The role of radiation in retroperitoneal sarcomas: a surgical perspective

Neoadjuvant radiotherapy for resectable retroperitoneal sarcoma: a meta-analysis

BACKGROUND

Neoadjuvant radiotherapy (NRT) for resectable retroperitoneal sarcoma (RPS) has been shown to be systematically feasible. Whether NRT has equivalent or better clinical effects compared to surgery alone for RPS patients remains controversial.

METHODS

We performed a systematic literature search of PubMed, Web of Science, Embase, ASCO Abstracts, and Cochrane library databases for studies in humans with defined search terms. Articles were independently assessed by 2 reviewers, and only randomized controlled trials and cohort studies were included. The hazard ratios (HRs) of overall survival (OS), recurrence-free survival (RFS), and local recurrence (LR) were extracted from included studies. Heterogeneity among study-specific HRs was assessed by the Q statistic and I² statistic. Overall HR was assessed by random-effects or fixed-effects models. Publication bias was tested by Begg's tests, and the quality of each study was assessed with the Newcastle Ottawa Scale.

RESULTS

A total of 12 eligible studies with 7778 resectable RPS patients were finally included in this study. The pooled analysis revealed the distinct advantages of NRT as compared to surgery alone, including longer OS (HR = 0.81, P < 0.001), longer RFS (HR = 0.58, P = 0.04), and lower LR (HR = 0.70, P = 0.03). No evidence of publication bias was observed.

CONCLUSION

NRT is likely to be beneficial for resectable RPS patients in terms of OS and RFS. However, more multicenter clinical trials are needed to confirm these findings.

Treatment for local control of retroperitoneal and pelvis sarcomas: A review of the literature

Retroperitoneal and pelvis sarcomas are uncommon tumors for which complete surgical resection is the mainstay of treatment. However, achieving complete gross resection with microscopically negative margins is challenging, and local recurrence rates can be high. Patients often succumb to uncontrolled local disease. Radiation therapy offers a potential means for sterilizing microscopic residual disease, although its use continues to be controversial. Chemotherapy alone or in combination with radiation continues to be investigated as an adjunct to surgery, along with immunotherapy and targeted therapies. In this review, we discuss the current management of retroperitoneal and pelvis sarcomas, focusing on studies of surgery and radiation therapy to maximize local control.

Retroperitoneal and Mesenteric Liposarcomas

Retroperitoneal liposarcomas are a rare entity and are comprised mostly of the well-differentiated and dedifferentiated subtypes. Eight-year survival ranges from 30% to 80% depending on histologic subtype and grade. Surgery is the cornerstone of treatment and compartment resection is the current standard. Mesenteric liposarcomas are extremely rare and comprise more high-grade lesions, with poorer prognosis of 50% 5-year overall survival. They are managed with a similar aggressive surgical approach. This review presents the current management of retroperitoneal and mesenteric liposarcomas.

Perioperative strategy and outcome in giant retroperitoneal dedifferentiated liposarcoma-results of a retrospective cohort study

Background and objectives

Retroperitoneal liposarcoma (RPLS) are common soft tissue sarcomas of adulthood. The aim of this study is to show resectability of even giant liposarcomas and to identify factors associated with recurrence and survival in primary retroperitoneal liposarcomas.

Methods

We retrospectively reviewed the records of patients with retroperitoneal liposarcoma. Seventy-seven patients met inclusion criteria. Out of these 10 patients with primary giant, dedifferentiated retroperitoneal liposarcomas were operated with en bloc compartment resection with intention of radical resection. Treatment consisted of neoadjuvant radiochemotherapy and surgical resection or surgical resection.

Results

In 6 patients, neoadjuvant radiochemotherapy was performed; 3 patients were treated with surgical resection alone and 1 patient received adjuvant chemotherapy. The median diameter of tumor size was 360 mm (300 to 440 mm). Operative outcome showed complete resection in all 10 patients. Local tumor free survival was in median 19 month. Tumor recurrence was seen in 3 of 4 patients (75%) without neoadjuvant radiochemotherapy, and in 2 of 6 patients (33%) after neoadjuvant radiochemotherapy in 2 years follow-up.

Conclusion

Even in case of giant retroperitoneal liposarcoma, complete resection is possible and remains the principal treatment. The rate of recurrence was improved in patients with neoadjuvant radiochemotherapy.

Intraoperative radiation therapy (IORT) for soft tissue sarcoma - ESTRO IORT Task Force/ACROP recommendations

PURPOSE

To describe guidelines for the use of intraoperative radiation therapy (IORT) in the treatment of soft-tissue sarcomas (STS).

METHODS

A panel of experts in the field performed a systematic literature review, supplemented their clinical experience and developed recommendations for the use of IORT in the treatment of STS.

RESULTS

Based on the evidence from the systematic literature review and the clinical experience of the panel members, recommendations regarding patient selection, incorporation into multimodal treatment concepts and the IORT procedure itself are made. The rationale for IORT in extremity and retroperitoneal STS is summarized and results of the major series in terms of patient and treatment characteristics, oncological outcome and toxicity are presented. We define surgical factors, volumes for irradiation, technical requirements, dose prescription, recording and reporting, treatment delivery and care during the course of IORT covering the main IORT techniques used for the treatment of STS. In extremity STS, evidence originates from a few small prospective and mainly from retrospective single centre studies. Based on those reports, IORT containing-approaches result in very high local control rates with low rates of acute and late toxicity. In retroperitoneal sarcomas, evidence is derived from one prospective randomized trial, a few prospective and a large number of retrospective studies. The randomized trial compared IORT combined with moderate doses of postoperative external-beam radiation therapy (EBRT) to high-dose postoperative EBRT alone after gross total resection, clearly favouring the IORT-containing approach. These results have been confirmed by the prospective and retrospective studies, which similarly showed high local control rates with acceptable toxicity, mainly favouring combinations of preoperative EBRT and IORT.

CONCLUSIONS

IORT-containing approaches result in high rates of local control with low to acceptable toxicity rates. Based on the available evidence, we made recommendations for the use of IORT in STS. Clinicians and researchers are encouraged to use these guidelines in clinical routine as well as in the design of future trials.

Perioperative radiotherapy versus surgery alone for retroperitoneal sarcomas: a systematic review and meta-analysis

Background

There is no clear evidence on whether radiotherapy (RT) improves treatment result in patients with retroperitoneal sarcomas (RPS).

Methods

A systematic literature search was performed using PubMed, Scopus and CENTRAL databases. Data were retrieved from published comparatives studies in patients with RPS undergoing surgery alone or RT plus surgery. The primary endpoints were the 5-year OS and the median OS. The secondary endpoints were the recurrence-free survival (RFS) and the R0-resection rate. Continuous outcomes were calculated by means of weighted mean difference (WMD).

Results

Ten out of 374 articles were analyzed. The median OS and the 5-year survival were significantly increased in patients treated with RT and surgery, compared to patients treated with surgery alone (p < 0.00001, p < 0.001). Median RFS was significantly increased in patients treated with either preoperative (p < 0.001) or postoperative (p = 0.001) RT compared to patients that underwent surgery alone. Finally, median R0-resection rate was similar between the two groups (p = 0.56).

Conclusion

RT along with radical surgery could be the standard of care in at least a subgroup of patients with RPS.

Overall survival after resection of retroperitoneal sarcoma at academic cancer centers versus community cancer centers: An analysis of the National Cancer Data Base

BACKGROUND

Operative resection remains the definitive curative therapy for retroperitoneal sarcoma. Data published recently show a correlation between improved outcomes for complex oncologic operations and treatment at academic centers. For large retroperitoneal sarcomas, operative resection can be complex and require multidisciplinary care. We hypothesized that survival rates vary between type of treating center for patients undergoing resection for retroperitoneal sarcoma.

METHODS

Patients with stage I to III nonmetastatic retroperitoneal sarcomas who underwent operative resection were identified from the National Cancer Database during the years 2004-2013. Treating centers were categorized as academic cancer centers or community cancer centers. Overall survival was analyzed by log-rank test and graphed using Kaplan-Meier method.

RESULTS

A total of 2,762 patients were identified. A majority of patients (59.4%, n = 1,642) underwent resection at an academic cancer centers. Median age at diagnosis was 63 years old. Neoadjuvant radiotherapy was more common at academic cancer centers, while adjuvant radiotherapy was more common at community cancer centers. Improved overall survival was seen at academic cancer centers across all stages compared with community cancer centers (P = .014) but, after multivariable Cox regression analysis, was not a significant independent predictor of survival (hazard ratio = 0.91, 95% confidence interval, 0.79-1.04, P = .171). Academic cancer centers exhibited a greater rate of R0 resection (55.9% vs 47.0%, P < .001) and a lesser odds of positive margins (odds ratio 0.83, 95% confidence interval, 0.69-0.99, P = .044) after multivariable logistic regression.

CONCLUSION

Resection for retroperitoneal sarcoma performed at academic cancer centers was an independent predictor of margin-negative resection but was not a statistically significant factor for survival. This observation suggests that site of care may contribute to some aspect of improved oncologic resection for retroperitoneal sarcoma.

Primary colonic well-differentiated / dedifferentiated liposarcoma of the ascending colon: a case report

BACKGROUND

Primary colonic and dedifferentiated liposarcomas are both remarkably rare. This work describes a case of primary colonic well-differentiated/dedifferentiated liposarcoma and reviews the clinical characteristics and current therapies for liposarcoma tumors.

CASE PRESENTATION

A 52-year-old woman was referred to our hospital with a submucosal tumor of the ascending colon. Clinical analysis by ultrasound colonoscopy and computed tomography revealed a partially ossified tumor with irregular edges continuous with the muscular layer. High F-18 deoxyglucose uptake was detected by positron emission tomography. Radical resection with lymph node dissection was performed, yielding a tumor specimen approximately 6.5 × 4.0 × 3.2 cm. Neoplastic spindle cell proliferation was found from submucosa to subserosa. Well-differentiated adipose tissue surrounded the tumor, but contained atypical nuclei with condensed chromosomes. Immunohistochemical staining was positive for p16, CDK4, and MDM2 expression. Based on these findings, a diagnosis of well-differentiated/dedifferentiated liposarcoma was given. Dedifferentiated liposarcomas are more aggressive than their well-differentiated, low-grade counterparts. While local recurrence can occur with both tumor types, dedifferentiated liposarcomas are more prone to developing distant metastases. The patient received no postoperative therapy, and no recurrences have been observed 12 months after surgery.

CONCLUSIONS

Here we report an extremely rare case of well-differentiated/dedifferentiated liposarcoma of the ascending colon. The dedifferentiated component was high-grade liposarcoma and well-differentiated liposarcoma was detected around the main tumor.

Single-center experience with intra-abdominal liposarcoma: Optimal minimum duration for postoperative remnant tumor screening

This study sought to identify factors related to the prognosis of intra-abdominal liposarcoma and to determine the optimal minimum duration for remnant tumor screening. Intra-abdominal liposarcoma is associated with high rates of incomplete resection and recurrence requiring a sophisticated follow-up strategy.Patients who underwent surgery for intra-abdominal liposarcoma were included. Cox analyses were used to analyze factors related to recurrence and survival. To determine the optimal minimum duration for remnant tumor screening, patients with recurrence after surgery despite gross complete resection were grouped by a postoperative detection time of 1, 3, or 6 months. Their survivals were compared to the gross incomplete resection group.A total of 168 patients were included. Kaplan-Meier 5-year disease-free survival was 35.9% and overall survival was 66.5%. Multiplicity (HR=2.528, CI=1.585-4.033, P < .001), organ invasion (HR = 1.628, CI = 1.020-2.598, P = .041), and FNCLCC grades (G2,HR = 1.730, CI = 1.000-2.994; G3, HR = 3.812, CI = 2.112-6.880, P < .001) were related to recurrence. Multiplicity (HR = 2.131, CI = 1.050-4.329, P = .036), organ resection ≥3 (HR = 2.857, CI = 1.322-6.174, P = .008), gross incomplete resection (HR = 4.368, CI = 1.890-10.097, P = .001), positive margin (HR = 2.766, CI = 1.367-5.600, P = .005), FNCLCC grade (G2,HR = 2.044, CI = 0.937-4.459; G3,HR = 4.470, CI = 1.893-10.557; P = .003), and RT (HR = 0.322, CI = 0.160-0.648, P = .001) were related to overall survival. Dividing patients into 1 month (P = .097) and 3 months (P = 0.063) did not yield significant differences in univariate analyses, whereas 6 months showed significant difference (P = .015) compared to the gross incomplete resection group. Patients with tumors detected within 6 months showed similar survival to the gross incomplete resection group (HR = 0.552, CI = 0.241-1.260, P = .158), whereas patients with tumor detection after 6 months showed better survival (HR = 0.325, CI = 0.149-0.708, P = .005).In conclusion, minimum duration of 6 months for remnant tumor screening using CT seems optimal.

Postoperative complications following intraoperative radiotherapy in abdominopelvic malignancy: A single institution analysis of 113 consecutive patients

BACKGROUND

Intraoperative radiotherapy (IORT) has advantages over external beam radiation therapy (EBRT). Few studies have described side effects associated with its addition. We evaluated our institution's experience with abdominopelvic IORT to assess safety by postoperative complication rates.

METHODS

Prospectively collected IRB-approved database of all patients receiving abdominopelvic IORT (via high dose rate brachytherapy) at Johns Hopkins Hospital between November 2006 and May 2014 was reviewed. Patients were discussed in multidisciplinary conferences. Those selected for IORT were patients for whom curative intent resection was planned for which IORT could improve margin-negative resection and optimize locoregional control. Perioperative complications were classified via Clavien-Dindo scale for postoperative surgical complications.

RESULTS

A total of 113 patients were evaluated. Most common diagnosis was sarcoma (50/113, 44%) followed by colorectal cancer (45/113, 40%), most of which were recurrent (84%). There were no perioperative deaths. A total of 57% of patients experienced a complication Grade II or higher: 24% (27/113) Grade II; 27% (30/113) Grade III; 7% (8/113) Grade IV. Wound complications were most common (38%), then gastrointestinal (25%). No radiotherapy variables were significantly associated with complications on uni/multi-variate analysis.

CONCLUSIONS

Our institution's experience with IORT demonstrated historically expected postoperative complication rates. IORT is safe, with acceptable perioperative morbidity.

Radiation Therapy for Soft-Tissue Sarcomas: A Primer for Radiologists

Radiation therapy (RT) plays an important role in multimodality therapy for soft-tissue sarcomas (STS). RT treatment paradigms have evolved significantly in recent years, and many different complex RT modalities are commonly used in STS. These include external-beam RT, intensity-modulated RT, stereotactic body RT, and brachytherapy. Imaging is essential throughout the treatment process. Plain radiographs, computed tomography (CT), magnetic resonance imaging, ultrasonography, and positron emission tomography/CT all play potential roles in the management of STS. Before RT, high-quality imaging is needed to direct management decisions, both by global tumor staging and detailed assessment of the extent of local disease. At the time of RT, precise planning imaging is required to delineate tumor volumes, including gross tumor volume, clinical target volume, and planning target volume, which are used to direct therapy. In addition, imaging at the time of RT must outline the location of adjacent vital organs, to optimize treatment efficacy and minimize toxicity. After RT, imaging is needed to assess the patient for tumor response to therapy. In addition, imaging at regular intervals is often required to monitor for recurrence of disease and potential complications of therapy. The purpose of this review is to familiarize radiologists with the indications for RT in STS, common therapeutic modalities used, roles of imaging throughout the treatment process, and complications of therapy.

Intraoperative radiation therapy (IORT) in soft-tissue sarcoma

Soft-tissue sarcoma (STS) represent a rare tumor entity, accounting for less than 1% of adult malignancies. The cornerstone of curative intent treatment is surgery with free margins, although the extent of the surgical approach has been subject to change in the last decades. Multimodal approaches usually including radiation therapy have replaced extensive surgical procedures in order to preserve functionality while maintaining adequate local control. However, the possibility to apply adequate radiation doses by external beam radiation therapy (EBRT) can be limited in some situation especially in case of directly adjacent organs at risk with low radiation tolerance. Application of at least a part of the total dose via intraoperative radiation therapy (IORT) with a single fraction during the surgical procedure may overcome those limitations, because radiosensitive structures can be moved out of the radiation field resulting in reduced toxicity while the enhanced biological effectivity of the high single dose improves local control. The current review summarizes rationale, techniques, oncological and functional outcomes including possible pitfalls and associated toxicities based on the published literature for IORT focusing on extremity and retroperitoneal STS. In extremity STS, combination of limb-sparing surgery, IORT and pre- or postoperative EBRT with moderate doses consistently achieved excellent local control rates at least comparable to approaches using EBRT alone but usually including patient cohorts with higher proportions of unfavourable prognostic factors. Further on, IORT containing approaches resulted in very high limb preservation rates and good functional outcome, probably related to the smaller high dose volume. In retroperitoneal STS, the combination of preoperative EBRT, surgery and IORT consistently achieved high local control rates which seem superior to surgery alone or surgery with EBRT at least with regard to local control and in some reports even to overall survival. Further on, preoperative EBRT in combination with IORT seems to be superior to the opposite combination with regard to local control and toxicity. No major differences in wound healing disturbances or postoperative complication rates can be observed with IORT compared to non-IORT containing approaches. Neuropathy of major nerves remains a dose limiting toxicity requiring dose restrictions or exclusion from target volume. Gastrointestinal structures and ureters should be excluded from the IORT area whenever possible and the IORT volume should be restricted to the available minimum. Nevertheless, IORT represents an ideal boosting method if combined with EBRT and properly executed by experiences users which should be further evaluated preferably in prospective randomized trials.

Tissue expander placement and adjuvant radiotherapy after surgical resection of retroperitoneal liposarcoma offers improved local control

Given that retroperitoneal liposarcoma (LPS) is extremely difficult to completely resect, and has a relatively high rate of recurrence, radiotherapy (RT) is the treatment of choice after surgical resection. However, it is difficult to obtain a sufficient radiation field because of the close proximity of surrounding organs. We introduce the use of tissue expanders (TEs) after LPS resection in an attempt to secure a sufficient radiation field and to improve recurrence-free survival.This study is a retrospective review of 53 patients who underwent surgical resection of LPS at Samsung Medical Center between January 1, 2005, and December 31, 2012, and had no residual tumor detected 2 months postoperatively. The median follow-up period was 38.9 months.Patients were divided into 3 groups. Those in group 1 (n = 17) had TE inserted and received postoperative RT. The patients in group 2 (n = 9) did not have TE inserted and received postoperative RT. Finally, those in group 3 (n = 27) did not receive postoperative RT. Multivariate analysis was performed to identify the risk factors associated with recurrence-free survival within 3 years. Younger age, history of LPS treatment, and RT after TE insertion (group 1 vs group 2 or 3) were significantly favorable factors influencing 3-year recurrence-free survival.TE insertion after LPS resection is associated with increased 3-year recurrence-free survival, most likely because it allows effective delivery of postoperative RT.

Neoadjuvant radiotherapy for retroperitoneal sarcoma: A systematic review

BACKGROUND AND OBJECTIVES

The multi-modal treatment of retroperitoneal sarcoma has seen increased use of neoadjuvant radiation. However, its effect on local recurrence and survival remain controversial. We aimed to synthesize and evaluate the literature.

METHODS

The review was conducted according the recommendation of the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) group with pre-specified inclusion and exclusion criteria.

RESULTS

Of 8,701 citations collected, 15 articles reported on 464 patients. The median age was 56 years (45-64). The predominant histological subtypes were liposarcoma (51.54%) and leiomyosarcoma (23.26%). Tumor differentiation composed of 37.1% well-, 12.8% moderate-, 46.0% poorly-, and 4.1% undifferentiated. Most studies featured external beam radiation therapy (EBRT) treatment regimen with some who included patients treated with IMRT instead. Median follow-up averaged 41.4 months (19-106 months). Median 5-year OS, PFS, and LRR rates were 58%, 71.5%, and 25%. Using the NCI CTCAE, toxicities from Grade 1 (Mild) through Grade 5 (death) were experienced by 18.8%, 10.2%, 16.3%, 0.7%, and 1.6% of patients.

CONCLUSIONS

NART is a safe to use for RPS, but its effect toward survival and local control remains unclear. Without randomized control trials, common reporting criteria for pro- and retrospective studies are needed to allow comparison between studies. J. Surg. Oncol. 2016;113:628-634. © 2016 Wiley Periodicals, Inc.

[Intra-abdominal and retroperitoneal sarcomas]

Sarcomas are a heterogeneous group of rare tumors that originate from mesenchymal tissue. Radical R0 resection is the only curative option, which is especially challenging in retroperitoneal or intra-abdominal sarcomas. This article describes the current data on optimal interdisciplinary and primarily surgical therapy of visceral sarcomas. Surgical resection of retroperitoneal sarcomas must be performed according to the principle of radical compartmental resection, i.e. with complete excision of the mass along with en bloc visceral resection of adjacent organs and tissues covering the tumor, which also contains any not obviously infiltrated neighboring organs. The main objective is R0 resection without opening the tumor capsule in the primary operation because the best long-term results can be achieved with this approach.

Comparison of Perioperative Radiation Therapy and Surgery Versus Surgery Alone in 204 Patients With Primary Retroperitoneal Sarcoma: A Retrospective 2-Institution Study

OBJECTIVE

To compare outcomes of patients with retroperitoneal or pelvic sarcoma treated with perioperative radiation therapy (RT) versus those treated without perioperative RT.

BACKGROUND

RT for retroperitoneal or pelvic sarcoma is controversial, and few studies have compared outcomes with and without RT.

METHODS

Prospectively maintained databases were reviewed to retrospectively compare patients with primary retroperitoneal or pelvic sarcoma treated during 2003-2011. Multivariate Cox regression models were used to assess associations with the primary endpoints: local recurrence-free survival (LRFS) and disease-specific survival.

RESULTS

At 1 institution, 172 patients were treated with surgery alone, whereas at another institution 32 patients were treated with surgery and perioperative proton beam RT or intensity-modulated RT with or without intraoperative RT. The groups were similar in age, tumor size, grade, and margin status (all P > 0.08). The RT group had a higher percentage of pelvic tumors (P = 0.03) and a different distribution of histologies (P = 0.04). Perioperative morbidity was higher in the RT group (44% vs 16% of patients; P = 0.004). After a median follow-up of 39 months, 5-year LRFS was 91% (95% confidence interval, 79%-100%) in the RT group and 65% (57%-74%) in the surgery-only group (P = 0.02). On multivariate analysis, RT was associated with better LRFS (hazard ratio, 0.26; P = 0.03). Five-year disease-specific survival was 93% (95% confidence interval, 82%-100%) in the RT group and 85% (78%-92%) in the surgery-only group (P = 0.3).

CONCLUSIONS

The addition of advanced-modality RT to surgery for primary retroperitoneal or pelvic sarcoma was associated with improved LRFS, although this did not translate into significantly better disease-specific survival. This treatment strategy warrants further investigation in a randomized trial.

Long-term Oncologic Outcomes After Neoadjuvant Radiation Therapy for Retroperitoneal Sarcomas

OBJECTIVE

To evaluate long-term survival among patients undergoing radiation therapy (RT), followed by surgical resection of retroperitoneal sarcomas (RPS).

BACKGROUND

Despite a lack of level 1 evidence supporting neoadjuvant RT for RPS, its use has increased substantially over the past decade.

METHODS

The 1998-2011 National Cancer Data Base was queried to identify patients who underwent resection of RPS. Subjects were grouped by use of neoadjuvant RT. Perioperative variables and outcomes were compared. Multivariable logistic regression was performed to assess predictors of neoadjuvant RT. Groups were propensity matched using a 2:1 nearest neighbor algorithm and short-term outcomes were compared. Finally, long-term survival was evaluated using the Kaplan-Meier method, with comparisons based on the log-rank test.

RESULTS

A total of 11,324 patients were identified. Neoadjuvant RT was administered to 696 patients (6.1%). During the study period, preoperative RT use increased from 4% to nearly 15%. Male sex, tumor size larger than 5 cm, treatment at an academic/research program, and higher tumor grade all predicted neoadjuvant RT administration. After propensity matching, the only difference in baseline characteristics was the use of neoadjuvant chemotherapy. Although neoadjuvant RT was associated with a higher rate of negative margins (77.5% vs 73.0%; P = 0.014), there was no corresponding improvement in 5-year survival (53.2% vs 54.2%; P = 0.695).

CONCLUSIONS

Despite the increasing use of neoadjuvant RT for patients with RPS, the survival benefit associated with this treatment modality remains unclear. Continued investigation is needed to better define the role of RT among patients with RPS.

Successful resection of a huge mediastinal liposarcoma extended to the bilateral thorax

Liposarcoma arising in the mediastinum is extremely rare. Herein we present a case of a 47-year-old man with a huge posterior mediastinal tumor that extended to the bilateral thorax. The patient underwent a complete resection of the tumor and experienced an uneventful recovery. Postoperative pathology finally revealed liposarcoma. The patient underwent follow-up for 25 months, during which time no recurrence was found.

Surgical management of retroperitoneal and pelvic sarcomas

Management of retroperitoneal sarcomas presents technical and oncological challenges. Imaging is crucial for diagnosis and to define local tumor extent. Complete gross resection at initial presentation is the best chance for cure, but there is controversy as to how this can be best achieved. There is a long-term risk of local recurrence, which is best treated with repeat resection if feasible. The roles of radiation and chemotherapy remain undefined.

The effect of neoadjuvant radiation therapy on perioperative outcomes among patients undergoing resection of retroperitoneal sarcomas

BACKGROUND

Neoadjuvant radiation therapy (RT) has several theoretical benefits in the treatment of retroperitoneal sarcoma (RPS), but concerns remain about treatment toxicity and perioperative morbidity. There are limited data regarding its effect on perioperative outcomes, most of which come from small, single-institution series. The purpose of this study was to evaluate the short-term (30-day) postoperative morbidity and mortality associated with neoadjuvant RT following resection of RPS.

METHODS

The 2005-2011 National Surgical Quality Improvement Program Participant User File was queried for patients undergoing RPS resection. Subjects were stratified by use of neoadjuvant RT. Perioperative variables and short-term 30-day outcomes were compared. Groups were then propensity matched using a 2:1 nearest-neighbor algorithm and multivariable logistic regression was performed to assess neoadjuvant RT as a predictor of short-term 30-day outcomes.

RESULTS

A total of 785 patients were identified. Neoadjuvant RT was administered to 71 (9.0%). Patients who received neoadjuvant RT were slightly younger (56 vs. 62 years, p < 0.001), but otherwise the groups were similar. After propensity matching, all baseline characteristics were highly similar. Median operative time was longer in the neoadjuvant RT group (279 vs. 219 min, p < 0.01), but there were no differences in mortality (1.4 vs. 2.1%, p = 0.71), major complications (28.2 vs. 25.2%, p = 0.69), overall complications (35.2 vs.33.2%, p = 0.83), early reoperation (5.6 vs. 7.4%, p = 0.81), or length of stay (7 vs. 7 days, p = 0.56). Following further adjustment with logistic regression, we confirmed that there were no differences in 30-day mortality or morbidity between patients who did and did not receive neoadjuvant RT.

CONCLUSIONS

Neoadjuvant RT does not appear to increase short-term (30-day) morbidity or mortality following resection of RPS. Continued investigation is needed to better define the role for radiation therapy among patients with this disease.

High-dose-rate intraoperative radiation therapy: the nuts and bolts of starting a program

High-dose-rate intraoperative radiation therapy (HDR-IORT) has historically provided effective local control (LC) for patients with unresectable and recurrent tumors. However, IORT is limited to only a few specialized institutions and it can be difficult to initiate an HDR-IORT program. Herein, we provide a brief overview on how to initiate and implement an HDR-IORT program for a selected group of patients with gastrointestinal and pelvic solid tumors using a multidisciplinary approach. Proper administration of HDR-IORT requires institutional support and a joint effort among physics staff, oncologists, surgeons, anesthesiologists, and nurses. In order to determine the true efficacy of IORT for various malignancies, collaboration among institutions with established IORT programs is needed.

[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.

Radiotherapy and surgery-an indispensable duo in the treatment of retroperitoneal sarcoma

The authors undertook a systematic review to designate the role that radiotherapy (RT) might play in the treatment of retroperitoneal sarcomas. Correlating with recent literature, the objective of this review was to evaluate whether there was enough evidence for the authors to develop an institutional treatment protocol concerning the use of RT in the treatment of retroperitoneal sarcoma. Furthermore, this was a call for surgeons to talk to radiation oncologists before performing surgery. The 2 objectives of this review were: 1) to determine the benefit of RT in terms of local control and/or survival in the treatment of retroperitoneal sarcomas and 2) to discover the optimal timing of RT in the treatment sequence. A computerized literature search was performed in the PubMed database, the Cochrane Library database, and reference lists; and journals also were searched by hand to identify all retrospective and prospective reports published since 1998 relating to RT treatment of adult retroperitoneal sarcoma. Mainly, analyses were sought that were based on a 5-year local control rate (LCR), 5-year disease-free survival, and 5-year overall survival (OS). If only 2 years follow-up were available, then the authors also noted this outcome. Toxicity data were collected and analyzed separately. The synthesis of the literature was based on 9 prospectively nonrandomized studies and 10 retrospective studies that, together, reviewed a total of 1426 patients. The 5-year LCR varied from 27% to 62%, and the results from other reports fell in between those values. The 5-year OS rate ranged from 12% to 90%, and complete resection and tumor grade were the most important prognostic factors in most studies. This review resulted in 7 recommendations concerning the use of RT in the treatment of retroperitoneal sarcoma. The authors concluded that there is good evidence from multiple single-institutions studies that RT improves the LCR in patients with retroperitoneal sarcoma. Until now, there has not been a translation of this approach into survival benefit. The current results indicated that preoperative external-beam RT followed by radical surgery seems to be the preferred sequence, and adding intraoperative RT is a safe procedure for dose escalation in the upper abdomen.

TNFalpha gene delivery therapy for solid tumors

IMPORTANCE OF THE FIELD

Multimodality therapy, including adjuvant and neoadjuvant chemotherapy and radiotherapy, is now the mainstay of treatment for the majority of non-hematologic cancers. Host toxicity can, however, be significant, which may contribute to local and/or systemic failures. Novel adjunctive treatments that can limit systemic exposure while synergizing with standard therapy hold promise in the fight against an increasing number of cancers.

AREAS COVERED IN THIS REVIEW

We discuss a TNFalpha gene delivery system used to generate high levels of intratumoral TNFalpha, while limiting systemic exposure. The delivery system utilizes a replication-deficient adenoviral vector. When injected intratumorally and activated by external beam radiation, infected cells synthesize and locally secrete large amounts of TNFalpha.

WHAT THE READER WILL GAIN

This review will provide the reader with a thorough understanding of the gene-based TNFalpha delivery system with special emphasis on product characteristics, mechanisms of action, clinical efficacy, safety and tolerability.

TAKE HOME MESSAGE

The TNFalpha gene delivery system holds promise as an adjunctive agent for improved local control and increasing resectability rates for many solid tumors. The completion of several ongoing randomized trials will help to better define the role for TNFalpha gene delivery therapy in the treatment of solid tumors.

Proton-beam, intensity-modulated, and/or intraoperative electron radiation therapy combined with aggressive anterior surgical resection for retroperitoneal sarcomas

BACKGROUND

We sought to reduce local recurrence for retroperitoneal sarcomas by using a coordinated strategy of advanced radiation techniques and aggressive en-bloc surgical resection.

METHODS

Proton-beam radiation therapy (PBRT) and/or intensity-modulated radiation therapy (IMRT) were delivered to improve tumor target coverage and spare selected adjacent organs. Surgical resection of tumor and adjacent organs was performed to obtain a disease-free anterior margin. Intraoperative electron radiation therapy (IOERT) was delivered to any close posterior margin.

RESULTS

Twenty patients had primary tumors and eight had recurrent tumors. Tumors were large (median size 9.75 cm), primarily liposarcomas and leiomyosarcomas (71%), and were mostly of intermediate or high grade (81%). PBRT and/or IMRT were delivered to all patients, preferably preoperatively (75%), to a median dose of 50 Gy. Surgical resection included up to five adjacent organs, most commonly the colon (n = 7) and kidney (n = 7). Margins were positive for disease, usually posteriorly, in 15 patients (54%). IOERT was delivered to the posterior margin in 12 patients (43%) to a median dose of 11 Gy. Surgical complications occurred in eight patients (28.6%), and radiation-related complications occurred in four patients (14%). After a median follow-up of 33 months, only two patients (10%) with primary disease experienced local recurrence, while three patients (37.5%) with recurrent disease experienced local recurrence.

CONCLUSIONS

Aggressive resection of retroperitoneal sarcomas can achieve a disease-negative anterior margin. PBRT and/or IMRT with IOERT may possibly deliver sufficient radiation dose to the posterior margin to control microscopic residual disease. This strategy may minimize radiation-related morbidity and reduce local recurrence, especially in patients with primary disease.

[Surgical therapy of abdominal and trunk soft tissue sarcomas]

Soft tissue sarcomas are rare tumours of mesenchymal cells which can arise in all parts of the body. Sarcomas of the trunk and abdominal cavity are a very heterogeneous group of tumours. This review focuses on retroperitoneal sarcomas, which tend to be asymptomatic for a long time, resulting in an advanced stage at presentation in most patients. Surgical resection is the basis for cure in these patients, possibly combined with radiation. In contrast to extremity sarcomas, the majority of patients with retroperitoneal sarcomas succumb to an isolated local recurrence of the disease. In case of local recurrence or distant metastases, surgical resection should again be contemplated.

Treatment of soft tissue sarcoma: a European approach

This article discusses the treatment of adult soft tissue sarcoma (excluding gastrointestinal stromal tumor), analyzing the principles underlying treatment and the results of surgery, radiotherapy, and chemotherapy. The focus is on the European approach in particular, and ongoing studies are summarized.

Outpatient Chemotherapy plus Radiotherapy in Sarcomas: Improving Cancer Control with Radiosensitizing Agents

Background

Cancer control by radiotherapy (RT) can be improved with concurrent chemotherapy. Outpatient strategies for sarcomas that combine chemotherapy and RT are possible since supportive care and RT techniques have improved.

Methods

The current status of non-anthracycline chemotherapy in combination with radiation for high-risk sarcoma is reviewed.

Results

Ifosfamide with mesna and newer activated ifosfamide agents (ZIO-201 and glufosfamide) have high potential to improve sarcoma cancer control. In Ewing's sarcoma and osteosarcoma, high-dose ifosfamide with mesna (2.8 g/m2/day of each x 5 days; mesna day 6) can be safely given to outpatients using continuous infusion. Reducing ifosfamide nephrotoxicity and central nervous system side effects are discussed. Other outpatient radiosensitization regimens include gemcitabine (600–1000 mg/m2/dose IV over 1 hour weekly x 2–3 doses), temozolomide (75 mg/m2/daily x 3–6 weeks), or temozolomide (100 mg/m2/dose daily x 5) + irinotecan (10 mg/m2/dose daily x 5 x 2 weeks). In osteosarcoma with osteoblastic metastases on bone scan, samarium (1 mCi/kg; day 3 of RT) and gemcitabine (600 mg/m2 IV over 1 hour day 9 of RT) is a radiosensitization strategy. Future drugs for radiosensitization include beta-D-glucose targeted activated ifosfamide (glufosfamide) and sapacitabine, an oral nucleoside with in vitro activity against solid tumors including sarcomas.

Conclusions

The potential to treat major causes of sarcoma treatment failure (local recurrence and distant metastases) with concurrent chemotherapy during radiation should be considered in high-grade sarcomas.