Soft tissue carcinoma in the retroperitoneum: an often neglected diagnosis

Complete metabolic response after Partially Ablative Radiotherapy (PAR) for bulky retroperitoneal liposarcoma: A case report

In the management of symptomatic inoperable retroperitoneal sarcomas (RPS), palliative radiotherapy (RT) is a potential treatment option. However, the efficacy of low doses used in palliative RT is limited in these radioresistant tumors. Therefore, exploring dose escalation strategies targeting specific regions of the tumor may enhance the therapeutic effect of RT in relieving or preventing symptoms. In this case report, we present the case of an 87-year-old patient with rapidly growing undifferentiated liposarcoma in the retroperitoneum, where surgical and systemic therapies were ruled out due to age and comorbidities. RT was administered using volumetric modulated arc therapy, delivering 20 Gy in 4 fractions twice daily to the macroscopic tumor and 40 Gy in 4 fractions twice daily (simultaneous integrated boost) to the central part of the tumor (Gross Tumor Volume minus 2 cm). An 18F-FDG-PET-CT scan performed after RT demonstrated a complete metabolic response throughout the entire tumor mass. Although the patient eventually succumbed to metastatic spread to the bone, liver, and lung after 9 months, no local disease progression or pain/obstructive symptoms were observed. This case highlights the technical and clinical feasibility of delivering ablative doses of RT to the central region of the tumor and suggests the potential for achieving a complete metabolic response and durable tumor control.

Survival Outcome of Retroperitoneal Sarcomas Treated With a Surgery-First Approach: A Single-Center Experience

Background Retroperitoneal sarcomas (RPS) are rare and complex tumors originating from the retroperitoneal space, an anatomical region nestled behind the abdominal cavity and shielded by the posterior abdominal wall. Late clinical presentation is a hallmark of retroperitoneal sarcomas. The symptoms are often nonspecific, and nodal metastases are rare. Computed tomography (CT) remains the investigation of choice, and a preoperative biopsy is usually not needed. Surgical resection remains the mainstay of treatment, along with adjuvant radiation and chemotherapy. Survival rates are in general poor, even after complete resection. In this study, we attempt to shed some light on the clinicopathological profiling of retroperitoneal sarcomas and their survival outcomes. Objective The objective of this study is to assess the demographic, clinical, and pathological profiling of patients with retroperitoneal sarcoma and to study the survival of patients with retroperitoneal sarcoma. Methodology We conducted a hospital-based retrospective observational study in a tertiary care center in South India between January 2011 and January 2021. We included all patients with histopathologically proven retroperitoneal sarcoma. Metastatic cases and those who underwent chemotherapy or radiation prior to presentation were excluded. Their demographics, pathological reports, and survival were followed up and collected, and statistical analysis was done. Results The study included 16 cases with retroperitoneal sarcomas across the decade in which the data was collected, confirming the rarity of the tumor, out of which more than 40% of patients were above the age of 60. The most common symptom was found to be a bloating sensation in nine patients, followed by abdominal pain in three patients. Seventy-five percent of the patients were found to have a T4 (i.e., a size of more than 15 cm) tumor at presentation. Well-differentiated liposarcoma was found to be the most common pathological variant accounting for 25% of the cases. The mean survival was found to be 8.05 years, which dropped to 5.74 years in Grade 3 tumors. Conclusion Retroperitoneal sarcomas are rare tumors of which liposarcoma is the most common variant. A significant reduction in the mean survival was identified in Grade 3 sarcomas compared to the cumulative survival time of Grade 1 and Grade 2 retroperitoneal sarcomas.

A retrospective study comparing contrast-enhanced computed tomography with 18F-FDG-PET/CT in the early follow-up of patients with retroperitoneal sarcomas

OBJECTIVE

To compare 18-fluorine-labeled 2-deoxy-2-fluoro-D-glucose PET/computed tomography ((18)F-FDG-PET/CT) with contrast enhancement computed tomography (CECT) in the early follow-up of patients who had undergone treatment for primitive retroperitoneal sarcomas (RS).

METHODS

This is a retrospective study on 24 patients who underwent (18)F-FDG-PET/CT and CECT within 2 years after therapy for RS. (18)F-FDG-PET/CT and CECT results were compared with results of histological examination and clinical-instrumental follow-up. We calculated the sensitivity and specificity of CECT and (18)F-FDG-PET/CT for retroperitoneal recurrences and compared them with results of the McNemar test. Negative predictive values (NPVs) and positive predictive values (PPVs) were calculated and the positive percentage agreement and negative percentage agreement were evaluated.

RESULTS

The sensitivity and specificity of (18)F-FDG-PET/CT were 66.7 and 100% and those for CECT were 58.3 and 50%, respectively. For (18)F-FDG-PET/CT, PPV was 100% [95% confidence interval (CI): 67-100%] and NPV was 75% (95% CI: 58-75%); for CECT, PPV was 54% (95% CI: 33-73%) and NPV was 55% (95% CI: 30-78%). Positive percentage agreement and negative percentage agreement were, respectively, 38 and 72% for retroperitoneal lesions, 42.8 and 100% for liposarcomas, 40 and 50% for leiomyosarcomas, 14.2 and 94% for abdominal lymph nodes, and 16.6 and 100% for lung metastasis. Neither technique gave reliable results for liver metastasis.

CONCLUSION

Our data show that (18)F-FDG-PET/CT has a higher overall specificity compared with CECT in identifying areas of recurrence, demonstrating its validity for early whole-body detection of lesions. In our hands (18)F-FDG-PET/CT seems to be a good tool in the early follow-up of patients experiencing recurrence of RS.

Local Management of Adult Soft Tissue Sarcomas

Soft tissue sarcomas (STS) are rare tumors classified into multiple histological subtypes and categorized into four sites: extremity and trunk, head and neck, retroperitoneal, and visceral, the latter now predominantly consisting of gastrointestinal stromal tumors. Well-planned, complete surgical resection is the mainstay of curative therapy for tumors at each of these sites. The success of surgery alone in controlling disease varies with the site, histologic grade, depth, and size of the tumor. For high-risk tumors, adjuvant therapy should be considered. In high-risk extremity tumors, adjuvant radiation has been proven in randomized trials to improve local control. Limb-sparing surgery combined with adjuvant radiation achieves equivalent local control to amputation, with the same distant relapse-free survival. Due to anatomical constraints, tumors of the head and neck and retroperitoneum are typically excised with close margins, providing a rationale for adjuvant radiation; the available evidence suggests but does not prove a benefit. Large-scale trials of adjuvant imatinib for gastrointestinal stromal tumors are currently being conducted. For tumors of the extremity/trunk, head and neck, and retroperitoneum, biopsy prior to definitive resection is recommended to establish the diagnosis and permit intelligent treatment planning with appropriate choice and sequencing of adjuvant therapies. This planning is most expeditiously done through multidisciplinary consultation at an experienced sarcoma center.

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.

Analysis of retroperitoneal tumors operated on in a gynecology clinic

AIM

To evaluate the patients with retroperitoneal tumors that presented as pelvic mass and were operated on in our gynecology clinic.

METHODS

Records of 16 patients were analyzed retrospectively.

RESULTS

All patients had a palpable mass on physical examination and abdominal pain was the most frequent symptom. The median diameter of the tumors was 15 cm. The postoperative histopathology of the patients was leiomyosarcoma in nine, retroperitoneal fibrosis in three, and paraganglioma, hamartoma, and dermoid cyst in three patients. All the tumors were excised almost completely. The incorrect preoperative diagnosis of the patients in this study is due to the presentation of the patients with non-specific symptoms and not considering the less common differential diagnosis of a pelvic mass.

CONCLUSION

For clinical signs of vascular or rectal displacement, or where there is evidence of ureteric obstruction, retroperitoneal pathology should be kept in mind.

Surgical management of retroperitoneal sarcomas associated with external and intraoperative electron beam radiotherapy

AIMS

To report outcomes of adults with retroperitoneal sarcoma (RS) treated by surgery, external beam radiotherapy (EBRT) and intraoperative electron beam radiotherapy (IORT).

METHODS

From July 1988 to February 2001; 24 patients with primary and recurrent RS were diagnosed and treated. The median dose and energy of IORT delivered was 15 Gy/9meV. EBRT dose varies between 45-50 Gy.

RESULTS

There were five primary and 19 recurrent tumours. One primary and five recurrent tumours underwent R0 resection. There were 12 liposarcomas and 19 grade I tumours; 13 patients developed local recurrence and three developed distant metastases.Twenty-two patients received IORT associated with EBRT: 11 developed recurrences. Six patients developed Neurotoxicity (4 grade II and 2 grade III). Disease free survival and overall survival at 5 years was 28 and 56% respectively.

CONCLUSIONS

EBRT with IORT treatment is a promising technique for local control. Lower recurrence rates are associated with radical (R0) surgical procedures.

Cancer surgery in the elderly

Surprisingly, cancer in the elderly is frequently treated in a poor manner, and the behaviour of the disease in elderly patients is often poorly understood. Cancer treatment varies significantly with age, the percentage of patients receiving definitive treatment declines with increasing age, and there is a decline in survival of cancer with age. One of the contributing factors may be that physicians are less likely to recommend specialist consultation for elderly patients. One has to keep in mind that cancer surgery in the elderly, without any co-morbidity, is safe, and that, nowadays, the morbidity and mortality increases minimally with the age of the patient. In contrast, the morbidity and mortality is 2-3 fold as high in the elderly cancer patients with co-morbidity compared with younger cancer patients. A better public education of the elderly may increase cancer awareness, and therefore decrease the risk of developing symptoms that require emergency surgery, with a subsequent three times increase in the mortality rate. Surgeons treating elderly cancer patients should realise that performance status is more important than age, and should always keep in mind the three major questions as recently formulated by Balducci; (1) is the patient going to die of cancer or with cancer, (2) is the patient able to tolerate the surgery and possible surgical-related complications, and (3) is the patient likely to suffer the complications of cancer during her/his life? The increased number of surgical treatment options in elderly cancer patients will lead to an increase in overall cancer survival in elderly cancer patients, and contribute to an improvement in their quality of life. Surgical oncologists should focus on how to manage the most common cancers in elderly people such as breast, colorectal, lung and prostate, as well as take an active part in palliative treatments.