Management of Retroperitoneal Sarcomas

Neoadjuvant Chemotherapy in Retroperitoneal Sarcoma: A National Cohort Study

INTRODUCTION

Management of retroperitoneal sarcoma (RPS) remains controversial, with the mainstay of treatment being surgery. While neoadjuvant radiation demonstrated no improvement in recurrence-free survival in a prospective randomized trial (STRASS), the role of neoadjuvant chemotherapy (NCT) remains unknown and is the subject of ongoing study (STRASS2).

METHODS

Patients who underwent surgical resection of high-grade RP leiomyosarcoma (LMS) or dedifferentiated liposarcoma (DDLS) were identified from the National Cancer Database (2006-2019). Predictors of NCT were analyzed using univariate and multivariate logistic regression analyses. Differences in 5-year survival were examined using the Kaplan-Meier (KM) method and by Cox proportional hazard modeling.

RESULTS

A total of 2656 patients met inclusion criteria. Fifty-seven percent of patients had DDLS and 43.5% had LMS. Six percent of patients underwent NCT. Patients who received NCT were younger (median age 60 vs 64 years, p < 0.001) and more likely to have LMS (OR 1.4, p = 0.04). In comparing NCT with no-NCT patients, there was no difference in 5-year overall survival (OS) on KM analysis (57.3% vs 52.8%, p = 0.38), nor was any difference seen after propensity matching (54.9% vs 49.1%, p = 0.48, N = 144 per group). When stratified by histology, there was no difference in OS based on receipt of NCT (LMS: 59.8% for NCT group, 56.6% for no-NCT, p = 0.34; DDLS: 54.2% for NCT group, 50.1% for no-NCT, p = 0.99).

CONCLUSION

In patients undergoing surgical resection of RP LMS or DDLS, NCT does not appear to confer an OS advantage. Prospective randomized data from STRASS2 will confirm or refute these retrospective data.

An Unexpected Cause of Syncope

Syncope is a common chief complaint among patients presenting to the emergency department, the etiology of which can often be discerned with a thorough history and physical examination. Inversely, liposarcomas are rare tumors that frequently pose a diagnostic challenge as the clinical presentation is highly nonspecific and varies greatly depending on the anatomic location and size of the tumor. Here we present a case of retroperitoneal liposarcomas (RLS) presenting to the emergency department (ED) with a sole complaint of syncope, resulting in a diagnostic dilemma. This clinical scenario highlights the significance of thorough physical examination regardless of the presenting chief complaint, as unexpected physical examination findings prompted an extended work-up and thus facilitated the diagnosis, providing the opportunity for early intervention and resection of the tumor.

Key performance indicators for improving outcomes from retroperitoneal sarcoma surgery in New Zealand

BACKGROUND

Retroperitoneal sarcomas are a rare and heterogenous group of tumours. There is increasing evidence that high volume sarcoma units achieve superior outcomes than low volume units. Due to the relatively small population, New Zealand is unlikely to generate a sufficient case volume to be considered high volume. To our knowledge, no well-established key performance indicators (KPIs) exist for retroperitoneal sarcoma surgery. In order to ensure quality standards we aim to propose KPIs which will act as a benchmark and a target for future quality improvement.

METHODS

Potential KPIs were generated by internal discussion within the sarcoma team, taking into consideration available guidelines and evidence. Cases treated through the unit since 2015 were audited to determine historical performance against these KPIs.

RESULTS

Eighty-six patients with primary retroperitoneal sarcomas were identified. 69% of patients were discussed at the sarcoma MDM prior to treatment, 62% underwent preoperative core biopsy. 82% of patients were seen and treated within target timeframes set by the Ministry of Health. 53% of patients underwent surgery with a sarcoma trained surgeon. R0/R1 rate was 88%. 90-day mortality was 4.6%.

CONCLUSIONS

Surgical treatment of retroperitoneal sarcomas is complex and can be associated with significant morbidity. The proposed KPIs provide a measure of service performance and provide targets for quality improvement.

Survival and prognostic factors in patients undergoing pulmonary metastasectomy for lung metastases from retroperitoneal sarcoma

BACKGROUND

Soft-tissue sarcomas are rare malignancies that consist of many different histologic subtypes and arise in various locations in the body. In patients with lung metastases from retroperitoneal sarcomas, the long-term outcomes and prognostic factors are unknown. This study is a retrospective review of patients undergoing pulmonary metastasectomy for retroperitoneal sarcoma metastases at one institution, with the purpose of determining prognostic factors and clinical outcomes.

METHODS

This is a single-center, retrospective cohort study of patients undergoing pulmonary metastasectomy for lung metastases from various sarcomas at Okayama University Hospital from January 2006 to December 2018. The Kaplan-Meier method and log-rank test were used for the analyses, and cut-off values of continuous variables were determined by a receiver operating characteristic curve analysis.

RESULTS

Twenty-four patients underwent the first pulmonary metastasectomy for lung metastases from retroperitoneal sarcoma in our hospital. Leiomyosarcoma was the most common histologic subtype of retroperitoneal sarcoma (79.2%, n = 19). Median overall survival was 49.9 months, and the 3-year and 5-year survival rates after the first pulmonary metastasectomy were 62.5% and 26.4% respectively. In univariate analysis, age ≥56 years, disease-free interval < 15 months, and size of metastasis (≥ 27 mm) were associated with poor survival.

CONCLUSION

Pulmonary metastasectomy can be considered as an effective management strategy in retroperitoneal sarcoma patients with lung metastases in appropriately selected cases, just as it is for other sarcomas.

Nonscrotal Causes of Acute Scrotum

Acute scrotum is characterized by intense acute scrotal pain, which may be associated with other symptoms and signs such as abdominal pain, inflammation, and fever. Many pathologic conditions can present in this way, most which involve the scrotal contents. Nonscrotal conditions, however, can rarely present clinically only as acute scrotum: among them, renal colic, aneurysm rupture or other causes of retroperitoneal hemorrhage, primary abdominal or pelvic tumors and metastases, pancreatitis, pelvic inflammation, and muscle injuries. The pathophysiologic characteristics of the clinical presentation, clues for diagnosis, and imaging features of a series of nonscrotal lesions presenting clinically with acute scrotal pain are herein reported and illustrated. In patients presenting with acute scrotal symptoms and normal scrotal ultrasound findings, nonscrotal causes of acute scrotal pain should be considered in the differential diagnosis. Therefore, an ultrasound investigation of the abdomen, groin, and thighs is indicated.

Minimally Invasive Versus Open Primary Resection for Retroperitoneal Soft Tissue Sarcoma: A Propensity-Matched Study From the National Cancer Database

BACKGROUND

Although well described for gastrointestinal and pelvic cancers, use of minimally invasive surgery (MIS) for the management of retroperitoneal soft tissue sarcoma (RPS) remains unknown. The current study aimed to describe patterns of MIS use and assess the association between MIS and clinical outcomes among patients undergoing surgery for RPS.

METHODS

Patients undergoing a primary resection for RPS between 2010 and 2014 were identified using the National Cancer Database. Multivariable logistic and Cox proportional hazards models were used to assess the association between use of MIS and clinical outcomes. Sensitivity analysis was performed using propensity score-matching (PSM).

RESULTS

This study identified 3844 patients who met the inclusion criteria. Of these patients, 89.3% (n = 3432) underwent an open surgery, whereas 10.7% (n = 412) underwent MIS. The patients undergoing MIS were more likely to present with smaller tumors (open vs MIS: median tumor size, 17 cm; interquartile range [IQR, 9.8-26.0] vs 10.5 cm [IQR, 6.5-18.0]) and to undergo surgery at community hospitals (26.8% vs 36.1%; both P < 0.001). Although MIS was associated with a shorter hospital length of stay [LOS] (median LOS, 6 days [IQR, 5-9 days] vs 4 days [IQR, 2-7]; P < 0.001), postoperative mortality and overall survival were comparable between the two treatment groups (all P > 0.05). These findings were confirmed using PSM.

CONCLUSIONS

MIS was associated with a shorter LOS, however, postoperative mortality and overall survival were comparable by operative approach. Future research is required to evaluate the use of MIS for the management of RPS. Policies are required to ensure that patients receive care in accordance with best practices and recommended guidelines.

Treatment of retroperitoneal sarcoma: current standards and new developments

PURPOSE OF REVIEW

Retroperitoneal sarcomas are rare tumors and with complex treatment. In this manuscript we give an overview of current standards in treatment of this disease and discuss new developments.

RECENT FINDINGS

Surgery with complete resection of the primary tumor is still the only curative modality. The role of preoperative radiotherapy is not clear and is currently being investigated in a clinical trial. Neo-adjuvant chemotherapy is not the standard of care but can be considered occasionally when complete resection is uncertain. Local and distant recurrent disease carries a dismal prognosis, although long-term survival can be achieved. Liposarcomas tend to recur locally, whereas distant recurrences are more often seen in leiomyosarcoma and other subtypes. Outcome improves when patients are treated in high volume sarcoma centers. In the metastatic setting, newer systemic agents have recently been approved.

SUMMARY

Treatment of retroperitoneal sarcomas is complex and all patients should be treated in multidisciplinary sarcoma centers. Increasing international collaboration of expert centers in sharing expertise and performing clinical trials might lead to better treatment and improved survival.

[Iliac arteries and aortic repair in patients with retroperitoneal sarcoma]

AIM

To evaluate the results of surgical treatment in patients with retroperitoneal sarcoma and invasion into great vessels.

MATERIAL AND METHODS

For the period 2009-2016 fourteenth patients with retroperitoneal sarcoma underwent resection and repair of great vessels at the abdominal department of N.N. Blokhin Russian Cancer Research Center. In 12 cases circular resection of infrarenal aorta, aortic bifurcation and iliac arteries followed by their replacement was made. 2 patients underwent circular resection of iliac arteries.

RESULTS

Postoperative morbidity was 42.8%. There was no postoperative mortality. 10 of 14 patients are alive from 2 to 70 months after surgery. One patient died in 2 months postoperatively from unknown reasons, 3 patients died in 18, 20 and 30 months respectively due to progression of the disease.

CONCLUSION

Overall survival and acceptable surgical risk underline the value of en block resection of retroperitoneal sarcoma together with involvement blood vessels.

Retroperitoneal Sarcomas

Retroperitoneal sarcomas are rare tumors, representing only 15% of all sarcomas. The mainstay of therapy is surgical resection with negative margins. However, this is challenging because of the late presentation of many of these tumors and involvement with adjacent structures. Decisions on radiation therapy and chemotherapy should be made in a multidisciplinary setting at a tertiary referral center.

[Retroperitoneal tumors]

BACKGROUND

Retroperitoneal tumors are rare malignancies. The retroperitoneum can host a wide spectrum of pathologies including primary or metastatic lesions.

OBJECTIVE

Treatment of retroperitoneal tumors is often associated with several challenges because of their relative late presentation and anatomic location.

MATERIALS AND METHODS

Because of various pathologies, a detailed case history, laboratory investigation and ultrasound should be performed. Radiologic examinations remain a major component in the diagnosis. In addition to computed tomography, magnetic resonance imaging and positron emission tomography are used. Although radiologic findings are often unspecific, there are often typical findings such as dissemination, margins, vascularization and tumor texture which contribute to the differential diagnosis even before making a definitive diagnosis. Due to the complexity of primary retroperitoneal tumors, which require different treatments depending on the final diagnosis, the treatment approach should be determined in a multidisciplinary tumor conference prior to histological confirmation and initiation of treatment.

CONCLUSION

To ensure the best potential curative treatment modality for retroperitoneal tumors, treatment is best performed in high-volume centers by a multidisciplinary team.

Extended resection including adjacent organs and Ki-67 labeling index are prognostic factors in patients with retroperitoneal soft tissue sarcomas

BACKGROUND

Because retroperitoneal soft tissue sarcomas (RPS) are extremely rare, there is a significant lack of clinicopathologic information to optimize the treatment strategy. The aim of this study was to evaluate the prognostic factors in RPS, with particular focus on the Ki-67 labeling index (LI).

METHODS

We included the data from a total of 23 patients who received treatment for primary RPS at a single center. The variables analyzed in this study included tumor size, histological type, malignancy grade, necrosis, mitosis, and Ki-67 LI. Kaplan-Meier and Cox proportional regression analyses of overall survival (OS) were performed to identify significant prognostic variables.

RESULTS

Of the 23 patients who underwent surgical resection, 9 (39%) underwent simple resection of the tumor and 14 (61%) extended resection including the adjacent organs. In the univariate analysis, a simple tumor resection and a high Ki-67 LI were associated with shorter OS. The multivariate analysis revealed that simple tumor resection and a high Ki-67 LI were independent negative prognostic factors for OS.

CONCLUSIONS

Our results suggested that combined resection of RPS and its adjacent organs improved OS. Pathologically, a high Ki-67 LI was significantly associated with negative prognosis.

Retroperitoneal mass presenting as recurrent inguinal hernia: A case report

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A retroperitoneal tumor can present as a scrotal mass.

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An irreducible, hard but painless scrotal mass should warn the clinician.

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Slow growing pattern of the hard scrotal mass is important for the differential diagnosis.

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CT is diagnostic for the retroperitoneal tumor and its scrotal extension.

Introduction

Retroperitoneal masses presenting as an inguinal hernia are rare conditions.

Presentation of case

A 53 year old male admitted with the symptoms of weight loss, abdominal discomfort and left sided recurrent inguinal hernia. Physical examination demonstrated an abdominal mass in the left flank and an irreducible, painless scrotal mass. He had a history of left sided inguinal hernia surgery six years ago. Computed tomography revealed a large enhancing left sided retroperitoneal mass invading the colon, pancreas and kidney and it was going down towards the left scrotum. Unblock tumor resection including the neighboring organs (left kidney, left colon, distal pancreas with spleen) was performed. Scrotal extension of the tumor was also excised and the inguinal canal was repaired primarily. Histopathology of the mass was myxoid-liposarcoma. The patient has disease free, without hernia recurrence but poor in renal function after twenty months follow-up.

Discussion

Large retroperitoneal tumors may grow towards the inguinal region and they can mimic an inguinal hernia. An irreducible, painless and hard scrotal mass should be considered from this perspective.

Management of patients with retroperitoneal tumors and a review of the literature

Background

Retroperitoneal tumors (RTs) develop insidiously and are generally seen as large masses, and 50% of RTs are larger than 20 cm at the time of diagnosis. In this article, we share our experience of 5 years of surgical management of RTs.

Methods

We evaluated 28 RT cases operated on in three education hospitals in Turkey from January 2008 onwards, with regard to patients’ demographic characteristics, complaints, weight loss figures, the location and size of the tumor, blood transfusion, intra-operational time, metastases (in malignant cases), additional organ resection, histological grade, local recurrences, average life expectancy, and post-operative treatment methods.

Results

The mean age of the patients was 49 years (range, 18 to 78 years). Twenty (71.43%) were female, and 8 (28.57%) were male. The primary complaint was abdominal pain in 18 patients (64.28%). CT scans were performed in 17 (61%) patients, 10 (35.4%) underwent abdominal MR imaging, and 1 (3.6%) underwent both abdominal CT and abdominal MR imaging. A mass was palpated in the pelvis (suprapubic region) in seven (25%) of the patients during physical examination. The largest tumors were detected in the left lumbar area. The mean tumor size was 12.78 cm (range, 2 to 30 cm). The mean intra-operational time was 192 min (range, 70 to 380 min). The mean hospitalization period was 11 days (range, 8 to 23 days). Seven (25%) patients were reported to have benign tumors, while 21 (75%) were reported to have malignant tumors. The most frequently seen malignant pathology was liposarcoma (eight cases; 38.09%) followed by leiomyosarcoma (five cases; 23.8%) and malignant fibrous histiocytoma (four cases; 19.04%). The earliest local recurrence was detected in the 12th month and the latest in the 28th month. A total of 11 (52.3%) of the total of 21 malignant cases experienced local recurrence within 3 years. The 3-year average life expectancy was 85.7% in the 18 malignant cases.

Conclusions

Due to the low response rate of all but two types of RT to chemotherapy, the best remaining treatment option is surgery with wide resection margins, whereby all macroscopic traces of tumor are removed.

Comparative effectiveness research for sarcoma

Modern multidisciplinary management of sarcoma represents several opportunities for comparative effectiveness research. Focusing on the outcomes of survival, quality of life and cost-effectiveness of care, the current state of the art is summarized. Specialized/regional care for sarcoma and the utility of tumor boards or multispecialty discussion is discussed. Issues related to treatment efficacy and sequencing in relation to chemotherapy, radiation, and surgery as well as margin reporting and surveillance are also discussed. Finally, future avenues of comparative effectiveness research for sarcoma are highlighted throughout the chapter.

Retroperitoneal tumors in the pelvis: a diagnostic challenge in gynecology

Retroperitoneal tumors can pose a diagnostic and therapeutic challenge to gynecologists because of their rarity, late presentation, and complex anatomical location in the retroperitoneum. This article reviews the diagnosis and management of retroperitoneal tumors in the pelvis, and highlights the potential pitfalls that may be faced by gynecologists.

Adjuvant radiotherapy in retroperitoneal sarcomas. A Scandinavian Sarcoma Group study of 97 patients

BACKGROUND

Currently there is no consensus on the use of adjuvant radiotherapy (RT) in retroperitoneal sarcoma (RPS). We have analysed clinical outcomes in patients with localised RPS treated at two Scandinavian Sarcoma Group (SSG) centres: Haukeland University Hospital (HUH), Bergen, Norway and Skåne University Hospital (SUH), Lund, Sweden to clarify the effects of adjuvant RT on local control and overall survival (OS).

MATERIAL AND METHODS

Local databases and registers at HUH and SUH as well as the SSG central register were used to identify RPS patients. Patients with localised RPS who underwent surgery in Bergen between 1988 and 2009 and in Lund from 1998 to 2009 were included. Medical records were examined for clinical data, tumour characteristics, treatment factors and follow-up status. Archived tumour sections and tumour tissue were reviewed, and when necessary, restained and reclassified. Cox regression was used to analyse the association of potential prognostic factors with local recurrence-free survival (LRFS), metastasis-free survival (MFS) and OS.

RESULTS

The study included 97 patients: 52 from Norway and 45 from Sweden. The proportion of high-grade tumours was 73%. The five-year LRFS, MFS and OS were 55%, 59% and 60%, respectively. RT was significantly associated with improved local control resulting in a five-year LRFS of 77% compared with 39% without (p < 0.001). Furthermore, five-year OS was 71% in the RT group in contrast to 52% with surgery alone (p = 0.019). In the adjusted analysis RT proved to be a significant factor also for MFS (HR = 0.42, 95% CI 0.20-0.88, p = 0.021). In addition, high-grade malignancy, large tumour and positive surgical margin were risk factors for local recurrence. High malignancy grade was the only significant adverse prognostic factor for metastasis. High age and high-grade malignancy were negative prognostic factors for OS.

CONCLUSION

Adjuvant RT was significantly associated with an improved five-year LRFS and OS.

Retroperitoneal Castleman's disease: advocating a multidisciplinary approach for a rare clinical entity

Background

Castleman’s disease is a rare and poorly understood disease entity that may resemble more common conditions and represents a clinical challenge to the treating surgeon.

Case presentation

In this report, we describe a case of a 61-year-old Caucasian woman with a symptomatic retroperitoneal mass. The specimen obtained from her resection contained a protuberant encapsulated mass, exhibiting microscopic features consistent with localized, unicentric Castleman’s disease. These characteristics included architectural features and immunohistochemical findings consistent with the hyaline vascular variant of Castleman’s disease.

Conclusion

We report a very rare case of a retroperitoneal hyaline vascular type of Castleman’s disease. We discuss the diagnostic dilemma Castleman’s disease may present to the surgeon, with an emphasis on multidisciplinary management of these patients. We also review current data on pathogenesis, treatment and outcomes.

Unusual presentation of retroperitoneal leiomyosarcoma mimicking an adnexal tumor with highly elevated serum CA-19-9

When retroperitoneal leiomyosarcoma develops in pelvic cavity, it often presents similar symptoms and radiological findings to adnexal tumor, therefore obscures diagnostic approaches until an exploratory laparotomy is performed. We report an unusual presentation of retroperitoneal leiomyosarcoma mimicking an adnexal tumor with extremely elevated serum CA-19-9. Though the most of the prominent mass was removed during surgery, there was massive bleeding due to tearing of internal iliac vein while dissecting the ureter close to vessels. This case focuses on the significance of considering retroperitoneal tumor even if the mass is located in ovarian fossa and has highly elevated serum level of CA-19-9. And in attempt of tumor removal, the excision needs to be clean-cut without damaging nerves or vessels around the mass and avoid causing any prospective complications.

Retropancreatic Retroperitoneal Tumors: A 30-year Experience with 38 Cases

Retropancreatic retroperitoneal tumors (RRTs) are seldom encountered in clinical practice. The lack of characteristics on clinical presentation and imaging make preoperative diagnosis difficult and surgical management remains a challenge. This retrospective report surveys the presenting diagnosis and surgical management of 38 patients with RRTs presenting at our center between August 1981 and May 2012. Six patients were misdiagnosed on the basis of computerized tomography and one each by magnetic resonance imaging and magnetic resonance cholangiopancreatography. Tumors were localized posterior to the pancreatic head and uncinate process (n = 18); posterior to the neck and body of the pancreas (n = 9); or posterior to the body and tail of the pancreas (n = 11). Thirty-three patients underwent surgical resections. Operative approaches were chosen on the basis of tumor size and localization. The tumors were mostly commonly originating from neurogenic tissue (n = 16). There were 25 benign neoplasms (65.8%), 10 malignant tumors (26.3%), and three undefined tumors. The morbidity of postsurgical complications was 21 per cent (eight of 38). The number of patients who underwent follow-up was 21, and the mean follow-up time was 35 months (range, 2 to 90 months). Three patients died during follow-up. The morbility of local recurrence was 10.5 per cent (four of 38). Definitive diagnosis of RRTs is made at laparotomy. Complete resection remains the fundamental objective of disease management. Different operative approaches should be used according to tumor localization and size.

[Vascular reconstruction for limb preservation during sarcoma surgery: a case series and a management algorithm]

OBJECTIVE

To evaluate the results of vascular reconstruction in soft tissue sarcoma surgery and establish an algorithm based on current evidence.

MATERIAL AND METHODS

We studied patients undergoing soft-tissue sarcoma in a tertiary hospital. A retrospective review of 8 cases was carried out, analysing the demographics, surgical planning, complications, disease-free survival and bypass patency.

RESULTS

Successful limb preservation was observed in all patients, and the bypass remained patent in all cases. The mean follow-up was 38.4 months average, with 87.5% survival and no recurrences.

CONCLUSIONS

The involvement of major vascular structures in soft tissue sarcomas of the limbs does not necessarily exclude resectability. In selected cases, resection is possible with vascular reconstruction and limb preservation. However, multidisciplinary planning is needed.

Retroperitoneal tumours: review of management

INTRODUCTION

The retroperitoneum can host a wide spectrum of pathologies, including a variety of rare benign tumours and malignant neoplasms that can be either primary or metastatic lesions. Retroperitoneal tumours can cause a diagnostic dilemma and present several therapeutic challenges because of their rarity, relative late presentation and anatomical location, often in close relationship with several vital structures in the retroperitoneal space.

MATERIALS AND METHODS

A comprehensive literature search was conducted using PubMed. Relevant international articles published in the last ten years were assessed. The keywords for search purposes included: retroperitoneum, benign, sarcoma, neoplasm, diagnosis and surgery, radiotherapy, chemotherapy. The search was limited to articles published in English. All articles were read in full by the authors and selected for inclusion based on relevance to this article.

RESULTS

Tumours usually present late and cause symptoms or become palpable once they have reached a significant size. Retroperitoneal tumours are best evaluated with good quality cross-sectional imaging and preoperative histology by core needle biopsy is required when imaging is non-diagnostic. Sarcomas comprise a third of retroperitoneal tumours. Other retroperitoneal neoplasms include lymphomas and epithelial tumours or might represent metastatic disease from known or unknown primary sites. The most common benign pathologies encountered in the retroperitoneum include benign neurogenic tumours, paragangliomas, fibromatosis, renal angiomyolipomas and benign retroperitoneal lipomas.

CONCLUSIONS

Complete surgical resection is the only potential curative treatment modality for retroperitoneal sarcomas and is best performed in high-volume centres by a multidisciplinary sarcoma team. The ability completely to resect a retroperitoneal sarcoma and tumour grade remain the most important predictors of local recurrence and disease-specific survival.

Complete and safe resection of challenging retroperitoneal tumors: anticipation of multi-organ and major vascular resection and use of adjunct procedures

BACKGROUND

Retroperitoneal tumors are often massive and can involve adjacent organs and/or vital structures, making them difficult to resect. Completeness of resection is within the surgeon's control and critical for long-term survival, particularly for malignant disease. Few studies directly address strategies for complete and safe resection of challenging retroperitoneal tumors.

METHODS

Fifty-six patients representing 63 cases of primary or recurrent retroperitoneal tumor resection between 2004-2009 were identified and a retrospective chart review was performed. Rates of complete resection, use of adjunct procedures, and perioperative complications were recorded.

RESULTS

In 95% of cases, complete resection was achieved. Fifty-eight percent of these cases required en bloc multi-organ resection, and 8% required major vascular resection. Complete resection rates were higher for primary versus recurrent disease. Adjunct procedures (ureteral stents, femoral nerve monitoring, posterior laminotomy, etc.) were used in 54% of cases. Major postoperative complications occurred in 16% of cases, and one patient died (2% mortality).

CONCLUSIONS

Complete resection of challenging retroperitoneal tumors is feasible and can be done safely with important pre- and intraoperative considerations in mind.

Retroperitoneal sarcoma: a rare cause of intestinal perforation in two cases

Retroperitoneal sarcoma is a rare malignancy often insidious in onset. At initial presentation, abdominal mass, pain or obstructive symptoms are the most common complaints. Here we present two patients who presented with abdominal discomfort and were discovered to have retroperitoneal sarcomas with secondary intestinal perforation. Perforation is a rare complication of retroperitoneal sarcoma, but one with the potential to significantly affect patient outcomes. Both patients underwent surgical resection and pathological characterization of their malignancies. The discovery of intestinal perforation during workup necessitates initiation of empirical antibiotic coverage and prompt surgical intervention.

Laparoscopic surgery for primary retroperitoneal tumors: a single institution experience of 14 cases

OBJECTIVE

To evaluate the feasibility and outcomes of laparoscopic surgery for primary retroperitoneal tumors (PRTs).

METHODS

Between January 2007 and July 2009, laparoscopic resection was attempted of PRT in 14 patients. The histological type of the tumor, operating characteristics, and outcomes were analyzed.

RESULTS

In the 14 patients (4 male), the median age was 44 years, with a median tumor diameter of 7.6 cm. Laparoscopic resection was successfully performed in 13 patients with a solely laparoscopic approach (n=11) or combined with a hand-assistant procedure (n=2). One case (epithelioid hemangioma) was converted to laparotomy. The median operating time for laparoscopy was 139 minutes with an estimated average blood loss of 59.2 mL. There were no transfusions or major complications. After a median follow-up of 17 months, all patients remained disease free.

CONCLUSIONS

Laparoscopic surgery for the resection of PRT is feasible and effective when performed by an experienced surgeon.

A case of perinephric liposarcoma which recurred ten years later from the initial operation

A 58-year old man was referred to our hospital for treatment of an abdominal mass. As for him, tumor resection with right nephrectomy had been performed ten years ago for a giant well-differentiated perinephric liposarcoma. CT examination showed a huge tumor shadow in the abdominal cavity. Abdominal MRI examination showed a 15 × 8 cm tumor with almost high signal intensity on the T2 weighted images. At laparotomy, a large bulky retroperitoneal tumor pointed out before an operation was found. Surgical extirpation of the tumor was performed. Besides, several tumors of the thumb head size were detected into right retroperitoneal fatty tissue. The right side mesocolon and the tumors were not able to exfoliate, therefore right hemicolectomy was performed. Histological features showed dedifferentiated liposarcoma. The postoperative course was uneventful. But eight months after surgery, he was admitted again for treatment of a 4 × 3 cm retroperitoneal tumor. Extirpation of the tumor was performed. Histological finding of this tumor also showed dedifferentiated liposarcoma. Dedifferentiation, occurring in 15% of the well-differentiated liposarcomas, sometimes may develop later. Long-term detailed follow-up is necessary for well-differentiated liposarcoma.

Addressing reported pro-apoptotic functions of NF-kappaB: targeted inhibition of canonical NF-kappaB enhances the apoptotic effects of doxorubicin

The ability of the transcription factor NF-κB to upregulate anti-apoptotic proteins has been linked to the chemoresistance of solid tumors to standard chemotherapy. In contrast, recent studies have proposed that, in response to doxorubicin, NF-κB can be pro-apoptotic through repression of anti-apoptotic target genes. However, there is little evidence analyzing the outcome of NF-κB inhibition on the cytotoxicity of doxorubicin in studies describing pro-apoptotic NF-κB activity. In this study, we further characterize the activation of NF-κB in response to doxorubicin and evaluate its role in chemotherapy-induced cell death in sarcoma cells where NF-κB is reported to be pro-apoptotic. Doxorubicin treatment in U2OS cells induced canonical NF-κB activity as evidenced by increased nuclear accumulation of phosphorylated p65 at serine 536 and increased DNA–binding activity. Co-treatment with a small molecule IKKβ inhibitor, Compound A, abrogated this response. RT–PCR evaluation of anti-apoptotic gene expression revealed that doxorubicin-induced transcription of cIAP2 was inhibited by Compound A, while doxorubicin-induced repression of other anti-apoptotic genes was unaffected by Compound A or siRNA to p65. Furthermore, the combination of doxorubicin and canonical NF-κB inhibition with Compound A or siRNA to p65 resulted in decreased cell viability measured by trypan blue staining and MTS assay and increased apoptosis measured by cleaved poly (ADP-ribose) polymerase and cleaved caspase 3 when compared to doxorubicin alone. Our results demonstrate that doxorubicin-induced canonical NF-κB activity associated with phosphorylated p65 is anti-apoptotic in its function and that doxorubicin-induced repression of anti-apoptotic genes occurs independent of p65. Therefore, combination therapies incorporating NF-κB inhibitors together with standard chemotherapies remains a viable method to improve the clinical outcomes in patients with advanced stage malignancies.