| | - Katja Fechner
- Department of Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Bavaria, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Bavaria, Germany
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10
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Traweek RS, Martin AN, Rajkot NF, Guadagnolo BA, Bishop AJ, Lazar AJ, Keung EZ, Torres KE, Hunt KK, Feig BW, Roland CL, Scally CP. Re-excision After Unplanned Excision of Soft Tissue Sarcoma is Associated with High Morbidity and Limited Pathologic Identification of Residual Disease. Ann Surg Oncol 2023; 30:480-489. [PMID: 36085392 DOI: 10.1245/s10434-022-12359-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/11/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with unplanned excision (UPE) of trunk and extremity soft tissue sarcoma (STS) present a significant management challenge for sarcoma specialists. Oncologic re-resection has been considered standard practice after UPE with positive or uncertain margins. A strategy of active surveillance or "watch and wait" has been suggested as a safe alternative to routine re-excision. In this context, the current study sought to evaluate short-term outcomes and morbidity after re-resection to better understand the risks and benefits of this treatment strategy. METHODS A retrospective, single-institution study reviewed patients undergoing oncologic re-resection after UPE of an STS during a 5-year period (2015-2020), excluding those with evidence of gross residual disease. Short-term clinical outcomes were evaluated together with final pathologic findings. RESULTS The review identified 67 patients undergoing re-resection after UPE of an STS. Of these 67 patients, 45 (67%) were treated with a combination of external beam radiation therapy (EBRT) and surgery. Plastic surgery was involved for reconstruction in 49 cases (73%). The rate of wound complications after re-resection was 45 % (n = 30), with 15 % (n = 10) of the patients experiencing a major wound complication. Radiation therapy and plastic surgery involvement were independently associated with wound complications. Notably, 45 patients (67%) had no evidence of residual disease in the re-resection specimen, whereas 13 patients (19 %) had microscopic disease, and 9 patients (13%) had indeterminate pathology. CONCLUSION Given the morbidity of re-resection and limited identification of residual disease, treatment plans and discussions with patients should outline the expected pathologic findings and morbidity of surgery.
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Affiliation(s)
- Raymond S Traweek
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Allison N Martin
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nikita F Rajkot
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - B Ashleigh Guadagnolo
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Andrew J Bishop
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexander J Lazar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Keila E Torres
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kelly K Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Barry W Feig
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christopher P Scally
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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11
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Patkar S, Kattepur AK, Khanna N, Bajpai J. Retroperitoneal Sarcomas: a Current Review on Management. Indian J Surg Oncol 2022; 13:542-558. [PMID: 36187536 PMCID: PMC9515254 DOI: 10.1007/s13193-022-01520-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 02/08/2022] [Indexed: 11/25/2022] Open
Abstract
Retroperitoneal sarcomas are heterogeneous tumours with variable disease biology and outcomes. The prognosis is primarily related to tumour histology and grade as well as the ability to achieve margin negative resection. Surgery involves compartment or contiguous organ resection to achieve the above goal. Careful utilization of neoadjuvant and adjuvant strategies like radiotherapy and/or chemotherapy can lead to improvement in margin status, thereby contributing to better local control and possibly reducing systemic dissemination. Use of targeted therapies has paved newer pathways of treatment integration centred on molecular and genetic targets. The aim of this review is to update the reader on all aspects of retroperitoneal sarcoma management including emphasis on pertinent and landmark trials in this regard.
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Affiliation(s)
- Shraddha Patkar
- Department of Gastrointestinal Oncology, Hepatobiliary Services, Tata Memorial Centre and HBNI, Dr Ernst Borges Marg, Parel, Mumbai 400012 India
| | - Abhay K. Kattepur
- Department of Surgical Oncology, Sri Devaraj Urs Academy of Higher Education and Research, Tamaka, Kolar, Karnataka India
| | - Nehal Khanna
- Department of Radiation Oncology, Tata Memorial Centre and HBNI, Dr Ernst Borges Marg, Parel, Mumbai India
| | - Jyoti Bajpai
- Department of Medical Oncology, Tata Memorial Centre and HBNI, Dr Ernst Borges Marg, Parel, Mumbai India
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12
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Definition of the Surgical Case Complexity in the Treatment of Soft Tissue Tumors of the Extremities and Trunk. Cancers (Basel) 2022; 14:cancers14061559. [PMID: 35326712 PMCID: PMC8946284 DOI: 10.3390/cancers14061559] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Soft tissue tumors are heterogeneous tumor entities that often require surgical intervention for treatment. While some tumors are easy to resect, others require extremely complex, interdisciplinary surgery depending on the tumor type, localization and biological behavior. Up to now, there has not been an instrument able to objectify the complexity of such a surgery; therefore, we attempted to establish a complexity score for the description of soft tissue tumor surgeries. Furthermore, we aimed to categorize surgeries in such a way that patients can be assigned the best treatment such that a cost-effective approach can be taken. Abstract Background: We intend to establish a complexity score for soft tissue tumor surgeries to compare the complexities of different soft tissue tumor surgeries and to ultimately assign affected patients to appropriate treatments. Methods: We developed a soft tissue tumor complexity score (STS-SCS) based on three pillars: in addition to patient-related factors, tumor biology and surgery-associated parameters were taken into account. The STS-SCS was applied to our sampling group of 711 patients. Results: The minimum STS-SCS was 4, the maximum score was 34 and the average score 11.4 ± 5.9. The scores of patients with malignant diagnoses were notably higher and more widely scattered than those of patients with benign or intermediate malignant tumors. To better categorize the complexities of individual surgeries, we established four categories using the collected data as a reference dataset. Each of the categories contained approximately one-quarter of the registered patients. Discussion: The STS-SCS allows soft tissue tumor surgeries to be retrospectively evaluated for their complexity and forms the basis for the creation of a prospective concept to provide patients with the right intervention in the right geographic location, which can lead to better results and provision of the most cost-effective overall treatment.
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13
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Kirchberg J, Blum SFU, Pablik J, Herold S, Hoffmann RT, Baretton G, Weitz J. [Preoperative diagnostics and typing of abdominal soft tissue sarcomas]. Chirurg 2021; 93:5-15. [PMID: 34757436 DOI: 10.1007/s00104-021-01528-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Abdominal sarcomas are a heterogeneous group of rare soft tissue tumors and can be localized intraperitoneally or retroperitoneally. A pretherapeutic differentiated subtyping is essential for planning an individual, multimodal treatment concept in an interdisciplinary team of experts. OBJECTIVE The central aspects of histology acquisition, imaging diagnostics and (molecular) pathological subtyping of abdominal soft tissue sarcomas are described in detail. MATERIAL AND METHODS Imaging and pathological diagnostics are depicted based on the German S3 guidelines on adult soft tissue sarcomas, a current literature search and personal experiences at the Sarcoma Center at the National Center for Tumor Diseases in Dresden (NCT/UCC). RESULTS Preoperative imaging and (molecular) pathological subtyping of abdominal soft tissue sarcomas place high demands on surgeons, radiologists and pathologists. Genome analyses of sarcomas have the potential to identify points of attack for individualized treatment options. The limitations of resectability can only be assessed by experienced sarcoma surgeons at specialized centers. CONCLUSION The treatment of abdominal soft tissue sarcomas at an experienced center is associated with a better prognosis. Even at the first suspicion of an abdominal sarcoma, a referral to an experienced center should be made in order to guarantee optimal expertise in diagnostics and treatment.
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Affiliation(s)
- J Kirchberg
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland. .,Sarkomzentrum Dresden am Nationalen Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland.
| | - S F U Blum
- Sarkomzentrum Dresden am Nationalen Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland.,Institut und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - J Pablik
- Sarkomzentrum Dresden am Nationalen Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland.,Institut für Pathologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - S Herold
- Sarkomzentrum Dresden am Nationalen Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland.,Institut für Pathologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - R T Hoffmann
- Sarkomzentrum Dresden am Nationalen Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland.,Institut und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - G Baretton
- Sarkomzentrum Dresden am Nationalen Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland.,Institut für Pathologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - J Weitz
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.,Sarkomzentrum Dresden am Nationalen Centrum für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Fetscherstraße 74, 01307, Dresden, Deutschland
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14
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Villano AM, Vidri RJ, Vo ET, Greco SH, Howell KJ, von Mehren M, Farma JM. National Trends in Treatment for Retroperitoneal Soft Tissue Sarcoma: A Modern Appraisal of Variability in Therapeutic Strategies. Ann Surg Oncol 2021; 29:2275-2285. [PMID: 34635978 DOI: 10.1245/s10434-021-10908-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/31/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Little level 1 evidence exists to guide multimodality treatment in retroperitoneal soft tissue sarcoma (RPS), which may lead to significant variation in therapeutic approaches. This analysis aimed to describe national RPS treatment trends and explore potential variability among low-/high-volume hospitals (LVH/HVHs). PATIENTS AND METHODS In total, 5992 patients who underwent resection for primary RPS were retrospectively identified in the National Cancer Database (2004-2017). Time trend analyses examined rates of multivisceral resection (MVR), radiation, and chemotherapy use. LVHs were defined as those carrying out fewer than ten resections per year (N = 5433), whereas HVHs were defined as those carrying out ten or more (N = 559). Descriptive statistics and logistic regression models compared trends between groups. RESULTS MVR was more frequent at HVHs (63.7% versus 43.5%, p < 0.001). Use of radiation varied widely by hospital volume. HVHs more frequently employed preoperative radiation as compared with LVHs (14.7% versus 8.1%, p < 0.001). Throughout the study period, LVHs increased utilization of preoperative radiation (2.6% to 12.0%, p < 0.001) whereas rates at HVHs remained stable. Overall, LVHs utilized postoperative radiation significantly more frequently as compared with HVHs (14.7% versus 2.7%, respectively, p < 0.001). Postoperative radiation at LVHs remained stable until 2013 and sharply declined thereafter (16.7% to 6.9%, p < 0.001). Rates of postoperative radiation use at HVHs remained lower than those at LVHs at all time points. CONCLUSIONS Strategies for resection and radiation use at LVHs have trended towards those of HVHs. Current national implementation of preoperative radiation, MVR, and chemotherapy remains heterogeneous. These findings inform future trial design and support standardization of care.
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Affiliation(s)
- Anthony M Villano
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Roberto J Vidri
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Elaine T Vo
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Stephanie H Greco
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Krisha J Howell
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Margaret von Mehren
- Department of Hematology and Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Jeffrey M Farma
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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15
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Delayed retroperitoneal liposarcoma diagnosis and management in a patient with massive obesity. Eur J Clin Nutr 2021; 75:1520-1522. [PMID: 33649526 DOI: 10.1038/s41430-020-00855-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/28/2020] [Accepted: 12/23/2020] [Indexed: 01/30/2023]
Abstract
People suffering from extreme obesity may be exposed to delayed diagnosis and treatment of cancer. A 37-year-old woman (weight = 245 kg, body mass index (BMI) = 79 kg/m2), presented a sepsis associated with nonspecific abdominal pain for 4 months. After several unsuccessful attempts due to her weight and a large waist circumference, abdominal CT scan was finally successfully performed and showed a large retroperitoneal mass. An ultrasound-guided core needle biopsy was performed and was in favor of a liposarcoma. Surgery was performed to remove the entire tumor of an estimated weight of 98 kg, a giant retroperitoneal dedifferentiated liposarcoma. This case highlights the difficulties to screen, diagnose, and manage cancers encountered in patients suffering from massive obesity.
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16
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[French ccAFU guidelines - update 2020-2022: retroperitoneal sarcoma]. Prog Urol 2021; 30:S314-S330. [PMID: 33349428 DOI: 10.1016/s1166-7087(20)30755-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE - To update French urological guidelines on retroperitoneal sarcoma. MATERIALS AND METHODS - Comprehensive Medline search between 2018 and 2020 upon diagnosis, treatment and follow-up of retroperitoneal sarcoma. Level of evidence was evaluated. RESULTS - Chest, abdomen and pelvis CT is mandatory to evaluate any suspected retroperitoneal sarcoma. MRI sometimes helps surgical planning. Before histological confirmation through biopsy, the patient must be registered in the French sarcoma pathology reference network. The biopsy standard should be an extraperitoneal coaxial percutaneous sampling before any retroperitoneal mass therapeutic decision. Surgery is retroperitoneal sarcoma cornerstone. The main objective is grossly negative margins and can be technically challenging. Multimodal treatment risks and benefits must be discussed in multidisciplinary teams. The relapse rate is related to tumor grade and surgical margins. Reported Negative margins rate thus encourage surgery in high-volume centers. CONCLUSION - Retroperitoneal sarcoma prognosis is poor and closely related to the quality of initial management. Centralization through dedicated sarcoma pathology network in a high-volume center is mandatory.
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17
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Straker RJ, Song Y, Shannon AB, Marcinak CT, Miura JT, Fraker DL, Karakousis GC. Preoperative Biopsy in Patients with Retroperitoneal Sarcoma: Usage and Outcomes in a National Cohort. Ann Surg Oncol 2021; 28:6868-6879. [PMID: 33591480 DOI: 10.1245/s10434-021-09691-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/17/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Preoperative biopsy (PBx) is often recommended for retroperitoneal sarcoma (RPS), but its utilization rate and impact on perioperative management and outcomes remains undefined. METHODS Using the National Cancer Database, patients who underwent resection of non-metastatic RPS were identified (2006-2014). Patients who did and did not undergo PBx of the primary tumor were compared using propensity matching, and factors associated with survival were assessed by multivariable analysis. RESULTS Of 2620 patients, 1110 (42.4%) underwent PBx. Factors significantly associated with performance of PBx included male sex [odds ratio (OR) 1.2, P = 0.035], tumor size ≤ 5 cm (OR 1.5, P = 0.012), tumor size > 5 to ≤ 10 cm (OR 1.3, P = 0.009), non-well-differentiated liposarcoma histology (OR 2.0, P ≤ 0.001), and treatment at a high-volume center (OR 1.3, P = 0.021). Receipt of PBx was significantly associated with administration of neoadjuvant radiation (OR 8.8, P < 0.001) or systemic therapy (OR 3.3, P < 0.001), radical surgical resection (OR 1.6, P < 0.001), and complete tumor resection (OR 1.5, P < 0.003). Neoadjuvant radiation [hazard ratio (HR) 0.7, P = 0.003] and complete tumor resection (HR 0.6, P < 0.001) were significantly associated with improved overall survival (OS). Performance of PBx was not associated with OS (HR 1.1, P = 0.070), and following propensity matching, 5-year OS did not differ between the two groups (56.5% PBx vs 58.4% no PBx, P = 0.247). CONCLUSIONS A minority of patients with non-metastatic RPS undergo PBx. PBx does not negatively impact survival, but may indirectly improve outcomes in select patients by virtue of receipt of neoadjuvant therapy and attainment of complete tumor resection.
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Affiliation(s)
- Richard J Straker
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Yun Song
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Adrienne B Shannon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Clayton T Marcinak
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI , USA
| | - John T Miura
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Douglas L Fraker
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Giorgos C Karakousis
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
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18
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Glasbey JC, Bundred J, Tyler R, Hunt J, Tattersall H, Gourevitch D, Almond LM, Desai AD, Ford SJ. The impact of postoperative radiological surveillance intensity on disease free and overall survival from primary retroperitoneal, abdominal and pelvic soft-tissue sarcoma. Eur J Surg Oncol 2021; 47:1771-1777. [PMID: 33549374 DOI: 10.1016/j.ejso.2021.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 10/22/2022] Open
Abstract
AIM This observational study aimed to evaluate the impact of intensity of radiological surveillance on survival following resection of retroperitoneal sarcoma. METHOD Retrospective cohort study of patients undergoing primary resection of soft tissue sarcoma arising in the retroperitoneum, abdomen or pelvis at a single, high-volume sarcoma centre. Intensity of follow-up regimes up to 5 postoperative years were categorized as 'European Society for Medical Oncology (ESMO) compliant' (intense), or 'non-ESMO compliant' (less-intense). The primary outcome measure was overall survival (OS). The secondary outcome measures were disease-free survival (DFS) and reoperation rate. Analyses were stratified by high (grade 2 or 3) or low (grade 1) tumour grade. RESULTS Of 168 patients, 67.1% had high-grade and 32.9% had low-grade disease. Overall, 40.0% of patients had ESMO-compliant radiological follow-up (high-grade:25.7%, low-grade:66.7%). 41.7% of patients died and 48.2% suffered local or distant recurrence by cessation of follow up. Upon univariable analysis for high-grade tumours, ESMO compliance reduced DFS (p = 0.066) but had no impact on OS. There was no significant difference in the reoperation rate in patients with ESMO-compliant and non-compliant follow-up (p = 0.097). In low-grade tumours, ESMO compliance significantly reduced DFS (p < 0.001), but without effecting OS. In risk-adjusted models for high-grade tumours, ESMO compliant follow-up was associated with reduced OS (HR:3.47, 1.40-8.61, p = 0.007) and no difference in DFS. In low-grade tumours, there was no association between overall ESMO compliance and OS or DFS. CONCLUSION This study did not find a benefit for high-intensity radiological surveillance and overall survival in patients undergoing primary resection for high or low-grade retroperitoneal sarcoma.
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Affiliation(s)
- J C Glasbey
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK
| | - J Bundred
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK
| | - R Tyler
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK
| | - J Hunt
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK
| | - H Tattersall
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK
| | - D Gourevitch
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK
| | - L M Almond
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK
| | - A D Desai
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK
| | - S J Ford
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH, UK.
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19
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Callegaro D, Raut CP, Ng D, Strauss DC, Honoré C, Stoeckle E, Bonvalot S, Haas RL, Vassos N, Conti L, Gladdy RA, Fairweather M, van Houdt W, Schrage Y, van Coevorden F, Rutkowski P, Miceli R, Gronchi A, Swallow CJ. Has the Outcome for Patients Who Undergo Resection of Primary Retroperitoneal Sarcoma Changed Over Time? A Study of Time Trends During the Past 15 years. Ann Surg Oncol 2020; 28:1700-1709. [PMID: 33073340 DOI: 10.1245/s10434-020-09065-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/09/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aimed to investigate changes in treatment strategy and outcome for patients with primary retroperitoneal sarcoma (RPS) undergoing resection at referral centers during a recent period. METHODS The study enrolled consecutive adult patients with primary non-metastatic RPS who underwent resection with curative intent between 2002 and 2017 at 10 referral centers. The patients were grouped into three periods according to date of surgery: t1 (2002-2006), t2 (2007-2011), and t3 (2012-2017). Five-year overall survival (OS), disease-specific survival (DSS), and crude cumulative incidence (CCI) of local recurrence (LR) and distant metastasis (DM) were calculated. Multivariable analyses for OS and DSS were performed. RESULTS The study included 1942 patients. The median follow-up period after resection varied from 130 months (interquartile range [IQR], 124-141 months) in t1 to 37 months (IQR, 35-39 months) in t3. The 5-year OS was 61.2% (95% confidence interval [CI], 56.4-66.3%) in t1, 67.0% (95 CI, 63.2-71.0%) in t2, and 71.9% (95% CI, 67.7-76.1%) in t3. The rate of macroscopically incomplete resection (R2) was 7.1% in t1 versus 4.7% in t3 (p = 0.066). The median number of resected organs increased over time (p < 0.001). In the multivariable analysis resection during t3 was associated with better OS and DSS. The 90-day postoperative mortality improved over time (4.3% in t1 to 2.3% in t3; p = 0.031). The 5-year CCI of LR and DM did not change significantly over time. CONCLUSIONS The long-term survival of patients who underwent resection for primary RPS has increased during the past 15 years. This increased survival is attributable to better patient selection for resection, quality of surgery, and perioperative patient management.
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Affiliation(s)
- Dario Callegaro
- Department of Surgical Oncology, Princess Margaret Cancer Centre/Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Chandrajit P Raut
- Department of Surgery, Dana-Farber Cancer Institute, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Deanna Ng
- Department of Surgical Oncology, Princess Margaret Cancer Centre/Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Dirk C Strauss
- Sarcoma Unit, Department of General Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Charles Honoré
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
| | | | | | - Rick L Haas
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nikolaos Vassos
- Sarcoma Unit, Department of General Surgery, Royal Marsden NHS Foundation Trust, London, UK.,Division of Surgical Oncology, Department of Surgery, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Lorenzo Conti
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Rebecca A Gladdy
- Department of Surgical Oncology, Princess Margaret Cancer Centre/Mount Sinai Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mark Fairweather
- Department of Surgery, Dana-Farber Cancer Institute, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Winan van Houdt
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Yvonne Schrage
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits van Coevorden
- Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Rosalba Miceli
- Department of Clinical Epidemiology and Trial Organisation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Carol J Swallow
- Department of Surgical Oncology, Princess Margaret Cancer Centre/Mount Sinai Hospital, Toronto, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada.
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20
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Patkar S, Kattepur AK, Shinde R, Goel M. Retroperitoneal Sarcomas: Prognostic Factors and Outcomes of a Series of Patients Treated at a Single Institution. Indian J Surg Oncol 2020; 11:223-234. [PMID: 32523267 DOI: 10.1007/s13193-020-01036-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 01/03/2020] [Indexed: 01/09/2023] Open
Abstract
Retroperitoneal sarcomas (RPS) are rare heterogeneous tumors arising in the retroperitoneum with unique biological and behavioral patterns that are thought to be closely linked to histology. The aim of the study was to audit our results and analyze various clinico-pathological factors including surgical excision, histology, and their implications on the recurrences and survival outcomes in RPS. Retrospective analysis of patients treated at a tertiary referral center in India from March 2008 to July 2017 was performed. The clinico-pathological variables were analyzed for their association with tumor recurrence and survival with special emphasis on histological subtype. The primary outcome was overall survival (OS). One hundred consecutive patients operated for RPS were analyzed. Of these, 27 were operated for recurrent tumors. Liposarcomas (LPS) and leiomyosarcomas (LMS) constituted 50% (n = 50) and 30% (n = 30) of patients respectively. Complete tumor excision was achieved in 83%, with 43% patients undergoing adjacent organ resection. At a median follow-up of 25.3 months, the median disease-free survival (DFS) and overall survival (OS) were 30 months and 87.8 months respectively. On multivariate analysis, tumor grade was the only factor to significantly affect survival (p = 0.001 for DFS and 0.005 for OS). There was no difference in survival outcomes between infiltrative and adhesive tumors with respect to adjacent organ invasion (p = 0.361 for OS). Tumor grade remains an important prognostic factor affecting disease-free and overall survival in retroperitoneal sarcomas irrespective of tumor size, site, and histology.
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Affiliation(s)
- Shraddha Patkar
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, 400012 India
| | - Abhay K Kattepur
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, 400012 India
| | - Rajesh Shinde
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, 400012 India
| | - Mahesh Goel
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, 400012 India
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21
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Gamboa AC, Gronchi A, Cardona K. Soft-tissue sarcoma in adults: An update on the current state of histiotype-specific management in an era of personalized medicine. CA Cancer J Clin 2020; 70:200-229. [PMID: 32275330 DOI: 10.3322/caac.21605] [Citation(s) in RCA: 253] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 12/13/2022] Open
Abstract
Soft-tissue sarcomas (STS) are rare tumors that account for 1% of all adult malignancies, with over 100 different histologic subtypes occurring predominately in the trunk, extremity, and retroperitoneum. This low incidence is further complicated by their variable presentation, behavior, and long-term outcomes, which emphasize the importance of centralized care in specialized centers with a multidisciplinary team approach. In the last decade, there has been an effort to improve the quality of care for patients with STS based on anatomic site and histology, and multiple ongoing clinical trials are focusing on tailoring therapy to histologic subtype. This report summarizes the latest evidence guiding the histiotype-specific management of extremity/truncal and retroperitoneal STS with regard to surgery, radiation, and chemotherapy.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Kenneth Cardona
- Division of Surgical Oncology, Winship Cancer Institute, Emory University Hospital Midtown, Atlanta, Georgia
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22
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Villano AM, Zeymo A, Chan KS, Unger KR, Shara N, Al-Refaie WB. Variations in Retroperitoneal Soft Tissue Sarcoma Outcomes by Hospital Type: A National Cancer Database Analysis. JCO Oncol Pract 2020; 16:e991-e1003. [PMID: 32267809 DOI: 10.1200/jop.19.00460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Surgical resection remains the cornerstone of retroperitoneal soft tissue sarcoma (RPS) treatment. Patient- and sarcoma-related factors are well known to influence survival outcomes. The effect of hospital-related factors on long-term survival, however, are not well understood. We sought to assess the relative contribution of hospital-level factors to mortality after surgical treatment of RPS. METHODS AND MATERIALS The 2004-2015 National Cancer Database was used to identify 10,113 patients who underwent surgical treatment of RPS. Patient-, sarcoma-, hospital-, and treatment-level factors were compared by increasing survival times. Stepwise multivariable Cox regression was performed that controlled for covariates to measure the relative contributions of these factors on overall survival (OS). Effect modification analyses ascertained how hospital type modulates the volume relationship with respect to RPS mortality. RESULTS Factors predictive of worsening OS were older age, nonprivate insurance, low income, presence of comorbidities, tumor histology, high grade or stage, and R2 resection (for all, P < .05). Increasing hospital surgical volume predicted decreasing risk of death across all survival times. However, analysis by hospital type demonstrated that compared with academic centers, the risk of death at community centers increased significantly as surgical volume increased (hazard ratio, 1.26; 95% CI, 1.03 to 1.53). CONCLUSION Hospital factors affect mortality after surgical treatment of RPS. Specifically, hospital type alters the surgical volume-outcome relationship for RPS mortality such that community centers perform worse with increasing volumes. Recommendations that higher surgical volume improves outcomes cannot be applied universally and must be re-examined in other complex surgical cancers.
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Affiliation(s)
- Anthony M Villano
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.,Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Alexander Zeymo
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.,MedStar Health Research Institute, Hyattsville, MD
| | - Kitty S Chan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.,MedStar Health Research Institute, Hyattsville, MD.,Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, DC
| | - Keith R Unger
- Department of Radiation Oncology, MedStar-Georgetown University Hospital, Washington, DC
| | - Nawar Shara
- MedStar Health Research Institute, Hyattsville, MD.,Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC
| | - Waddah B Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.,Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.,MedStar Health Research Institute, Hyattsville, MD
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23
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Reply to: Considerations on “impact of centralization of services on outcomes in a rare tumour: Retroperitoneal sarcomas”. Eur J Surg Oncol 2020; 46:708. [DOI: 10.1016/j.ejso.2019.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 11/19/2022] Open
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24
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An Evaluation of the Eighth Edition of the American Joint Committee on Cancer (AJCC) Staging System for Retroperitoneal Sarcomas Using the National Cancer Data Base (NCDB): Does Size Matter? Am J Clin Oncol 2019; 42:160-165. [PMID: 30394881 DOI: 10.1097/coc.0000000000000486] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Retroperitoneal sarcomas (RPS) are often large at diagnosis calling into question the seventh edition AJCC size classification of <5 cm (T1) or ≥5 cm (T2). The eighth edition expands T stage into 4 categories (T1: ≤5 cm, T2: 5<x≤10 cm, T3: 10<x≤15 cm, T4: >15 cm). We evaluated the prognostic ability of the eighth edition using the National Cancer Database (NCDB). METHODS Patients with RPS treated between 1998 and 2011 were identified from the NCDB; overall survival (OS) was compared. RESULTS Of the 6427 patients identified, 9% had tumors ≤5 cm (n=580), 19.4% 5<x≤10 cm (n=1246), 20.2% 10<x≤15 cm (n=1298) and 47.4% >15 cm (n=3045). With the eighth edition, stage II patients (G2/3 ≤5 cm) have a similar OS to stage IIIA patients (G2/3 5 cm<x≤10 cm), and patients with larger tumors (stage IIIB, G2/3>10 cm) show a decrease in OS. Tumor size as a continuous variable had a modest effect on survival (HR, 1.004; P=0.04). On multivariate analysis, higher T-stage was associated with decreased OS (T4 HR, 1.3; P<0.001) but high grade and incomplete resection (R2) were stronger prognostic factors. The c-index for both editions were similar (80.13 eighth vs. 80.08 seventh). CONCLUSIONS The eighth edition AJCC staging system for retroperitoneal sarcoma incorporates larger tumor size parameters that better characterize most patients, but tumor size alone is only a modest predictor of outcome.
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25
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Schmitz R, Adam MA, Blazer DG. Overcoming a travel burden to high-volume centers for treatment of retroperitoneal sarcomas is associated with improved survival. World J Surg Oncol 2019; 17:180. [PMID: 31684956 PMCID: PMC6829854 DOI: 10.1186/s12957-019-1728-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/15/2019] [Indexed: 01/07/2023] Open
Abstract
Background Guidelines recommend treatment of retroperitoneal sarcomas (RPS) at high-volume centers. However, high-volume centers may not be accessible locally. This national study compared outcomes of RPS resection between local low-volume centers and more distant high-volume centers. Methods Patients treated for RPS were identified from the National Cancer Database (1998–2012). Travel distance and annual hospital volume were divided into quartiles. Two groups were identified: (1) short travel to low-volume hospitals (ST/LV), (2) long travel to high-volume hospitals (LT/HV). Outcomes were adjusted for clinical, tumor, and treatment characteristics. Results Two thousand five hundred ninety-nine patients met the inclusion criteria. The LT/HV cohort was younger and more often white (p < 0.01). The LT/HV group had more comorbidities, higher tumor grade, and more often radical resections and radiotherapy (all p < 0.05). The ST/LV group underwent significantly more R2 resections (4.4% vs. 2.6%, p = 0.003). Thirty-day mortality was significantly lower in the LT/HV group (1.2% vs. 2.8%, p = 0.0026). Five-year survival was better among the LT/HV group (63% vs. 53%, p < 0.0001). After adjustment, the LT/HV group had a 27% improvement in overall survival (HR 0.73, p = 0.0009). Conclusions This national study suggests that traveling to high-volume centers for the treatment of RPS confers a significant short-term and long-term survival advantage, supporting centralized care for RPS.
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Affiliation(s)
- Robin Schmitz
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Mohamed A Adam
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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26
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Tirotta F, Desai A, Ford SJ, Strauss DC, Almond LM. Considerations on "Impact of centralisation of services on outcomes in a rare tumour: Retroperitoneal sarcomas". Eur J Surg Oncol 2019; 46:706-707. [PMID: 31668979 DOI: 10.1016/j.ejso.2019.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 10/17/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Fabio Tirotta
- Department of Sarcoma and General Surgery, Midlands Abdominal and Retroperitoneal Sarcoma Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anant Desai
- Department of Sarcoma and General Surgery, Midlands Abdominal and Retroperitoneal Sarcoma Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Samuel J Ford
- Department of Sarcoma and General Surgery, Midlands Abdominal and Retroperitoneal Sarcoma Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dirk C Strauss
- Department of Sarcoma Surgery, The Royal Marsden NHS Foundation Trust, Fulham Road, London, UK
| | - L Max Almond
- Department of Sarcoma and General Surgery, Midlands Abdominal and Retroperitoneal Sarcoma Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
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27
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Villano AM, Zeymo A, Chan KS, Shara N, Al-Refaie WB. Identifying the Minimum Volume Threshold for Retroperitoneal Soft Tissue Sarcoma Resection: Merging National Data with Consensus Expert Opinion. J Am Coll Surg 2019; 230:151-160.e2. [PMID: 31672672 DOI: 10.1016/j.jamcollsurg.2019.09.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/10/2019] [Accepted: 09/16/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The complexity of retroperitoneal soft tissue sarcoma (RPS) surgery has prompted international recommendations to regionalize it to high-volume hospitals (HVHs). A minimum procedural volume threshold for RPS is not yet defined, hampering effective referral and regionalization in the US. This multihospital study sought to establish an HVH threshold informed by national data and international expert opinion. STUDY DESIGN The 2004-2015 National Cancer Database identified 8,721 surgically treated RPS patients. Multivariable models, using linear splines, identified annual volume thresholds predictive of overall and 90-day mortality. Transatlantic Australasian Retroperitoneal Soft Tissue Sarcoma Working Group members (n = 48) completed a 15-item survey regarding these data. RESULTS Overall mortality risk was reduced by 4% per additional case (hazard ratio [HR] 0.96, 95% CI 0.95 to 0.98) up to a threshold of 13 cases/year; no further reduction was observed over 13 (HR 0.99, 95% CI 0.97 to 1.01). After revealing the results from our statistical analysis, 71.4% of respondents who initially chose >30 cases/year as a cutoff shifted their response to a lower value. More than 56% cited 11 to 20 procedures/year as the cutoff for an HVH. Median survival in hospitals with <13 vs >13 cases/year was 94 vs 139 months, respectively (p < 0.001). Forty percent of respondents cited 1% to 2% as an acceptable 90-day mortality. This was achieved with a minimum of 13 cases/year based on risk-adjusted survival analysis. CONCLUSIONS This is the first multicenter analysis to merge data-driven RPS surgery volume thresholds to clinically meaningful sarcoma expert opinions. These findings will help inform national/international consensus recommendations, a practical volume threshold, trial design, and motivate evidence-based hospital referral.
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Affiliation(s)
- Anthony M Villano
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Alexander Zeymo
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Hyattsville, MD
| | - Kitty S Chan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Hyattsville, MD
| | - Nawar Shara
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, DC; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC
| | - Waddah B Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC; MedStar Health Research Institute, Hyattsville, MD.
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28
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[French ccAFU guidelines - Update 2018-2020: Retroperitoneal sarcoma]. Prog Urol 2019; 28 Suppl 1:R167-R176. [PMID: 31610871 DOI: 10.1016/j.purol.2019.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To update French urological guidelines on retroperitoneal sarcoma. METHODS Comprehensive Medline search between 2016 and 2018 upon diagnosis, treatment and follow-up of retroperitoneal sarcoma. Level of evidence was evaluated. RESULTS Chest, abdomen and pelvis CT is mandatory to evaluate any suspected retroperitoneal sarcoma. MRI sometimes helps surgical planning. Before histological confirmation through biopsy, the patient must be registered in the French sarcoma pathology reference network. The biopsy standard should be an extraperitoneal coaxial percutaneous sampling before any retroperitoneal mass therapeutic decision. Surgery is retroperitoneal sarcoma cornerstone. The main objective is grossly negative margins and can be technically challenging. Multimodal treatment risks and benefits must be discussed in multidisciplinary teams. The relapse rate is related to tumor grade and surgical margins. CONCLUSION Retroperitoneal sarcoma prognosis is poor and closely related to the quality of initial management. Centralization through dedicated sarcoma pathology network in a high-volume center is mandatory.
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29
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Judge SJ, Lata‐Arias K, Yanagisawa M, Darrow MA, Monjazeb AM, Kirane AR, Bold RJ, Canter RJ, Canter DJ. Morbidity, mortality and temporal trends in the surgical management of retroperitoneal sarcoma: An ACS‐NSQIP follow up analysis. J Surg Oncol 2019; 120:753-760. [DOI: 10.1002/jso.25649] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/18/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Sean J. Judge
- Department of SurgeryUniversity of California Davis Medical CenterSacramento California
| | | | - Mio Yanagisawa
- Department of SurgeryUniversity of California Davis Medical CenterSacramento California
| | - Morgan A. Darrow
- Department of PathologyUniversity of California Davis Medical CenterSacramento California
| | - Arta M. Monjazeb
- Department of Radiation OncologyUniversity of California Davis Medical CenterSacramento California
| | - Amanda R. Kirane
- Department of SurgeryUniversity of California Davis Medical CenterSacramento California
| | - Richard J. Bold
- Department of SurgeryUniversity of California Davis Medical CenterSacramento California
| | - Robert J. Canter
- Department of SurgeryUniversity of California Davis Medical CenterSacramento California
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Jiang T, Zhao Q, Tian G, Chen X, Wu L. Irreversible electroporation ablation of end-stage metastatic retroperitoneal lesions: Report on three cases and literature review. Exp Ther Med 2019; 18:2243-2249. [PMID: 31410175 DOI: 10.3892/etm.2019.7780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 04/26/2019] [Indexed: 12/16/2022] Open
Abstract
Metastatic retroperitoneal tumors constitute an end-stage disease with poor prognosis that represents a heavy global health burden. The present study aimed to explore the efficacy of irreversible electroporation ablation (IRE) therapy in patients with end-stage retroperitoneal tumors. Between April 2016 and September 2017, three patients with unresectable retroperitoneal malignant tumors were enrolled. Among these cases, ultrasound (US)-guided IRE was palliatively performed for targeting 3 tumors (1 tumor per patient) located around the abdominal aorta. Post-treatment contrast-enhanced US (CEUS) and contrast-enhanced computed tomography (CECT) scans were subsequently performed to evaluate the area adjacent to the ablation zone and determine the prognosis. During the follow-up, the cases experienced a reduction of pain (mean score of 5.8 decreased to 2.2, based on the visual analogue scale), and had an overall survival rate ranging from 2 to 11 months. Case 1 remained alive at the time of submission of this study, but case 2 died within 2 months and case 3 within 11 months due to liver metastases of the primary tumor. At the 3-week follow-up, the CEUS image for case 1 exhibited a contrast defect with a sufficient ablation margin, in accordance with the CECT at 1.5 months following IRE, exhibiting complete tumor necrosis without contrast enhancement. Overall, these results suggest that US-guided percutaneous IRE may be effective in the treatment of end-stage retroperitoneal tumors. However, further studies are required to substantiate the conclusions of the present study. The present clinical trial was registered at clinicaltrials.gov (ID: NCT02822066) on June 20th, 2016.
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Affiliation(s)
- Tian'An Jiang
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China
| | - Qiyu Zhao
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China
| | - Guo Tian
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China
| | - Xinhua Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China
| | - Liming Wu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003, P.R. China
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31
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Bonvalot S, Gaignard E, Stoeckle E, Meeus P, Decanter G, Carrere S, Honore C, Delhorme JB, Fau M, Tzanis D, Causeret S, Gimbergues P, Guillois JM, Meunier B, Le Cesne A, Ducimetiere F, Toulmonde M, Blay JY. Survival Benefit of the Surgical Management of Retroperitoneal Sarcoma in a Reference Center: A Nationwide Study of the French Sarcoma Group from the NetSarc Database. Ann Surg Oncol 2019; 26:2286-2293. [DOI: 10.1245/s10434-019-07421-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
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32
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Peacock O, Patel S, Simpson JA, Walter CJ, Humes DJ. A systematic review of population-based studies examining outcomes in primary retroperitoneal sarcoma surgery. Surg Oncol 2019; 29:53-63. [PMID: 31196494 DOI: 10.1016/j.suronc.2019.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 02/09/2019] [Accepted: 03/02/2019] [Indexed: 12/24/2022]
Abstract
Retroperitoneal sarcomas (RPS) are rare mesenchymal tumours. Their rarity challenges our ability to understand expected outcomes. The aim of this systematic review was to examine 30-day morbidity and mortality, overall survival rates and prognostic predictors from population-based studies for patients undergoing curative resection for primary RPS. A systematic literature review of EMBASE, MEDLINE, PUBMED and the Cochrane library was performed using PRISMA for population-based studies reporting from nationally registered databases on primary RPS surgical resections in adults. The main outcomes evaluated were 30-day morbidity and mortality and overall survival rates. The use of additional treatment modalities and predictors of overall survival were also examined. Fourteen studies (n = 12 834 patients) reporting from 3 national databases, (Surveillance, Epidemiology and End Results (SEER), the United States National Cancer Database (US NCDB) and the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP)) were analysed. The reported overall 30-day morbidity and mortality were 23% (n = 191/846) and 3% (n = 278/10 181) respectively. Reported use of perioperative radiotherapy was 28%. No study reported loco-regional recurrence rates. Overall reported 5-year survival ranged from 52% to 62%. Independent predictors of overall survival were age of the patient, resection margin, tumour grade and size, histological subtype and receipt of radiotherapy. This review of population-based data demonstrated relatively low 30-day morbidity rates in patients undergoing curative surgical resections for primary RPS. Thirty-day mortality rates were similar to other abdominal tumour groups. There remains a paucity of data reporting recurrence rates, however 5-year survival rates ranged from 52 to 62%.
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Affiliation(s)
- Oliver Peacock
- Colorectal Surgery Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, United Kingdom.
| | - Shailen Patel
- Colorectal Surgery Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, United Kingdom
| | - Jonathan A Simpson
- Colorectal Surgery Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, United Kingdom
| | - Catherine J Walter
- Colorectal Surgery Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, United Kingdom
| | - David J Humes
- Colorectal Surgery Unit, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, United Kingdom; NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University of Nottingham, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, United Kingdom
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Increased survival of non low-grade and deep-seated soft tissue sarcoma after surgical management in high-volume hospitals: a nationwide study from the Netherlands. Eur J Cancer 2019; 110:98-106. [DOI: 10.1016/j.ejca.2019.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/31/2018] [Accepted: 01/05/2019] [Indexed: 12/18/2022]
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Villano AM, Zeymo A, McDermott J, Barrak D, Unger KR, Shara NM, Chan KS, Al-Refaie WB. Regionalization of Retroperitoneal Sarcoma Surgery to High-Volume Hospitals: Missed Opportunities for Outcome Improvement. J Oncol Pract 2019; 15:e247-e261. [DOI: 10.1200/jop.18.00349] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE: Surgery continues to be the dominant therapy for the management of retroperitoneal soft-tissue sarcoma (RPS). Many groups advocate performing these resections at high-volume hospitals (HVHs), given their complexity. We therefore sought to explore whether RPS surgery has indeed begun to regionalize to HVHs in the same manner as pancreatic cancer (PC) surgery during the last decade. METHODS: We identified 70,763 patients who underwent surgical resection for RPS or PC using the National Cancer Database (2004 to 2015). Patients were stratified by hospital surgical volume. We performed an adjusted time trend analysis to compare trends in performance of surgery at HVHs for RPS versus PC. Multivariable logistic analyses were then performed, controlling for covariables, to elucidate relationships between patient-, hospital-, and treatment-related variables that may contribute to these observed trends. RESULTS: Only 9.6% of patients underwent RPS surgery at HVHs. During this time period, the odds ratio of undergoing RPS compared with pancreatectomy at HVHs was 0.65 ( P < .05). Time trend analysis estimated that whereas both procedures are regionalizing, the rate of RPS regionalization grew at 30.5% of the rate of PC (1.017 v 1.056; P < .001) and remained consistent after using several hospital volume thresholds and hospital volume as a continuous variable. CONCLUSION: Results from this retrospective multi-institutional analysis uncovered a lag in the regionalization of surgery for RPS compared with PC surgery. These findings reinforce the call to regionalize surgery for RPS to HVHs in a manner that is similar to that of other procedures in complex cancer surgery.
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Affiliation(s)
- Anthony M. Villano
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar-Georgetown University Hospital, Washington, DC
| | - Alexander Zeymo
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar Health Research Institute, Hyattsville, MD
| | - James McDermott
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Dany Barrak
- Medstar-Washington Hospital Center, Washington, DC
| | | | - Nawar M. Shara
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar Health Research Institute, Hyattsville, MD
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC
| | - Kitty S. Chan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Waddah B. Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar-Georgetown University Hospital, Washington, DC
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Cananzi FCM, Ruspi L, Sicoli F, Minerva EM, Quagliuolo V. Did outcomes improve in retroperitoneal sarcoma surgery? Surg Oncol 2018; 28:96-102. [PMID: 30851921 DOI: 10.1016/j.suronc.2018.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/31/2018] [Accepted: 11/05/2018] [Indexed: 01/12/2023]
Abstract
In the last decades, the deeper understanding of the biological basis of the disease, along with the advances of surgical techniques and oncologic multimodal treatments, have led to an overall increase of survival of cancer patients. However, significant amelioration of the prognosis of rare and under-investigated tumors such as soft tissue sarcoma is less evident. In this review, main changes in the surgical management of retroperitoneal sarcoma (RPS) are discussed in order to figure out whether actual improvement in RPS outcome has been occurred in the last years.
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Affiliation(s)
- Ferdinando Carlo Maria Cananzi
- Surgical Oncology Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Milan, Italy.
| | - Laura Ruspi
- Surgical Oncology Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Federico Sicoli
- Surgical Oncology Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | | | - Vittorio Quagliuolo
- Surgical Oncology Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
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Murez T, Savoie PH, Fléchon A, Durand X, Rocher L, Camparo P, Morel-Journel N, Ferretti L, Sèbe P, Méjean A. RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : sarcomes rétropéritonéaux French ccAFU guidelines — Update 2018—2020: Retroperitoneal sarcoma. Prog Urol 2018; 28:S165-S174. [PMID: 30473000 DOI: 10.1016/j.purol.2018.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 12/01/2022]
Abstract
This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy).
Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations.
Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.010.
C’est cette nouvelle version qui doit être utilisée pour citer l’article.
This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published.
The replacement has been published at the doi:10.1016/j.purol.2019.01.010.
That newer version of the text should be used when citing the article.
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Affiliation(s)
- T Murez
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie et transplantation rénale, CHU Lapeyronie, 371, avenue du Doyen-Gaston-Giraud, 34295, Montpellier cedex 5, France.
| | - P-H Savoie
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital d'instruction des armées Sainte-Anne, BP 600, 83800, Toulon cedex 09, France
| | - A Fléchon
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'oncologie médicale, centre Léon-Bérard, 28, rue Laennec, 69008, Lyon, France
| | - X Durand
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital d'instruction des Armées Bégin, 69, avenue de Paris, 94160, Saint Mande, France
| | - L Rocher
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service de radiologie, CHU Paris Sud, site Kremlin-Bicêtre, AP-HP, 94270, Le Kremlin-Bicêtre, France
| | - P Camparo
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Centre de pathologie, 51, rue de Jeanne-D'Arc, 80000, Amiens, France
| | - N Morel-Journel
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, centre hospitalier Lyon Sud (Pierre Bénite), HCL groupement hospitalier du Sud, 69495, Pierre Bénite cedex, France
| | - L Ferretti
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, MSP de Bordeaux-Bagatelle, 203, route de Toulouse, BP 50048, 33401, Talence cedex, France
| | - P Sèbe
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, groupe hospitalier Diaconesses Croix Saint Simon, 125, rue d'Avron, 75020, Paris, France
| | - A Méjean
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017, Paris, France; Service d'urologie, hôpital européen Georges-Pompidou, université Paris Descartes, AP-HP, 75015, Paris, France
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Keung EZ, Chiang YJ, Cormier JN, Torres KE, Hunt KK, Feig BW, Roland CL. Treatment at low-volume hospitals is associated with reduced short-term and long-term outcomes for patients with retroperitoneal sarcoma. Cancer 2018; 124:4495-4503. [PMID: 30317543 DOI: 10.1002/cncr.31699] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/29/2018] [Accepted: 06/15/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Retroperitoneal sarcomas (RPS) are rare tumors for which complete surgical resection remains the mainstay of treatment. The objective of the current study was to determine the impact of hospital case volume on outcomes in patients with RPS. METHODS A total of 6950 patients with primary RPS who underwent surgical resection were identified from the National Cancer Data Base (1998-2011). Treating hospitals were classified by annual case volume; low-volume hospitals (LVHs) and high-volume hospitals (HVHs) were defined as those with ≤10 cases per year and >10 cases per year, respectively. Overall survival (OS) was compared using Kaplan-Meier curves. Cox proportional hazard models were created to compare risks. RESULTS Of the 1131 reporting hospitals, the majority (1127 hospitals; 99.6%) were LVHs treating the majority of patients (6270 patients; 90.2%). Patients treated at LVHs were more likely to have lower grade and smaller tumors, receive radiotherapy, and undergo incomplete macroscopic (R2) resection. Patients treated at HVHs had lower 30-day readmission rates (1.8% vs 3.4%; P<.001), 30-day (1.9% vs 3.1%; P=.004) and 90-day (3.2% vs 5.7%; P=.007) mortality, longer median OS (76.2 months vs 64.2 months; P<.001), and higher 5-year OS rates (58% vs 52%; P<.001). After controlling for age, sex, insurance status, tumor size, tumor grade, surgical resection margin status, and radiotherapy administration, treatment at an HVH was found to be independently associated with a reduced risk of death (hazard ratio, 0.77; 95% confidence interval, 0.65-0.91 [P=.003]). CONCLUSIONS Primary RPS are rare tumors, and to our knowledge few surgeons and institutions have significant experience and expertise in their multidisciplinary management and surgical resection. Although additional studies are needed, patient outcomes may be impacted by the case volume and expertise of the treating facility.
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Affiliation(s)
- Emily Z Keung
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Janice N Cormier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Keila E Torres
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelly K Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Barry W Feig
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christina L Roland
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Putt ME. Is surgery for retroperitoneal sarcoma at "low-volume" hospitals a bad idea? Cancer 2018; 124:4447-4451. [PMID: 30317541 DOI: 10.1002/cncr.31750] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/26/2018] [Indexed: 01/24/2023]
Affiliation(s)
- Mary E Putt
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Snow HA, Hitchen TX, Head J, Herschtal A, Bae S, Chander S, Chu J, Hendry S, Ngan SY, Desai J, Choong PFM, Henderson M, Gyorki DE. Treatment of patients with primary retroperitoneal sarcoma: predictors of outcome from an Australian specialist sarcoma centre. ANZ J Surg 2018; 88:1151-1157. [DOI: 10.1111/ans.14842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/16/2018] [Accepted: 07/24/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Hayden A. Snow
- Department of Cancer Surgery; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Tatiana X. Hitchen
- Department of Cancer Surgery; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Jessica Head
- Department of Cancer Surgery; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Alan Herschtal
- Centre for Biostatistics and Clinical Trials; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Susie Bae
- Department of Medical Oncology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Sarat Chander
- Department of Radiation Oncology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Julie Chu
- Department of Radiation Oncology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Shona Hendry
- Department of Anatomical Pathology; St Vincent's Hospital; Melbourne Victoria Australia
- Department of Pathology; The University of Melbourne; Melbourne Victoria Australia
| | - Samuel Y. Ngan
- Department of Radiation Oncology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Department of Radiation Oncology; The University of Melbourne; Melbourne Victoria Australia
| | - Jayesh Desai
- Department of Oncology; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Peter F. M. Choong
- Department of Cancer Surgery; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
- Department of Orthopaedic Surgery; St Vincent's Hospital; Melbourne Victoria Australia
| | - Michael Henderson
- Department of Cancer Surgery; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
| | - David E. Gyorki
- Department of Cancer Surgery; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Department of Surgery; The University of Melbourne; Melbourne Victoria Australia
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Abstract
This article begins by introducing the historical background surrounding the volume-outcomes relationship literature, particularly in complex cancer surgery. The state of evidence surrounding mortality, as well as other outcomes, in relation to both hospital and surgeon procedure volume is synthesized. Where it is understood, the level of adoption of regionalization of various complex surgeries in the United States is also presented. Various controversies are weighed and discussed. Finally, various models of regionalization and proposed alternatives to regionalization from the peer-reviewed literature are presented.
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Affiliation(s)
- Stephanie Lumpkin
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA
| | - Karyn Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA.
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Abarca T, Gao Y, Monga V, Tanas MR, Milhem MM, Miller BJ. Improved survival for extremity soft tissue sarcoma treated in high-volume facilities. J Surg Oncol 2018; 117:1479-1486. [PMID: 29633281 DOI: 10.1002/jso.25052] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/26/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES The purpose of this investigation was to determine the effect of hospital volume on treatment decisions, treatment results, and overall patient survival in extremity soft tissue sarcoma. METHODS The National Cancer Database was used to identify patients ≥18 years of age with non-metastatic soft tissue sarcoma of the extremity treated with surgery. Patients in high- and low-volume centers were matched by propensity score and placed into two equal comparative groups of 2437 patients each. RESULTS Chemotherapy was used at a higher rate in high-volume centers (22% vs 17%, P < 0.001) and external beam radiation usage was similar (55% vs 52%, P = 0.108). There was a lower incidence of positive margins in high-volume centers (12% vs 17%, P < 0.001). There was no significant difference in the rates of limb salvage surgery or readmissions at high-volume hospitals compared to low-volume. In a multivariate Cox proportional hazards model, low-volume facilities demonstrated diminished overall survival at all time points (hazard ratio at 5 years = 1.24, 95%CI 1.10-1.39). CONCLUSIONS Treatment at high-volume hospitals was associated with fewer positive margins and increased overall survival at 2, 5, and 10 years. Continued efforts should focus on optimizing the balance between patient access to specialty care and experience of the treating center.
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Affiliation(s)
- Tyler Abarca
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Yubo Gao
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Varun Monga
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Munir R Tanas
- Department of Pathology, University of Iowa, Iowa City, Iowa
| | - Mohammed M Milhem
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Benjamin J Miller
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa
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Venigalla S, Nead KT, Sebro R, Guttmann DM, Sharma S, Simone CB, Levin WP, Wilson RJ, Weber KL, Shabason JE. Association Between Treatment at High-Volume Facilities and Improved Overall Survival in Soft Tissue Sarcomas. Int J Radiat Oncol Biol Phys 2018; 100:1004-1015. [PMID: 29485042 PMCID: PMC5830163 DOI: 10.1016/j.ijrobp.2017.12.262] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/06/2017] [Accepted: 12/11/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE Soft tissue sarcomas (STS) are rare malignancies that require complex multidisciplinary management. Therefore, facilities with high sarcoma case volume may demonstrate superior outcomes. We hypothesized that STS treatment at high-volume (HV) facilities would be associated with improved overall survival (OS). METHODS AND MATERIALS Patients aged ≥18 years with nonmetastatic STS treated with surgery and radiation therapy at a single facility from 2004 through 2013 were identified from the National Cancer Database. Facilities were dichotomized into HV and low-volume (LV) cohorts based on total case volume over the study period. OS was assessed using multivariable Cox regression with propensity score-matching. Patterns of care were assessed using multivariable logistic regression analysis. RESULTS Of 9025 total patients, 1578 (17%) and 7447 (83%) were treated at HV and LV facilities, respectively. On multivariable analysis, high educational attainment, larger tumor size, higher grade, and negative surgical margins were statistically significantly associated with treatment at HV facilities; conversely, black race and non-metropolitan residence were negative predictors of treatment at HV facilities. On propensity score-matched multivariable analysis, treatment at HV facilities versus LV facilities was associated with improved OS (hazard ratio, 0.87, 95% confidence interval, 0.80-0.95; P = .001). Older age, lack of insurance, greater comorbidity, larger tumor size, higher tumor grade, and positive surgical margins were associated with statistically significantly worse OS. CONCLUSIONS In this observational cohort study using the National Cancer Database, receipt of surgery and radiation therapy at HV facilities was associated with improved OS in patients with STS. Potential sociodemographic disparities limit access to care at HV facilities for certain populations. Our findings highlight the importance of receipt of care at HV facilities for patients with STS and warrant further study into improving access to care at HV facilities.
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Affiliation(s)
- Sriram Venigalla
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Kevin T Nead
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ronnie Sebro
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David M Guttmann
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sonam Sharma
- Department of Radiation Oncology, Mount Sinai School of Medicine, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - William P Levin
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robert J Wilson
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kristy L Weber
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jacob E Shabason
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Sandrucci S, Ponzetti A, Gianotti C, Mussa B, Lista P, Grignani G, Mistrangelo M, Bertetto O, Di Cuonzo D, Ciccone G. Different quality of treatment in retroperitoneal sarcomas (RPS) according to hospital-case volume and surgeon-case volume: a retrospective regional analysis in Italy. Clin Sarcoma Res 2018; 8:3. [PMID: 29507712 PMCID: PMC5830336 DOI: 10.1186/s13569-018-0091-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 02/05/2018] [Indexed: 11/10/2022] Open
Abstract
Background Retroperitoneal sarcomas (RPS) should be surgically managed in specialized sarcoma centers. However, it is not clearly demonstrated if clinical outcome is more influenced by Center Case Volume (CCV) or by Surgeon Case Volume (SCV). The aim of this study is to retrospectively explore the relationship between CCV and SCV and the quality of surgery in a wide region of Northern Italy. Methods We retrospectively collected data about patients M0 surgically treated for RPSs in 22 different hospitals from 2006 to 2011, dividing them in two hospital groups according to sarcoma clinical activity volume (HCV, high case volume or LCV, low case volume hospitals). The HCV group (> 100 sarcomas observed per year) included a Comprehensive Cancer Center (HVCCC) with a high sarcoma SCV (> 20 cases/year), and a Tertiary Academic Hospital (HVTCA) with multiple surgeon teams and a low sarcoma SCV (≤ 5 cases/year for each involved surgeon). All other hospitals were included in the LCV group (< 100 sarcomas observed per year). Results Data regarding 138 patients were collected. Patients coming from LCV hospitals (66) were excluded from the analysis as prognostic data were frequently not available. Among the 72 remaining cases of HCV hospitals 60% of cases had R0/R1 margins, with a more favorable distribution of R0/R1 versus R2 in HVCCC compared to HVTCA. Conclusions In HCV hospitals, sarcoma SCV may significantly influence RPS treatment quality. In low-volume centers surgical reports can often miss important prognostic issues and surgical quality is generally poor.
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Affiliation(s)
- Sergio Sandrucci
- 1Visceral Sarcoma Unit, University of Turin, Cso Dogliotti 14, 10126 Turin, Italy
| | - Agostino Ponzetti
- Medical Oncology 1 Division, Città della Salute e della Scienza, Turin, Italy
| | - Claudio Gianotti
- 1Visceral Sarcoma Unit, University of Turin, Cso Dogliotti 14, 10126 Turin, Italy
| | - Baudolino Mussa
- 3Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Patrizia Lista
- Medical Oncology 1 Division, Città della Salute e della Scienza, Turin, Italy
| | - Giovanni Grignani
- 4Department of Medical Oncology, Candiolo Cancer Institute-FPO, IRCCS, Candiolo, Italy
| | | | | | - Daniela Di Cuonzo
- Cancer Epidemiology Unit, Città della Salute e della Scienza, Turin, Italy
| | - Giovannino Ciccone
- Cancer Epidemiology Unit, Città della Salute e della Scienza, Turin, Italy
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Moris D, Petrou A, Papalampros A, Tsilimigras DI, Felekouras E. Retroperitoneal sarcomas: does the center really matter? Surgery 2017; 163:971-972. [PMID: 29203285 DOI: 10.1016/j.surg.2017.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Dimitrios Moris
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Athanasios Petrou
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Papalampros
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Diamantis I Tsilimigras
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Felekouras
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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