EFFECT OF RESECTION AND OUTCOME IN PATIENTS WITH RETROPERITONEAL SARCOMA

Survival outcomes of surgery for retroperitoneal sarcomas: A systematic review and meta-analysis

Background

Definitive evidence to guide clinical practice on the principles of surgery for retroperitoneal sarcomas (RPSs) is still lacking. This study aims to summarise the available evidence to assess the relative benefits and disadvantages of an aggressive surgical approach with contiguous organ resection in patients with RPS, the association between surgical resection margins and survival outcomes, and the role of surgery in recurrent RPS.

Methods

We searched PubMed, the Cochrane Library, and EMBASE for relevant randomised trials and observational studies published from inception up to May 1, 2021. Prospective or retrospective studies, published in the English language, providing outcome data with surgical treatment in patients with RPS were selected. The primary outcome was overall survival (OS).

Findings

In total, 47 articles were analysed. There were no significant differences in the rates of OS (HR: 0.93; 95% CI: 0.83–1.03; P = 0.574) and recurrence-free survival (HR: 1.00; 95% CI: 0.74–1.27; P = 0.945) between the extended resection group and the tumour resection alone group. Organ resection did not increase postoperative mortality (OR: 1.00; 95% CI: 0.55–1.81; P = 0.997) but had a relatively higher complication rate (OR: 2.24, 95% CI: 0.94–5.34; P = 0.068). OS was higher in R0 than in R1 resection (HR: 1.34; 95% CI: 1.23–1.44; P < 0.001) and in R1 resection than in R2 resection (HR: 1.86; 95% CI: 1.35–2.36; P < 0.001). OS was also higher in R2 resection than in no surgery (HR: 1.26; 95% CI: 1.07–1.45; P < 0.001), however, subgroup analysis showed that the pooled HR in the trials reporting primary RPS was similar between the two groups (HR, 1.14; 95% CI, 0.87–1.42; P = 0.42). Surgical treatment achieves a significantly higher OS rate than does conservative treatment (HR: 2.42; 95% CI: 1.21–3.64; P < 0.001) for recurrent RPS.

Conclusions

For primary RPS, curative-intent en bloc resection should be aimed, and adjacent organs with evidence of direct invasion must be resected to avoid R2 resection. For recurrent RPS, surgical resection should be considered as a priority. Incomplete resection remains to have a survival benefit in select patients with unresectable recurrent RPS.

Aggressive Surgical Approach for Treatment of Primary and Recurrent Retroperitoneal Soft Tissue Sarcoma

To analyze treatment and survival in a series of resected patients with primary or recurrent retroperitoneal sarcoma (RPS) treated and prospectively followed at a single institution. Between July 1994 and December 2015, 89 patients (36 M, 53 F; mean age 60 years, range 25-79) were evaluated. For the purpose of analysis, complete resection was defined as removal of gross tumor with histologically confirmed clear resection margins. Eighty-three out of the 89 patients (93%), 46 of whom affected by primary RPS, and 37 by recurrent RPS, underwent surgical exploration. Sixty-two had a grossly and microscopically complete resection. Fifty-three out of 83 patients (64%) underwent removal of contiguous intra-abdominal organs. Preoperative mortality was nil and significant preoperative complications occurred in six cases only (7%). High-grade tumor pointed out to be a significant variable for a worse survival in all 83 patients amenable to undergo surgical resection (57% 5 years survival for low grade vs 14% for high grade; P = 0.0004). Among completely resected patients, only histologic grade clearly affected disease-free survival (72% 5 years survival for low grade vs 50% for high grade; P = 0.04), while the role of preoperative blood transfusions (67% 5 years survival for non-transfused patients vs 29% for transfused patients; P = 0.05) has to be evaluated in connection to patient complexity. Histological grade and recurrence are the most valuable prognostic predictors; in this clinical subset, an aggressive surgical approach in both primary and recurrent RPS is associated with a best long-term survival and disease-free survival.

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.

Modern surgical techniques for management of soft tissue sarcomas involving the spine: outcomes and complications

Several types of soft tissue sarcomas may locally extend to the spine. The best therapeutic strategy for such lesions strongly depends on the histological diagnosis. In this article the authors provide an up-to-date review of current guidelines regarding the management of soft tissue sarcomas involving the spine. Special attention is given to outcomes and complications of modern surgical series in order to highlight current challenges in the management of such lesions.

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.