Resectability of retroperitoneal sarcomas: a matter of surgical technique?

Surgical Principles of Primary Retroperitoneal Sarcoma in the Era of Personalized Treatment: A Review of the Frontline Extended Surgery

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.

Did outcomes improve in retroperitoneal sarcoma surgery?

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.

Retroperitoneal Sarcoma. Outcome Analysis in a Teaching Hospital in Eastern India- a Perspective

Primary Retroperitoneal Sarcomas are relatively uncommon tumors with varied manifestations, ill-defined prognostic factors and uncertain management modalities. We undertook this study to review patients who presented with primary or recurrent RPS at our institute during the study period. Between 2008 and 2010, 23 patients were evaluated. Statistical analysis was done using the chi square test or Fisher's exact test. Recurrence was calculated using Kaplan Meier curves. The log-rank test was used to compare differences in survival or relapse. Among the 23 patients, 13 were males. Majority (52.2 %) presented with abdominal lump located in umbilical and right hypochondrial region. Surgery was done in 20 (87 %) patients for primary RPS and three (13 %) for recurrent RPS at initial presentation. 14 (61 %) received complete tumor resection, six (27 %) incomplete microscopic resection, and three (13 %) incomplete macroscopic resection. In univariate Cox's proportional hazard model on time ('timer') to event ('relapse') analysis, all the variables like older age (p = 0.027), male sex (p = 0.012), incomplete resection (p = 0.008), large size (0.047) and high grade (p = 0.047) became significant predictor of early recurrence. However, multivariate analysis showed that only extent of resection, grade and sex were statistically significant predictors. Complete tumor resection of retroperitoneal sarcoma (n = 14) was associated with a significantly lesser recurrence compared with unclear resection (n = 9, p = 0.002). The median time between surgery and first recurrence was 15 months. High-grade sarcomas had a significantly higher recurrence (n = 10; median: 24, 95 % CI) than low-grade sarcomas (n = 13, median: 15; 95 %CI P < 0.01). Furthermore, the survival of male patients were worse than that of females (p = 0.036). Completeness of resection, tumor grade and sex are prognostic factors of retroperitoneal soft tissue sarcomas.

Personalizing surgical margins in retroperitoneal sarcomas

Retroperitoneal sarcomas are a group of diseases that behave differently from one another. Well-differentiated liposarcomas have an indolent biology but show a tendency to recur locally even years after primary resection. Dedifferentiated liposarcomas are characterized by a very high local recurrence risk, while the metastatic risk mainly depends on the histological characteristics of the dedifferentiated component. In leiomyosarcomas, hematogenous spread informs prognosis while local recurrences are far less common. Surgery is the cornerstone of treatment of all retroperitoneal sarcoma subtypes and its quality is the only treatment-related factor able to improve the oncological outcome. A frontline extended surgical approach is all the more critical in subtypes in which local control directly impacts prognosis.

Retroperitoneal sarcomas- a challenging problem

Retroperitoneal sarcomas are relatively rare tumours and usually present in a locally advanced stage. Liposarcoma is the most common histopathology. If operable, surgery is the treatment of choice. The role of adjuvant chemotherapy or radiotherapy is not yet defined. Advanced cases are treated by chemotherapy. The prognosis is poor in patients with positive resection margins, high-grade tumours and recurrent tumours.

[Surgery and postoperative radiation therapy in primary retroperitoneal sarcomas: experience of the cancer centre Alexis-Vautrin]

PURPOSE

Surgical resection remains the standard treatment for patients with resectable retroperitoneal sarcomas. The aim of this study was to retrospectively analyse the outcomes of patients with primary retroperitoneal sarcoma.

PATIENTS AND METHODS

We analysed data of 50 patients with primary retroperitoneal sarcoma who underwent curative-intent resection from 1975 to 2008. External beam radiotherapy and chemotherapy were delivered postoperatively. Demographics, surgical, pathological variables and chemo/radiation therapy were analysed as prognosis factors.

RESULTS

There were 22 males and 28 females (mean age 54 ± 13 years). Surgery required visceral resections in 30 patients. There were 16 leiomyosarcomas, 25 liposarcomas and eight other sub-types. Twenty-one patients had clear surgical margins. Twenty-eight patients received postoperative external beam radiotherapy (median 45 Gy) and 15 received chemotherapy. At the end of the follow-up (median 55 months), local recurrence occurred in 39% (n=14) among R0/R1 resection group (n=36). Postoperative external beam radiotherapy tends to increase the time of local recurrence from surgery (27 vs. 13 months, P=0.05). The overall survival rates were 81%, 55% and 46% at 1, 3 and 5 years, respectively. Although R0 resection (P=0.01), well tumour differentiation (P=0.004) and postoperative external beam radiotherapy (P=0.02) significantly influenced overall survival in univariate analysis, only R0 resection was an independent prognostic factor in a multivariate analysis.

CONCLUSION

We confirm the pre-eminence of radical surgery with negative margins as major prognostic factor and the benefit of postoperative radiotherapy.

[Natural history and management of retroperitoneal sarcoma: Review of the literature by the Oncology committee of the French association of urology]

INTRODUCTION

The objective of this article of review is to precise the natural history and rules of treatment of retroperitoneal sarcoma. These elements are sometimes ignored of the urologists.

MATERIAL AND METHOD

A systematic review of the literature over the 15 last years was carried out on Medline database.

RESULTS

The sarcomas of the rétropéritoine are found with diagnosis delay because they don't have specific symptoms. The imagery is sometimes characteristic but only percutaneous biopsy is able to confirm the diagnosis. Retroperitoneal sarcomas are characterized by the high rate of local recurrence, which is related to the survival rate. The main prognostic factors are negative margins and grade of the tumor. The role of adjuvant radiotherapy is limited by the radio sensitivity of the abdominal viscera and the postoperative rehandlings. Today, the role of the neoadjuvant radiotherapy is in evaluation in prospective study. The effectiveness of chemotherapy is limited.

CONCLUSION

Complete compartmental surgery without tumor rupture is the cornerstone of treatment. This complex surgery should be performed in a high-volume center.

Current concepts in the management of retroperitoneal soft tissue sarcoma

Soft tissue sarcomas (STS) in the retroperitoneum are usually diagnosed at the late stages. Surgery is the mainstay of treatment. The technique of resection is standardized. After dissection of the retroperitoneal blood vessel, a retroperitoneal plane of dissection adjacent to the spinal foramina is established in between the layers of the abdominal wall. Complete resection with tumor-free resection margins is the primary goal in retroperitoneal sarcoma surgery. Preoperative assessment of pathoanatomical growth patterns with respect to retroperitoneal vascular structures--as well as to visceral and retroperitoneal organs--influences surgical strategies and thus the surgical outcome. Blood vessel replacement and a multivisceral en bloc approach improve the quality of resection. Blood vessel involvement is stratified in type I (arterial and venous involvement), type II (arterial involvement), type III(venous involvement), and type IV (no vascular involvement). Adjuvant and neoadjuvant treatment options (chemotherapy, targeted therapy, and radiation therapy) are currently being investigated. A prospective randomized phase III trial has shown a positive effect of neoadjuvant chemotherapy combined with regional hyperthermia in disease-free survival, response rate, and local control. Subsets of liposarcomas (myxoid and round cell type) are selectively responsive to novel drugs, such as trabectedin, a DNA-binding agent. Radiotherapy is applied in higher-grade locally advanced retroperitoneal STS. The optimal technique of delivering radiotherapy remains to be determined. The restricted number of patients with retroperitoneal STS and unsatisfying results in local tumor control and long-term survival indicate the need for multi-institutional cooperative studies. An international effort is required to improve the evidence level on multimodal treatment algorithms.

Primary malignant retroperitoneal tumors: Analysis of a single institutional experience

AIMS

In order to achieve complete resection in the surgical management of retroperitoneal tumors, it is crucial to know the tumor's anatomical location relative to neighboring organs.

METHODS

Forty-nine patients with primary malignant retroperitoneal tumors were divided by tumor location into two groups [upper abdomen (group 1) or lower abdomen (group 2)], and clinicopathological features, tumor recurrence, and patient survival were assessed.

RESULTS

No significant differences in preoperative clinical characteristics existed between two groups, and liposarcoma was the most frequently observed tumor type. The difference in the rates of complete resection between the two groups was not statistically significant (75.9% for group 1 and 85% for group 2). En-bloc combined resection was performed in 52% and 30% of patients in groups 1 and 2, respectively. The local recurrence rate in group 2 (31.3%) was higher than that in group 1 (9.5%), despite the fact that the differences in rates of complete resection and distant recurrence rates (14.3% in group 1 and 12.5% in group 2) between the two groups were not statistically significant. The overall 5-year survival rates were 67.9% for group 1 and 43.2% for group 2 (p=0.038). The 5-year survival rate of patients with tumors smaller than 10 cm was 78.4%, while that of patients with tumors larger than 10 cm was 38.1% (p=0.017). The 5-year survival rate after complete excision was 61%, whereas that after incomplete resection or biopsy only was 40.0% (p<0.0001).

CONCLUSIONS

An upper abdominal tumor location is a positive prognostic factor even if small tumor size (<10 cm) and complete resection of the tumor are still more important factors to improve outcome in patients with malignant primary retroperitoneal tumors. Because complete resection was shown to be the most important prognostic factor, an aggressive and careful surgical approach is recommended for the treatment of such tumors.

Long-term prognosis of primary retroperitoneal soft tissue sarcoma

AIMS

To evaluate the result of treatment and long-term outcome of a population-based cohort of patients with retroperitoneal soft tissue sarcoma (RSTS).

METHODS

Between 1 January 1989 and 1 January 1994, 143 patients diagnosed as having primary RSTS were selected from a national pathology database (PALGA) in the Netherlands. In this population-based group of patients, the result of surgery, overall survival (OS) and disease-free survival (DFS) were analysed as well as factors affecting OS and DFS. Median follow-up was 10.2 years.

RESULTS

Operative treatment resulted in a complete tumour resection in 55% of the patients (n=78), low- and intermediate-grade tumours were more often completely resected than high-grade tumours (P=0.016). Five- and 10-year cumulative OS was 39% and 21%, respectively, while DFS was 22% and 17%, respectively. In a multivariate analysis low malignancy grade (P=0.017) and a complete tumour resection (P<0.001) were associated with better OS.

CONCLUSIONS

Complete tumour resection and low malignancy grade were independent favourable prognosticators. However, these factors were related too, since surgical success was influenced by malignancy grade.

Perioperative outcome in sarcoma surgery

INTRODUCTION

Soft tissue sarcomas (STS) are rare tumors accounting for less than 1% of all malignancies. Although disease-specific surgical management is increasingly important, only few data are available for STS. Here, we analyze a single institution setting focusing on perioperative surgical and clinical parameters.

METHODS

Prospectively gathered data of all adult patients undergoing surgery for STS including gastrointestinal stroma tumors (GIST) between October 2001 and October 2004. Patients undergoing only biopsy or ambulatory surgery were excluded. Statistical analysis was performed using SAS(R) software and patient's data from a computerized sarcoma registry.

RESULTS

159 patients with a median age of 60.2 years underwent a total of 179 operations. Three major sites of occurrence were notified: the visceral cavity (VIS) (36.3%), the retroperitoneum (RET) (31.3%), and the extremities (EXT) (27.4%). GIST (53.9%) were the most common type in the VIS, liposarcoma (62.5%) in the RET, and either liposarcoma (30.6%) or malignant fibrous histiocytoma (28.6%) in the EXT. Recurrence was treated in more than half of the patients with RET STS, and in almost one third of the EXT lesions, while primary occurrence dominated in the VIS. Median operation times in the VIS, RET, and EXT were 210, 240, and 120 min, respectively. Blood loss was 300, 500, and 50 ml for VIS, RET, and EXT operations. Morbidity was 26.2, 30.4, and 34.7% in VIS, RET, and EXT operations, respectively (reoperation rates were 9.4, 5.4, and 14.3%). Mortality was 1.5, 8.9, and 2.0% for VIS, RET, and EXT. Length of hospital stay in the groups was comparable.

CONCLUSION

STS surgery of a single surgical unit contains predominantly VIS, RET, and EXT tumors. The STS subtype varies with location, as does length of operation, blood loss, morbidity, mortality, and reoperation rate. These data are helpful for planning the perioperative management of adult patients with STS and can be used for prognostic analyses.

Intensificación terapéutica intraoperatoria en el tratamiento de los sarcomas abdominales localmente avanzados

INTRODUCTION

Sarcomas are rare tumors that develop from mesenchymal cells. Their management is difficult due to their changing histology, location, and behavior. In this article, we discuss the use of two intraoperative therapeutic intensification techniques, intraoperative radiotherapy (IORT) and hyperthermic intraoperative intraperitoneal chemotherapy (HIIC), in the treatment of locally advanced abdominal sarcomas and peritoneal sarcomatosis.

MATERIAL AND METHODS

We analyzed a series of 20 consecutive patients diagnosed with advanced abdominal sarcoma and 5 patients with a diagnosis of peritoneal sarcomatosis who were evaluated and treated in our department from December 1996 to October 2005. In advanced abdominal sarcoma, we performed complete or maximal resection followed by IORT. In peritoneal sarcomatosis we performed massive cytoreduction followed by HIIC.

RESULTS

The survival rate in advanced abdominal sarcomas without sarcomatosis was 65% at 26 months. Among the 5 patients diagnosed with peritoneal sarcomatosis, 3 were alive, and 2 were without recurrence at 20 months of follow-up.

CONCLUSIONS

IORT associated with radical surgery seems to improve local control and survival in advanced abdominal sarcomas. Maximal cytoreduction plus HIIC used as treatment of peritoneal sarcomatosis is a feasible technique that offers a therapeutic option with curative intent.

Clinical results of surgery for retroperitoneal sarcoma with major blood vessel involvement

PURPOSE

The study was conducted to evaluate the clinical results of resection for retroperitoneal soft tissue sarcoma (STS) with vascular involvement.

METHODS

The study group consisted of consecutive patients (mean age, 52 years) who underwent surgery for retroperitoneal STS with vascular involvement. The procedures were performed between 1988 and 2004. Vessel involvement by STS was classified as type I, artery and vein; type II, only artery; type III, only vein; and type IV, neither artery nor vein (excluded from the analysis). Patient data were prospectively gathered in a computerized database and retrospectively analyzed.

RESULTS

Of 141 patients with retroperitoneal STS, 25 (17.7%) underwent surgery for tumors with vascular involvement. The most common vascular involvement pattern was vein only (type III) at 64%. Arterial and vein (type I) and arterial only (type II) involvement were observed in 16% and 20% of the cases, respectively. STS originating from the vessel wall (primary vessel involvement) was seen in eight patients, and 17 patients had secondary vascular involvement. Resection and vascular repair were done in 22 patients (no vascular repair in three patients due to ligation of the external iliac vein in one patient, and debulking procedures in two). All patients with arterial involvement (type I and II) had arterial reconstruction consisting of aortic replacement (Dacron, n = 3; and expanded polytetrafluoroethylene [ePTFE], n = 2), iliac repair (Dacron, n = 3), and truncal reimplantation (n = 1). The inferior vena cava (6 ePTFE tube grafts, 3 ePTFE patches, 2 venoplasties), iliac vein (1 ePTFE bypass, 1 Dacron bypass, 1 venous patch), and superior mesenteric vein (1 anastomosis, 1 Dacron bypass) were restored in 80% of the patients (n = 16) with either arterial and venous or only venous involvement (type I and type III setting). Morbidity was 36% (hemorrhage, others), and mortality was 4%. At a median follow-up of 19.3 months (interquartile range, 12.8 to 49.9 months) the arterial patency rate was 88.9%, and the venous patency rate was 93.8% (primary and secondary). Thrombosis developed in one arterial and venous (type I) iliac reconstruction due to a perforated sigmoid diverticulitis 12 months after surgery. The local control rate was 82.4%. The 2-year and 5-year survival rates were 90% and 66.7% after complete resection with tumor-free resection margins (n = 10 patients, median survival not reached at latest follow-up). The median survival was 21 months in patients with complete resection but positive resection margins (n = 7) and 8 months in patients with incomplete tumor clearance (n = 8, persistent local disease or metastasis).

CONCLUSIONS

Patency rates and an acceptable surgical risk underline the value of en bloc resection of retroperitoneal STS together with involvement of blood vessels. The oncologic outcome is positive, especially after complete resection with tumor-free resection margins. A classification of vascular involvement can be used to plan resection and vascular replacement as well as to compare results among reports in a standardized fashion.

EFFECT OF RESECTION AND OUTCOME IN PATIENTS WITH RETROPERITONEAL SARCOMA

BACKGROUND

A consecutive series of 47 patients with retroperitoneal sarcoma (RPS) were resected and prospectively followed.

METHOD

Between July 1994 and March 2005, 47 patients (24 men, 23 women; mean age, 56 years; range, 17-82 years) were evaluated.

RESULTS

A total of 23 patients had primary RPS and 24 patients had recurrent RPS. A total of 30 out of 47 patients (64%) underwent removal of contiguous intra-abdominal organs. The peroperative mortality was nil and significant preoperative complications occurred in eight cases only (17%). High tumour grade and incomplete resection were significant variables for a worse survival in all 47 patients, both in the univariate and multivariate analyses (P = 0.008 and P = 0.016, respectively). Among 28 radically resected patients, only histological grade affected overall survival (90% 5-year survival for low-grade tumour vs 26% 5-year survival for high-grade tumour; P = 0.006) with a similar effect noted for disease-free survival.

CONCLUSIONS

Histological grade was the only factor that affected overall and disease-free survival for RPS tumours. An aggressive surgical approach in both primary and recurrent RPS is associated with long-term survival.

Primary and recurrent retroperitoneal soft tissue sarcoma: prognostic factors affecting survival

BACKGROUND AND OBJECTIVES

To analyze treatment and survival in 34 patients (28 resected) with primary or recurrent retroperitoneal sarcoma (RPS).

METHODS

Between July 1994 and January 2001, 34 patients (15M, 19F; mean age: 56 years, range: 25-77) were evaluated. Complete resection was defined as removal of gross tumor with histologically confirmed clear resection margins.

RESULTS

Twenty-eight out of 34 patients (82%) (15 were affected by primary RPS, and 13 by recurrent RPS), underwent surgical exploration. Twenty-three patients had a grossly and microscopically complete resection, (3 having a grossly incomplete resection and 2 patients with a grossly complete resection having histologically involved resection margins). Twenty-one out of 28 patients (75%) underwent removal of contiguous intra-abdominal organs. Preoperative mortality was nil, and morbidity occurred in six cases only (21%). High tumor grade results a significant variable for a worse survival in all 28 patients (100% 5 years survival for low grade vs. 0% for high grade; P = 0.0004). Amongst completely resected patients, only histologic grade and peroperative blood transfusions affected disease-free survival (P = 0.04 and P = 0.05, respectively).

CONCLUSIONS

An aggressive surgical approach in both primary and recurrent RPS is associated with long-term survival.

Place et techniques de radiothérapie dans le traitement des sarcomes des tissus mous de l'adulte

In soft tissue sarcoma, surgical resection remains the cornerstone of therapy for localized disease. Quality of margins is very important to evaluate. In case of marginal or incomplete resection, a new enlarged surgical resection should always be discussed before administration of any adjuvant treatments. Many retrospective studies and 2 randomized studies (one of adjuvant brachytherapy and one of external beam radiotherapy) have shown that adjuvant radiotherapy after complete surgery reduces significantly the risk of local recurrence in extremity soft tissue sarcomas. Combination of surgery and pre- or postoperative radiotherapy has therefore become the standard treatment with a local recurrence rate <or=25% and very few amputations. A recent randomized study has compared pre-op to postoperative radiotherapy. The results in terms of local control are similar in both arms (93 and 92% at 5 years) but the risk of early complications is higher in the preoperative arm and the risk of late sequela is higher in the postoperative arm. Surgical resection without radiotherapy may be considered after discussion at best within a multidisciplinary meeting, if surgical margins are considered satisfactory, in superficial, small tumours and low-grade. In retroperitoneal sarcomas, adjuvant radiotherapy is not a standard. It may decrease the risk of local recurrence but at the price of an increased gastro-intestinal toxicity. A randomized trial is warranted. Because of its rarity, and the risk of recurrence both local and metastatic, treatment should preferentially be discussed with a multimodality specialized approach.

Chirurgie des sarcomes rétropéritonéaux

Retroperitoneal sarcomas comprise approximately 15% of all soft tissue sarcomas and 50% of all retroperitoneal tumours. Helical CT of the abdomen and pelvis, with selective use of MRI will establish the extent of the tumour, its retroperitoneal location, the degree of necrosis, and the evidence of metastasis. A CT guided core needle biopsy is the optimal pre operative tissue sampling. A complete surgical resection is the mainstay of the treatment with a rim of normal tissue that often requires removal of adjacent organs. The 5-year probability of local control is approximately 50%. The role of adjuvant therapy is evolving and at present should not be used outside the investigational setting.

Retroperitoneal sarcomas

Retroperitoneal sarcomas are rare neoplasms. CT or MR imaging is performed in patients with these tumors to detect local extent and distant metastases of the tumor and for preoperative surgical planning. Most sarcomas cannot be characterized as to cell type with CT or MR, with the exceptions being liposarcomas and intracaval leiomyosarcomas. Similarly histological grading cannot be made definitively with imaging alone, the exception being liposarcoma since well differentiated liposarcomas contain more macroscopic fat than do less differentiated liposarcomas. After surgery, follow up imaging with CT or MR and careful scrutiny of the tumor bed and resection site are essential to detect early recurrences, which can often be managed with re-resection.

Retroperitoneal sarcoma: 25 years of experience with aggressive surgical treatment at the Institute of Oncology, Ljubljana

BACKGROUND AND OBJECTIVES

Retroperitoneal sarcomas are rare malignant tumors with an aggressive course of disease and high local recurrence rate. Local disease is the main cause of death. A retrospective study was undertaken to evaluate the results of aggressive surgical treatment in a series of patients of primary and recurrent retroperitoneal sarcomas.

PATIENTS AND METHODS

From 1975 to 2000, 155 patients with retroperitoneal tumors were operated on at the Institute of Oncology, Ljubljana. Patients with fibromatosis and children less than 16 years were excluded from further calculation. Out of the rest 139 patients, 102 patients had localized retroperitoneal sarcoma, and 37 patients had retroperitoneal sarcoma with distant metastases Leiomyosarcoma was the most common type of histology, followed by liposarcoma and schwannoma. Their referral status was as follow: 56 had primary sarcoma, 20 residual sarcoma after operation elsewhere and 26 already recurrent sarcoma. Our treatment approach was aggressive. We removed surgically primary tumor, recurrent sarcoma and metastases, whenever possible. To this end, we performed, 235 operations for retroperitoneal sarcomas on 139 patients (up to 8 operations on 1 patient).

RESULTS

Complete resection was done in 97 of 102 patients with localized sarcoma (resectability rate 95%); in 55 patients, R0 resection was made, in 42 patients, R1 resection, in 3 patients, debulking procedure, and in 2 patients biopsy alone. In 118, patients at least one organ was resected completely or partially en bloc with tumor. The 5-, 10-, and 15-year survivals of patients with localized sarcoma were 52%, 36%, and 22%, respectively. The 5-year survival of patients with metastases was 12% (P = 0.0002), the 5- and 10-year survival rates of patients with R0 resection were 75% and 64%, respectively, and of those with R1 resection, 25% and 8%, respectively (0 < 0.00001). High tumor grade was associated with poor survival. The 5-year local recurrence rate of patients with primary sarcoma and of those with locally recurrent sarcoma was 37% and 71%, respectively (P = 0.04). After the first local recurrence, the 5- and 10-year survival rates were 42% and 26%, after the second local recurrence 45% and 22%, after the third local recurrence 43% and 11%, and after the fourth local recurrence 51% and 17%, respectively.

CONCLUSION

Complete surgical resection without microscopic residuum and contamination is likely to offer the best chances for long-term survival. Until there are no other treatment modalities, aggressive surgery for recurrent sarcoma is recommended.

[Primary retroperitoneal tumors in adults: report of 11 cases]

The primitive retroperitoneal tumors are tumors which diagnosis isolate and thus the prognosis is poor. The authors assess the resectability of these tumors and the therapeutic results. We performed a retrospective study during 5 years, 11 patients were reviewed, in the unit of visceral surgical emergency of UHC Ibn-Rochd in Casablanca. The median age was 44 years old. The revealing signs were pains (67%), abdominal mass (54%), and compressive signs in 78%. The diagnosis was based on the computerized tomography in 10 cases (90%), the ultrasound sonography in 3 cases, and the IVU in 3 cases when it was necessary. The treatment was surgical in all cases. The resection was curative in 58%, 1 patient received chemotherapy. Histologically, the mesenchymatous variety was the most frequent (68%) and almost malignant (80%), the ectodermic origin was noted in 3 cases, and the vestigial in 1 case. The long-term follow-up was characterized by recurrence in 4 cases and 3 patients were lost to follow-up. The prognosis of the primitive retroperitoneal tumors is poor, because of a late diagnosis, and the malignant, and recurrent potential of these tumors.

The management of retroperitoneal liposarcoma with synchronous intra-duodenal sarcoma

Intra-abdominal (as opposed to extremity or limb and limb-girdle) soft tissue sarcomas (STS) are rare and account for less than 1% of all diagnosed neoplasms. These tumours are usually associated with a poor prognosis and are often locally invasive and metastatic at the time of presentation. Retroperitoneal sarcomas with synchronous or metachronous different histological types are rare and intra-duodenal sarcomas extremely unusual. A case of a giant retroperitoneal STS weighing approximately 15 kg consisting of two histologically different types is presented. Intra-duodenal involvement with sarcoma was found intra-operatively. We discuss the management of this condition in the context of an illustrative case in our recent experience.

Management of soft tissue sarcomas of the abdomen and pelvis

OBJECTIVE

Soft tissue sarcomas of the abdomen or pelvis are rare tumours that usually arise in the retroperitoneum but may also arise from the gastrointestinal tract or other abdominal organs. The aim of this study was to assess patient outcome following treatment of these tumours at a tertiary referral centre.

PATIENTS AND METHODS

Data on all patients with soft tissue tumours treated under the care of one surgeon between January 1990 and December 2000 was reviewed.

RESULTS

Over the 11-year period 61 patients underwent 79 operations for a soft tissue sarcoma of the abdomen or pelvis. Macroscopic clearance of tumour at operation was achieved in 45 (74%) of the 61 patients, for primary tumours this was 97%, recurrent tumours 50% and metastases 33%. The median survival for those undergoing complete resection was 50 months (range 3-238 months, median follow-up 33 months). This compared with a median survival of only 6 months range (1-127 months) for those that had incomplete resection (P = 0.001). The 5-year survival for patients that had complete resection was 61.5%, however, over one-third of the 5-year survivors have since recurred.

CONCLUSION

This study confirms that most primary soft tissue sarcomas of the abdomen or pelvis are resectable and the majority of patients will experience a long disease free interval following resection.

Retroperitoneal sarcomas: combined modality treatment approaches

Retroperitoneal soft tissue sarcomas are rare tumors estimated to account for 15%of all patients with soft tissue sarcoma seen in referral populations. The standard of care for patients with localized, resectable retroperitoneal sarcomas is surgical resection with gross and microscopically negative margins. However, owing to the large size and locally advanced nature of these tumors, this goal is difficult to achieve in most patients. As a result, the disease is characterized by a high propensity for local recurrence and a grade-specific risk for distant metastasis. Over the past decade, there has been considerable research into combined modality treatment of these tumors. The present report outlines current concepts relating to the diagnosis, staging, and management of retroperitoneal sarcomas. Emphasis is placed on evolving combined modality treatment approaches and current investigational strategies.

Retroperitoneal sarcoma: Time for a change in attiude?

BACKGROUND

Retroperitoneal sarcoma (RPS) is considered a disease with poor prognosis partly because of the difficulty with diagnosis at an early stage. This review assesses the current best practice principles for RPS and finds evidence suggesting a better outlook for appropriately managed cases. Recommendations are made for improving diagnostic certainty before laparotomy and inappropriate transperitoneal biopsy occur.

METHODS

A critical review of the English language literature was conducted using MEDLINE software and searching the terms 'retroperitoneal sarcoma' alone or in combination with 'prognosis', 'surgery' and 'adjuvant therapy'.

CONCLUSIONS

Retroperitoneal sarcoma is a rare disease but when appropriately managed the disease-free survival can be improved and may even approach that of extremity soft tissue sarcoma. One of the greatest barriers to improving outcome is the misinterpretation of clinical signs and an over-reliance on ultrasound diagnosis in pelvic presentations, or misinterpretation of clinical signs and/or computer tomography (CT) scans in abdominal masses. Physicians referring patients with a retroperitoneal mass should consider more frequently the less common differential diagnoses of an abdominopelvic mass including retroperitoneal sarcoma. This is especially true in circumstances where there is a circumscribed, predominantly solid tumour, with clinical or radiological signs of vascular or rectal displacement, ureteric obstruction and/or classic renal rotational displacement. The more frequent use of CT scans with intravenous and oral contrast with referral prior to inappropriate transperitoneal biopsy is recommended. In atypical cases where preoperative biopsy is necessary, extraperitoneal routes are preferable. Complete en bloc surgical excision at the first laparotomy is the treatment of choice in RPS. Macroscopic clearance may necessitate resection of adjacent viscera, neurovascular structures or abdominopelvic walls but, if achieved, may lead to long-term survival depending on individual tumour biology.

[Retroperitoneal liposarcoma. Case report]

We report one case of retroperitoneal liposarcoma treated by surgery and radiotherapy. With the literature, we discuss the pathologic and therapeutic aspect of this lesion.

Locoregional recurrence of retroperitoneal soft tissue sarcoma: second chance of cure for selected patients

BACKGROUND

Locoregional recurrence of a retroperitoneal soft tissue sarcoma (RSTS) may offer a second chance of curative surgical treatment. In a population-based study the proportion of patients developing isolated locoregional recurrences (LR) was determined and the outcome of these patients was analysed.

METHOD

In a retrospective nationwide study, data were collected on 142 patients treated between 1 January 1989 and 1 January 1994 for primary RSTS. In patients who had been treated radically for their primary sarcoma (77/142, 54%), the pattern of recurrence was evaluated. Factors predictive of survival for patients with LR were studied.

RESULTS

After a median follow-up of 86 (range 60-101) months, 32 patients (42%) had developed LR, and distant metastasis (DM) had been diagnosed in 17 patients (22%). Median disease-free interval between the initial operation and the establishment of LR or DM was 22 and 19 months, respectively. Five-year cumulative survival of patients with established LR was 37% in comparison with 11% for patients with DM (P=0.062). Factors predictive of favourable outcome in patients with LR were the absence of multifocal recurrence (n=13 P=0.01), lipomatous histomorphology (n=20 P=0.02), and a complete resection of recurrent sarcoma (n=17 P=0.04).

CONCLUSION

After a median follow-up of 7 years following radical treatment of a primary RSTS, 42% of the patients had developed isolated locoregional recurrences. A complete resection of recurrent disease, lipomatous histomorphology and the absence of multifocal growth influenced prognosis favourably.

The management of retroperitoneal soft tissue sarcoma: a single institution experience with a review of the literature

AIM

Ten percent of soft tissue sarcomas (STS) arise in the retroperitoneal tissues. The prognosis for patients with retroperitoneal sarcoma is poor with a 5-year survival rate between 12% and 70%. Stage at presentation, high histological grade, unresectable primary tumour and incomplete resection are associated with a less favourable outcome.

METHODS

Complete follow-up data were available on 22 patients who underwent surgery for retroperitoneal STS in our institution between 1990 and 2000. Patient, tumour and treatment variables were analysed including use of adjuvant therapy and survival status.

RESULTS

Eighteen patients underwent surgery for primary disease, four patients were treated for recurrent disease or metastases. Ten patients presented with pain, seven with an abdominal mass, other presentation included weight loss and haematuria. Thirteen patients presented with tumours larger than 10 cm. The tumours were seven liposarcomas, six leiomyosarcomas, three malignant fibrous histiocytomas, two rhabdomyosarcomas, two malignant schwannomas and two undifferentiated sarcomas. Six primary tumours were completely excised, five patients received radiotherapy and five received chemotherapy. Local recurrence rate was 45% and recurrence-free interval for 10 patients with recurrence was 11 months. Five patients received radiotherapy and five received chemotherapy. The median survival for patients with primary tumours was 36 months, and 5-year survival was 44%. Adjuvant therapy was not associated with higher survival rates.

CONCLUSION

This study re-emphasizes the poor outcome of patients with retroperitoneal STS. Adjuvant radiotherapy and chemotherapy do not appear to be any proven benefit and the single most important prognostic factor is aggressive successful en bloc resection of the primary tumour. Our resection rate and 5-year survival rates are comparable with previous reported UK series although lower than large reports from North American centres. This might partly be explained by difficulty in data collection in a retrospective analysis, but may reflect inadequate subspecialization in UK centres.

High-dose-rate intraoperative radiation therapy (HDR-IORT) for retroperitoneal sarcomas

PURPOSE

Retroperitoneal sarcomas represent a formidable challenge to the treating oncologist due to their location, large size, and poor prognosis. The purpose of this study was to determine if the addition of high-dose-rate intraoperative radiation therapy (HDR-IORT) to surgery and external beam radiotherapy (EBRT) would improve the outcome in these patients.

METHODS AND MATERIALS

Thirty-two patients with retroperitoneal soft tissue sarcoma were prospectively treated according to a protocol that included maximal tumor resection, HDR-IORT, and postoperative EBRT when feasible. Twelve patients presented with primary and 20 with locally recurrent disease. The tumors were high-grade in 20 patients and low-grade in 12 patients. Complete gross resection was achieved in 30 patients. HDR-IORT was given to a dose of 12-15 Gy. Additional EBRT was given to 78% of patients to a dose of 45-50.4 Gy. The two patients with gross residual disease received an additional I-125 permanent implant to a median peripheral dose of 140-160 Gy. The median follow-up was 33 months (range 1-77 mo).

RESULTS

The 5-year actuarial local control rate for the whole group was 62%. For patients with primary disease, the local control rate was 74% compared to 54% in patients with recurrent disease (p = 0.4). The overall 5-year distant metastasis-free survival rate was 82%. In patients with high-grade tumors the rate was 70% vs. 100% in those with low-grade tumors. This difference was statistically significant, p = 0.05. The 5-year disease-free and overall survival rates were 55% and 45%, respectively. The most common type of post-treatment complication was gastrointestinal obstruction (18%) followed by fistula formation (9%), peripheral neuropathy (6%), hydronephrosis (3%), and wound complication (3%).

CONCLUSIONS

We are encouraged by the favorable local control rate and the acceptable morbidity with this new technique applied to a challenging patient population.

Gynaecological presentation of retroperitoneal tumours

OBJECTIVE

To illustrate the problems associated with mistaken pre-operative diagnosis following gynaecological presentation of patients with retroperitoneal tumours.

DESIGN

A case series of five referrals.

RESULTS

Non-gynaecological tumours were not suspected in each case and hence there was a failure to undertake further pre-operative investigation and referral to a specialised soft tissue sarcoma service. This resulted in four of the patients having an unnecessary laparotomy with an inappropriate transperitoneal biopsy undertaken when the retroperitoneal tumour was discovered. The mistaken diagnosis of ovarian malignancy lead to increased morbidity, compromise of potential for a long disease free interval and/or possibly lessened the chance of cure in each case.

CONCLUSIONS

Misinterpretation of clinical signs and an over-reliance on ultrasound diagnosis were the commonest causes of inappropriate management of these patients. Gynaecologists should consider more frequently the other, less common differential diagnoses of a pelvic mass. This is especially true in circumstances with a predominantly solid tumour, where there are clinical signs of vascular or rectal displacement, or where there is ultrasound evidence of ureteric obstruction. The more frequent utilisation of a computerised tomography scan with intravenous and oral contrast with referral before inappropriate transperitoneal biopsy are recommended as complete en bloc surgical excision at the first laparotomy is the treatment of choice in virtually all primary retroperitoneal tumours.

The biological significance of failure at the primary site on ultimate survival in soft tissue sarcoma

Local tumor recurrence after complete resection may be due to treatment factors or represent a manifestation of tumor biology. The association of local tumor recurrence, distant metastases, and death in patients undergoing treatment for extremity soft tissue sarcoma (STS) has been described but continues to be enigmatic. After definitive multimodality treatment for extremity STS, local tumor recurrence is associated with development of distant metastasis, and metastases are implicated in subsequent disease-specific death. The relationship is an enigma, and the causality is unclear. Conversely, for patients with retroperitoneal STS, a direct relationship between local tumor recurrence and disease-specific death has been shown. In this article, current concepts are analyzed and reviewed.

Retroperitoneal soft-tissue sarcoma: analysis of 500 patients treated and followed at a single institution

OBJECTIVE

To analyze treatment and survival of a large cohort of patients with retroperitoneal soft-tissue sarcomas (STS) treated and prospectively followed at a single institution.

SUMMARY BACKGROUND DATA

Retroperitoneal STS are relatively uncommon and constitute a difficult management problem. Although surgical resection is often difficult or impossible, current chemotherapy is not effective and radiation is limited by toxicity to adjacent structures. Thus, complete surgical resection remains the most effective modality for selected primary and recurrent disease.

METHODS

Five hundred patients with retroperitoneal STS were admitted and treated between July 1, 1982, and September 30, 1997, and prospectively followed. Patient, tumor, and treatment variables were analyzed for disease-specific and disease-free survival. Survival was determined with the Kaplan-Meier method. Statistical significance was evaluated using the logrank test for univariate influence and Cox model stepwise regression for multivariate influence.

RESULTS

Two hundred seventy-eight patients (56%) had primary disease and 222 (44%) recurrent disease. Median follow-up was 28 months (range 1 to 172 months), 40 months for survivors. Median survival was 72 months for patients with primary disease, 28 months for those with local recurrence, and 10 months for those with metastasis. For patients with primary or locally recurrent tumors, unresectable disease, incomplete resection, and high-grade tumors significantly reduced survival time.

CONCLUSIONS

In this study of patients with retroperitoneal STS, stage at presentation, high histologic grade, unresectable primary tumor, and positive gross margin are strongly associated with the tumor mortality rate. Patients approached with curative intent should undergo aggressive attempts at complete surgical resection. Incomplete resection should be undertaken only for symptom relief.