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Gorji L, Nikahd M, Onuma A, Tsilimigras D, Madison Hyer J, Ruff S, Ilyas FZ, Contreras C, Grignol VP, Kim A, Pollock R, Pawlik TM, Beane JD. Comparing Multivisceral Resection with Tumor-only Resection of Liposarcoma Using the Win Ratio. Ann Surg Oncol 2024; 31:3389-3396. [PMID: 38347333 PMCID: PMC10997686 DOI: 10.1245/s10434-024-14985-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 01/15/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Multivisceral resection of retroperitoneal liposarcoma (LPS) is associated with increased morbidity and may not confer a survival benefit compared with tumor-only (TO) resection. We compared both approaches using a novel statistical method called the "win ratio" (WR). METHODS Patients who underwent resection of LPS from 2004 to 2015 were identified from the National Cancer Database. Multivisceral resection was defined as removal of the primary site in addition to other organs. The WR was calculated based on a hierarchy of postoperative outcomes: 30-day and 90-day mortality, long-term survival, and severe complication. RESULTS Among 958 patients (multivisceral 634, TO 324) who underwent resection, the median age was 63 years (interquartile range [IQR] 54-71) with a median follow-up of 51 months (IQR 30-86). There was no difference in the WR among patients who underwent TO versus multivisceral resection in the matched cohort (WR 0.82, 95% confidence interval [CI] 0.61-1.10). In patients aged 72-90 years, those who underwent multivisceral resection had 36% lower odds of winning compared with patients undergoing TO resection (WR 0.64, 95% CI 0.40-0.98). A subgroup analysis of patients classified as not having adjacent tumor involvement at the time of surgery revealed that those patients who underwent multivisceral resection had 33% lower odds of winning compared to TO resection (WR 0.67, 95% CI 0.45-0.99). CONCLUSIONS Based on win-ratio assessments of a hierarchical composite endpoint, multivisceral resection in patients without adjacent tumor involvement may not confer improved outcomes. This method supports the rationale for less invasive resection of LPS in select patients, especially older patients.
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Affiliation(s)
- Leva Gorji
- Department of Surgery, Kettering Health Dayton, Dayton, OH, USA
| | - Melica Nikahd
- Department of Biomedical Science-Biomedical informatics Columbus, Columbus, OH, USA
| | - Amblessed Onuma
- Department of Surgery, The Ohio State University Wexner Medical Center Columbus, Columbus, OH, USA
| | - Diamantis Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center Columbus, Columbus, OH, USA
| | - J Madison Hyer
- Department of Biomedical Science-Biomedical informatics Columbus, Columbus, OH, USA
| | - Samantha Ruff
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Farhan Z Ilyas
- College of Medicine, The Ohio State University Columbus, Columbus, OH, USA
| | - Carlo Contreras
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Valerie P Grignol
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Alex Kim
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Raphael Pollock
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Joal D Beane
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA.
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Othman H, Shapiro J, Chung P, Gladdy RA. Progress in Retroperitoneal Sarcoma Management: Surgical and Radiotherapy Approaches. Semin Radiat Oncol 2024; 34:164-171. [PMID: 38508781 DOI: 10.1016/j.semradonc.2024.02.002] [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: 03/22/2024]
Abstract
Surgical resection is the cornerstone of curative treatment for retroperitoneal sarcomas (RPS), aiming for complete excision, yet the complexity of RPS with its proximity to vital structures continues to lead to high local recurrence rates after surgery alone. Thus, the role of radiotherapy (RT) continues to be refined to improve local control, which remains an important goal to prevent RPS recurrence. The recently completed global randomized trial to evaluate the role of surgery with and without preoperative RT - STRASS1, did not demonstrate a significant overall benefit for neoadjuvant RT based on the pre-specified definition of abdominal recurrence-free survival, however, sensitivity analysis using a standard definition of local recurrence and analysis of outcomes by compliance to the RT protocol suggests histology-specific benefit in well- and some de-differentiated liposarcomas. Ultimately, multidisciplinary collaboration and personalized approaches that consider histological sarcoma types and patient-specific factors are imperative for optimizing the therapeutic strategy in the management of RPS.
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Affiliation(s)
- Hiba Othman
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Joel Shapiro
- Department of Surgery, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada, Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada
| | - Peter Chung
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Rebecca A Gladdy
- Department of Surgery, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada, Department of Surgical Oncology, Princess Margaret Cancer Centre, University of Toronto, Ontario, Canada..
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Kamarajah SK, Baia M, Naumann DN, Mahmood F, Parente A, Almond M, Tirotta F, Ford SJ, Dahdaleh F, Desai A. Association between centre volume and allocation to curative surgery and long-term survival for retroperitoneal sarcoma. BJS Open 2023; 7:zrad059. [PMID: 37498965 PMCID: PMC10373904 DOI: 10.1093/bjsopen/zrad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/09/2023] [Accepted: 04/29/2023] [Indexed: 07/29/2023] Open
Affiliation(s)
- Sivesh K Kamarajah
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, UK
- Academic Department of Surgery, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Marco Baia
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - David N Naumann
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Fahad Mahmood
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Alessandro Parente
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Max Almond
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Fabio Tirotta
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Samuel J Ford
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Fadi Dahdaleh
- Edward-Elmhurst Health Hospital, Chicago, Illinois, USA
| | - Anant Desai
- Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, Birmingham, UK
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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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Surgical Principles of Primary Retroperitoneal Sarcoma in the Era of Personalized Treatment: A Review of the Frontline Extended Surgery. Cancers (Basel) 2022; 14:cancers14174091. [PMID: 36077627 PMCID: PMC9454716 DOI: 10.3390/cancers14174091] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Surgery is the only curative treatment for localized disease in retroperitoneal sarcoma (RPS). Frontline extended surgery, or compartmental surgery, is a recent surgical strategy consisting of resecting the tumor together with adjacent organs, with the aim of minimizing marginality. This review provides a practical step by step description of this standardized procedure, tailored to histologic behavior, tumor localization, and patient condition. Abstract Surgery is the key treatment in retroperitoneal sarcoma (RPS), as completeness of resection is the most important prognostic factor related to treatment. Compartmental surgery/frontline extended approach is based on soft-tissue sarcoma surgical principles, and involves resecting adjacent viscera to achieve a wide negative margin. This extended approach is associated with improved local control and survival. This surgery must be tailored to tumor histology, tumor localization, and patient performance status. We herein present a review of compartmental surgery principles, covering the oncological and technical basis, and describing the tailored approach to each tumor subtype and localization in the retroperitoneum.
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Fiore M, Baia M, Conti L, Piccioni F, Mariani L, Pasquali S, Seregni E, Maltese G, Galizia M, Radaelli S, Villa AM, Valenza F, Gronchi A. Residual Adrenal Function After Multivisceral Resection With Adrenalectomy in Adult Patients. JAMA Surg 2022; 157:415-423. [PMID: 35195679 PMCID: PMC8867388 DOI: 10.1001/jamasurg.2021.7588] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance The risk of developing adrenal insufficiency (AI) following adrenalectomy has been insufficiently studied in the context of multivisceral resection (MVR). Objective To evaluate the incidence of AI in patients undergoing MVR with en bloc adrenalectomy. Design, Setting, and Participants Prospective observational longitudinal study in a single referral center including 56 consecutive adult patients undergoing retroperitoneal sarcoma surgery from June 2019 to August 2020. Those who were candidates for MVR with en bloc adrenalectomy and had no preexisting adrenal impairment were considered eligible. Of these, 4 individuals were excluded because they did not receive adrenalectomy at the time of surgery and 2 because they were not considered evaluable for the main end point. Follow-up was set at 4 months after surgery, and 49 patients completed follow-up. Data were analyzed from October 2020 to September 2021. Exposures Diagnosis of AI was determined by low-dose (1 μg) adrenocorticotropic hormone (ACTH) stimulation test with a threshold of 20 μg/dL in blood samples retrieved 30 and 60 minutes after stimulation. ACTH test was repeated on postoperative days 1 and 10 and at 4 months' follow-up. Main Outcome and Measures The primary end point was incidence and relevance of AI after MVR. Secondary end points were associations with patient- and tumor-related factors, impact on perioperative hemodynamic management, and association with postoperative morbidity and mortality. Results Fifty patients (26 female; median [IQR] age, 59 [46-67] years) were evaluable. Incidence of AI was 64% (32 of 50 patients) in the early postoperative period and 38.5% (15 of 39 patients) at follow-up. Patients with AI showed lower postoperative cortisol values. Factors associated with risk of AI at univariate analysis were high American Society of Anesthesiologists score (odds ratio [OR], 0.31; 95% CI, 0.14-0.48) and high malignancy grade (OR, 0.35; 95% CI, 0.24-0.46). Clinical outcomes not associated with AI included morbidity, mortality, reoperation rate, admission to intensive care unit, length of intensive care unit stay, total hospital stay, and long-term quality of life. Conclusions and Relevance In this study, AI after MVR with en bloc adrenalectomy was frequent, even in patients with adequate preoperative adrenal function. Despite this, adrenalectomy can be safely performed. Patients at risk should be monitored in the long term to exclude underrated impairment of adrenal function.
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Affiliation(s)
- Marco Fiore
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marco Baia
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy,Midlands Abdominal and Retroperitoneal Sarcoma Unit, Queen Elizabeth Hospital, University Birmingham Hospital NHS Trust, Birmingham, United Kingdom
| | - Lorenzo Conti
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy,Department of Surgery, ASST dei Sette Laghi, Varese, Italy
| | - Federico Piccioni
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigi Mariani
- Unit of Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sandro Pasquali
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Ettore Seregni
- Nuclear Medicine, Department of Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gabriele Maltese
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Mauro Galizia
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Radaelli
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandro Maria Villa
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Franco Valenza
- Anesthesia and Intensive Care Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy,Università degli Studi di Milano, Milan, Italy
| | - Alessandro Gronchi
- Sarcoma Service, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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7
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Baia M, Conti L, Pasquali S, Sarre-Lazcano C, Abatini C, Cioffi SPB, Della Valle S, Greco G, Vigorito R, Casirati A, Proto P, Gavazzi C, Gronchi A, Fiore M. Delayed Gastric Emptying After Multivisceral Resection for Retroperitoneal Sarcoma. Ann Surg Oncol 2022; 29:3264-3270. [PMID: 35031920 DOI: 10.1245/s10434-021-11154-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Delayed gastric emptying (DGE) is a common complication in surgery, but incidence and relevance following multivisceral resection are unknown. METHODS Data from 100 consecutive patients treated for primary retroperitoneal sarcoma (RPS) were analyzed from our institutional prospectively maintained database from January 2019 to April 2020. DGE severity was graded according to the International Study Group of Pancreatic Surgery and classified as primary or secondary to other complications. The primary outcome was incidence and grade of clinically relevant DGE (grades B-C). Secondary outcomes were correlation with patient, tumor, and treatment characteristics, and non-DGE morbidity [Clavien-Dindo (CD) grade ≥ 3]. RESULTS Forty-two patients developed DGE and 28 had clinically relevant DGE. DGE was primary in 10 patients and secondary in 18 patients; the most common associated complications were: infections (11/18, 61.1%), pancreatic leak (7/18, 38.9%), bleeding (6/18, 33.3%), and bowel leak (6/18, 33.3%). DGE was related to longer length of hospital stay (P < 0.001), ICU admission (P = 0.004), ICU length of stay (P = 0.001), postoperative complications (CD [Formula: see text] 3 in 14/28 in DGE patients vs 11/72 in no-DGE; P = 0.04), and re-operation (P = 0.03). With multivariate analysis, the independent risk factors for DGE were patient comorbidities (OR 1.05; 95% CI 1.01-1.1; P = 0.04) and tumor size (OR 1.05; 95% CI 1.0-1.1; P = 0.02). DISCUSSION Following multivisceral resection, DGE is a clinically relevant event that can be caused by an underlying complication. Prompt diagnosis and treatment of both DGE and any underlying complications led to full recovery in all cases.
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Affiliation(s)
- Marco Baia
- Sarcoma Service, Department of Surgery, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Lorenzo Conti
- Ospedale Galmarini di Tradate - ASST Settelaghi, Varese, Tradate, Italy
| | - Sandro Pasquali
- Sarcoma Service, Department of Surgery, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Catherine Sarre-Lazcano
- Sarcoma Service, Department of Surgery, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Carlo Abatini
- Sarcoma Service, Department of Surgery, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | | | - Serena Della Valle
- Clinical Nutritional Service, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Giorgio Greco
- Department of Radiology, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Raffaella Vigorito
- Department of Radiology, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Amanda Casirati
- Clinical Nutritional Service, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Paolo Proto
- Anesthesiology Department, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Cecilia Gavazzi
- Clinical Nutritional Service, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Alessandro Gronchi
- Sarcoma Service, Department of Surgery, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Marco Fiore
- Sarcoma Service, Department of Surgery, IRCCS Fondazione Istituto Nazionale dei Tumori di Milano, Milan, Italy.
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Postoperative Outcome of Surgery with Pancreatic Resection for Retroperitoneal Soft Tissue Sarcoma: Results of a Retrospective Bicentric Analysis on 50 Consecutive Patients. J Gastrointest Surg 2021; 25:2299-2306. [PMID: 33236323 DOI: 10.1007/s11605-020-04882-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/12/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUNDS Multivisceral resection is the standard treatment for retroperitoneal sarcoma (RPS) during which pancreas resection may be necessary. METHODS All consecutive patients operated for RPS with pancreatectomy in 2 expert centers between 1993 and 2018 were retrospectively analyzed. RESULTS Fifty patients (median age: 57 years, IQR: [46-65]) with a primary (n = 33) or recurrent (n = 17) RPS underwent surgery requiring pancreas resection (distal pancreatectomy (DP) (n = 43), pancreaticoduodenectomy (PD) (n = 5), central pancreatectomy (n = 1), and atypical resection (n = 1)). Severe postoperative morbidity (Clavien-Dindo III-IV) was observed in 14 patients (28%), and 7 of them (14%) required reoperation for anastomotic bowel leakage (n = 5), gastric volvulus (n = 1), or hemorrhage (n = 1). Pancreas-related complications occurred in 25 patients (50%): 10 postoperative pancreatic fistulas (POPF) (grade A (n = 12), grade B (n = 6), grade C (n = 1)), 13 delayed gastric emptying (grade A (n = 8), grade B (n = 4), grade C (n = 1)), 1 hemorrhage (grade C). Postoperative mortality was 4% (n = 2), all following PD, caused by a massive intraoperative air embolism and by a multiple organ failure after anastomotic leakage. Pathological analysis confirmed pancreatic involvement in 17 (34%) specimens. Microscopically complete resection (R0) was achieved in 22 (44%) patients. After a follow-up of 60 months, 36 patients (75%) were still alive, among whom 27 without recurrence (56%). CONCLUSION Pancreatic resection during RPS surgery is associated with significant postoperative morbidity and mortality. PD should be avoided whenever possible while other procedures seemed achievable without excessive morbidity and with long-term survival.
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Hwang H, Kwon YH, Lim HK, Kim J, Park KJ. Retroperitoneal sarcomas: Outcomes of repeated resections. KOREAN JOURNAL OF CLINICAL ONCOLOGY 2020; 16:96-103. [PMID: 36945717 PMCID: PMC9942735 DOI: 10.14216/kjco.20015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 08/18/2020] [Accepted: 11/18/2020] [Indexed: 11/07/2022]
Abstract
Purpose Retroperitoneal sarcomas (RPS) are rare malignant tumors arising from mesenchymal cells. The objective of this study was to review the treatment experiences and to identify prognostic factors for overall survival (OS) after primary resection and subsequent reoperations for recurrences. Methods The medical records of patients who underwent resection for RPS at our institution between June 2002 and December 2016 were retrospectively reviewed. Univariate and multivariable Cox proportional hazards modeling was used to assess the prognostic factors for OS. Results A total of 48 patients were enrolled. On multivariable analysis in primary resection group, the FNCLCC (Fédération Nationale des Centres de Lutte Contre le Cancer) grade was a significant prognostic factor for OS (P=0.006). The patients who received chemotherapy after primary resection were significantly associated with poor prognosis (P=0.009). The 5-year OS rate after primary resection (n=48) were 58.1% and the 5-year cumulative reoperation rate after primary resection was 62.5%. After second resection for recurrence after primary resection (n=23), the 5-year OS rate was 64.3%. There was a tendency towards decreased surgery-free survival rate as the number of repeated resections for recurrent RPS increased. In the subset of patients (n=16) who underwent more than 3 repeated resections at our institute, the 5-year OS rate was 75.0%, indicating that repeated resections are not associated with worse outcome. Conclusion Only low tumor grade was an independent favorable prognostic factor for OS. Although the prognosis for RPS remains poor, repeated resections for recurrence are not associated with poor prognosis. Aggressive surgical strategies for recurred RPS patients are warranted.
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Affiliation(s)
- Hyeonuk Hwang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon-Hye Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Ki Lim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jeesun Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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10
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Fiore M, Caraceni A, Gronchi A. ASO Author Reflections: Understanding the Impact of Primary Retroperitoneal Sarcoma Resection on Patient Well-being: One Step Forward in Learning How Caring for Patients is as Important as Curing Their Cancers. Ann Surg Oncol 2020; 28:3917-3918. [PMID: 33249522 DOI: 10.1245/s10434-020-09416-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Marco Fiore
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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11
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Fiore M, Brunelli C, Miceli R, Manara M, Lenna S, Rampello NN, Callegaro D, Colombo C, Radaelli S, Pasquali S, Caraceni AT, Gronchi A. A Prospective Observational Study of Multivisceral Resection for Retroperitoneal Sarcoma: Clinical and Patient-Reported Outcomes 1 Year After Surgery. Ann Surg Oncol 2020; 28:3904-3916. [PMID: 33175262 DOI: 10.1245/s10434-020-09307-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Primary retroperitoneal sarcoma (RPS) may require multivisceral resection (MVR). Clinical outcome (morbidity and renal function) and quality of life (QoL) are not as well reported as the oncologic outcome. METHODS Patients with primary RPS who underwent surgery between 2014 and 2016 were prospectively enrolled in an observational longitudinal study. At baseline, then at 4 and 12 months, the study measured Clavien-Dindo morbidity, estimated glomerular filtration rate (EGFR), EORTC QLQ-C30, QLQ-CR29, DN4 (neuropathic pain [NP]), lower-extremity functional scale (LEFS), and the brief pain inventory. The primary end point was the difference in global health status (GHS/QoL). The secondary end points were EGFR changes, difference in other QLQ-C30 scales, pain intensity, NP, and LEFS. The study is registered at ClinTrials.gov (NCT03480399). RESULTS Of 74 patients, 58 were evaluable. Morbidity grade 3 or higher was 24.1%, and mortality was 1.3%. After nephrectomy, the mean 1-year EGFR change was -33.9%. The GHS/QoL at baseline was 58.6 and had increased of 6.9 points at 1 year, comparable with that of the general population. A transient worsening in pain and diarrhea had recovered at 12 months. Average pain was mild and did not differ at 12 months. However, NP was found in 41.4% of the patients and was significantly associated with resection of the psoas muscle. At baseline, LEFS was already lower than the normative value, and worsening after surgery was not clinically relevant. CONCLUSION A QoL measure after MVR in primary RPS is complex and requires multiple tools. Whereas overall MVR is safe and associated with an improvement in GHS/QoL, chronic NP is frequent and deserves specific attention. Pre-surgery rehabilitation tracks may help to prevent or reduce chronic NP.
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Affiliation(s)
- Marco Fiore
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Rosalba Miceli
- Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Michele Manara
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Susanna Lenna
- Department of Surgery, ASST Ovest Milanese, Legnano Hospital, Legnano, Italy
| | - Nicolò N Rampello
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Dario Callegaro
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Chiara Colombo
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Radaelli
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sandro Pasquali
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Augusto T Caraceni
- Palliative Care, Pain Therapy and Rehabilitation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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12
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Almas T, Khan MK, Murad MF, Ullah M, Shafi A, Ehtesham M, Zaidi SMJ, Hussain S, Kaneez M. Clinical and Pathological Characteristics of Soft Tissue Sarcomas: A Retrospective Study From a Developing Country. Cureus 2020; 12:e9913. [PMID: 32968575 PMCID: PMC7505639 DOI: 10.7759/cureus.9913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Soft tissue sarcomas remain an exceedingly rare malignancy. While soft tissue sarcomas boast a high mortality rate, their characteristics and behavior patterns are poorly understood. This study aims to evaluate the various aspects that pertain to soft tissue sarcomas, including their histology, tumor characteristics, survival rates, and therapeutic modalities. Methods A retrospective study analyzing the data from 19 patients presenting over four years with a histologically confirmed diagnosis of soft tissue sarcomas was conducted. The patients were studied for various parameters, including tumor site and the particular pathological subtypes. The data obtained were analyzed using the SPSS 23.0 statistical software (IBM Corporation, Armonk, NY), and the results were then tabulated. Results A total of 19 patients with a confirmed diagnosis of a soft tissue sarcoma were included in the study. The mean age of the patients included was 45.32 ± 16.88 years. Wide local excision was the most common surgical procedure employed for the resection of these tumors. Within the cohort, the mortality rate was noted to hover at 10.52%. Gastrointestinal stromal tumors were observed in 21% of the patients and were therefore the most common histological subtype. Of the patients included, 42.10% required blood transfusion during the perioperative time. Most of the tumors were noted to be intermediate grade, with high-grade tumors observed in 26.3% of the cases. Conclusion Soft tissue sarcomas remain a rare but potent cause of death in developing countries. The diversity of the tissues that they afflict renders their prompt detection a diagnostic challenge. A meticulous exploration of the various characteristics honed by soft tissue sarcomas, such as the particular histological subtype and the associated mortality rates, can better elucidate the prognosis and the eventual disease outcomes.
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Affiliation(s)
- Talal Almas
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Muhammad Kashif Khan
- Surgical Oncology, Federal Government Poly Clinic (Post Graduate Medical Institute), Islamabad, PAK.,Surgical Oncology, Maroof International Hospital, Islamabad, PAK
| | | | - Muneeb Ullah
- General Surgery, Maroof International Hospital, Islamabad , PAK
| | - Adil Shafi
- General Surgery, Maroof International Hospital, Islamabad, PAK
| | - Maryam Ehtesham
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | | | - Salman Hussain
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Mehwish Kaneez
- Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK
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13
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Villano AM, Zeymo A, Nigam A, Chan KS, Shara N, Unger KR, Al-Refaie WB. Radical excision for retroperitoneal soft tissue sarcoma: A national propensity-matched outcomes analysis. Surgery 2020; 168:831-837. [PMID: 32709488 DOI: 10.1016/j.surg.2020.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Given the rarity of retroperitoneal soft tissue sarcoma, few studies have assessed if radical excision of retroperitoneal soft tissue sarcoma with adjacent organs improves survival outcomes. This propensity score-matched study aimed to evaluate the impact of radical excision versus resection of tumor alone. METHODS The National Cancer Database 2004 to 2015 was used to assess short- and long-term outcomes of resection of tumor alone versus radical excision (tumor plus ≥1 adjacent organs) via 1:1 propensity-matched analyses. Subgroup analyses included low-grade, high-grade, liposarcoma, leiomyosarcoma, adjacent organ involvement alone, localized tumors alone, and high-volume hospitals (≥10 resections/y). Multivariable logistic regression models identified factors associated with radical excision. RESULTS Comparison of propensity-matched groups (N = 1,139/group) revealed no significant differences in 30-day mortality, 90-day mortality, or overall survival (for all, P > .580). For all subgroup analyses comparing resection of tumor alone with radical excision, including localized tumors without organ invasion (N = 208/group), there were no identified differences in short- or long-term survival. Although it yielded lower R2 resection rates (P = .007), radical excision was associated with greater mean length of stay (P < .001). CONCLUSION Radical excision was not associated with improved retroperitoneal soft tissue sarcoma survival irrespective of grade, histology, hospital volume, or adjacent organ involvement. Resection of ostensibly involved adjacent viscera may increase morbidity without survival benefit. These results inform ongoing discussion regarding histology-tailored, situation-specific extent of retroperitoneal soft tissue sarcoma resections.
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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
| | - Aradhya Nigam
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - 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
| | - Nawar Shara
- MedStar Health Research Institute, Hyattsville, MD; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC
| | - Keith R Unger
- Department of Radiation Oncology, MedStar-Georgetown University Hospital, 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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14
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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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15
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Montero A, Nuñez M, Hernando O, Vicente E, Ciervide R, Zucca D, Sanchez E, López M, Quijano Y, Garcia-Aranda M, Alonso R, Valero J, Chen X, Alvarez B, Fernandez-Leton P, Rubio C. Retroperitoneal soft-tissue sarcomas: Radiotherapy experience from a tertiary cancer center and review of current evidence. Rep Pract Oncol Radiother 2020; 25:643-655. [PMID: 32565743 DOI: 10.1016/j.rpor.2020.05.006] [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: 12/16/2019] [Revised: 04/14/2020] [Accepted: 05/25/2020] [Indexed: 12/19/2022] Open
Abstract
Background Surgery remains to be the main therapeutic approach for retroperitoneal sarcomas (RPS) although evidence supports that complementary radiotherapy increases local-control and survival. We present a multidisciplinary management and experience of a tertiary cancer center in the treatment of RPS and analyze current evidence of radiotherapy efficacy. Patients and methods We retrospectively reviewed 19 patients with primary or relapsed RPS treated between November 2009 and October 2018. Multidisciplinary approach comprised complete resection in 15 patients (79%) achieving resection R0 in 11 patients (58%), R1 in 4 patients (21%) and R2 in 2 patients (10%). Seven patients (37%) underwent a preoperative radiation (PRORT), 10 patients (53%), post-operative radiation (PORT) and 2 patients (10%), received radiotherapy exclusively. Ten patients (53%) received adjuvant chemotherapy. Results With a median follow-up of 24 months (2-114 months), actuarial rates of loco-regional relapse free survival (LRFS) at 1, 2 and 3 years were 77%, 77% and 67%, respectively. Actuarial rates of distant-metastases-free survival (DMFS), disease-free survival (DFS) and overall survival (OS) at 1, 2 and 3 years were 100%, 100% and 80% for DMFS; 94%, 77% and 67% for DFS and 100%, 91% and 91% for OS, respectively. Only surgical margins (negative vs. positive) showed significance for 3y-LRFS: 100% vs. 34.3%, p = 0.018. Treatment tolerance was acceptable with no acute or late toxicity higher than grade 2. Conclusions Complementary radiotherapy appears to be useful and well tolerated for the multidisciplinary management of RPS. Presence of positive surgical margins seems to be the most relevant prognostic factor through the follow-up.
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Affiliation(s)
- A Montero
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - M Nuñez
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - O Hernando
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - E Vicente
- Department of General Surgery, University Hospital HM Sanchinarro, Madrid, Spain
| | - R Ciervide
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - D Zucca
- Department of Medical Physics, University Hospital HM Sanchinarro, Madrid, Spain
| | - E Sanchez
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - M López
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - Y Quijano
- Department of General Surgery, University Hospital HM Sanchinarro, Madrid, Spain
| | - M Garcia-Aranda
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - R Alonso
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - J Valero
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - X Chen
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - B Alvarez
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
| | - P Fernandez-Leton
- Department of Medical Physics, University Hospital HM Sanchinarro, Madrid, Spain
| | - C Rubio
- Department of Radiation Oncology, University Hospital HM Sanchinarro, Madrid, Spain
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16
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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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17
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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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