Retroperitoneal and Truncal Sarcomas: Prognosis Depends Upon Type Not Location

A systematic review of the role of chemotherapy in retroperitoneal sarcoma by the Australia and New Zealand sarcoma association clinical practice guidelines working party

BACKGROUND

In primary localised resectable retroperitoneal sarcoma (RPS), loco-regional and distant relapse occur frequently despite optimal surgical management. The role of chemotherapy in improving outcomes is unclear.

METHODS

A systematic review was conducted, using the population, intervention, comparison outcome (PICO) model, to evaluate whether neoadjuvant or adjuvant chemotherapy improve outcomes in adults with primary localised resectable RPS. Medline, Embase and Cochrane Central were queried for publications from 1946 to June 2022 that evaluated recurrence free survival, overall survival, and post operative complications. Each study was screened by two independent reviewers for suitability. A qualitative synthesis of the results was performed.

RESULTS

Twenty three studies were identified; one meta-analysis of retrospective studies and 22 retrospective studies including three with propensity matched cohorts. Most studies did not analyse outcomes by histology, detail treatment regimens, provide baseline characteristics or selection criteria for those receiving chemotherapy. Evidence of selection bias was illustrated in several studies. Newcastle-Ottawa quality of retrospective cohort studies was good for 12 studies and poor for 10 studies. All studies were assessed as Level III-2 evidence by the Australian NHMRC hierarchy. Overall, the addition of neoadjuvant or adjuvant chemotherapy to surgery was not associated with improvement in local recurrence, metastasis free survival, disease free survival or overall survival in primary localised resectable RPS. There is some evidence of an association of chemotherapy with worse overall survival. One single centre study showed that neoadjuvant chemotherapy was not associated with increased post operative complications compared to surgery alone in primary localised resectable RPS.

CONCLUSIONS

There is currently no evidence that demonstrates the addition of chemotherapy to surgery improves outcomes in adult patients with primary localised resectable RPS. Available evidence is limited by its retrospective nature and high likelihood of selection bias with chemotherapy generally administered to patients at higher risk of recurrence and many patients not receiving care in high volume sarcoma centres. Randomised trials are required to conclusively determine the role of chemotherapy in primary localised resectable RPS.

Overall Survival and Associations of Insurance Status Among Hispanic Men With High-Risk Prostate Cancer

Objectives Our objectives were to (1) determine the association between ethnicity and high-risk prostate cancer (PCa) survival and (2) determine whether this association is modified by insurance status. Methods We performed a retrospective review of the National Cancer Database (NCDB) from 2004 to 2017 of non-Hispanic White (NHW), Hispanic White (HW), or Black men with high-risk PCa. A multivariate Cox regression model was built to test the association between overall survival (OS) and race/ethnicity, insurance status, and their interaction, controlling for various socioeconomic and disease-specific variables. Results A total of 94,708 men with high-risk PCa were included in the analysis. Both HW and Black men had lower socioeconomic status characteristics and lower rates of private insurance. Race/ethnicity was significantly associated with OS in the adjusted analysis. Only Medicare demonstrated significantly worse OS. NHW (covariate-adjusted hazard ratio (aHR): 1.83, 95% CI: 1.45-2.32) and Black (aHR: 1.71, 05% CI: 1.34-2.19) men demonstrated significantly worse survival when compared to HW men. Subgroup analysis demonstrated significant differences occurring among HW men with private insurance/managed care when compared to those not insured, Medicaid, Medicare, and other government insurance types. Conclusion Despite socioeconomic and demographic disadvantages, HW men demonstrate improved OS compared to NHW men. Furthermore, HW men demonstrated improved OS compared to NHW men within nearly each insurance status type. This finding is likely the result of a complex multifactorial web and as such serves as an interesting hypothesis-generating study.

Long-term disease-free survival of an undifferentiated pleomorphic sarcoma of the spleen: A case report and literature review

INTRODUCTION

Undifferentiated pleomorphic sarcoma (UPS) primarily occurs in the soft tissues of the extremities, trunk, and retroperitoneum. As the primary UPS of the spleen (splenic UPS) is extremely rare, to the best of our knowledge, only 19 cases have been reported in English literature. No cases of long-term survival without a local or distant recurrence have been reported.

PATIENT CONCERNS

We report the case of a 37-year-old man who was referred to our hospital for a splenic tumor. He had no past medical or relevant familial history. On abdominal computed tomography (CT), a low attenuation solid mass and cystic component with mural calcifications were present at the lower pole of his spleen. The fluorodeoxyglucose-positron emission tomography (CT) indicated it as malignant tumor of the spleen.

DIAGNOSES

The patient's provisional diagnosis was deduced to be angiosarcoma, which was the most common malignant tumor of the spleen.

INTERVENTIONS

An elective laparoscopic splenectomy was performed, and the histology of the tumor was consistent with UPS (pT1, pN0, cM0, and AJCC8th). No adjuvant therapy was administered.

OUTCOMES

Ten years have passed since the patient's splenectomy, and he continues to do well, without evidence of local or distant recurrence.

LESSONS

To the best of our knowledge, this is the first case of long-term recurrence-free survival after surgical management of a splenic UPS. It is probable that radical splenectomy during the disease played the most important role in the patient's long-term survival. Understanding the characteristic findings of a splenic UPS in an abdominal CT may help to diagnose properly.

Deep Learning Networks for Automatic Retroperitoneal Sarcoma Segmentation in Computerized Tomography

The volume estimation of retroperitoneal sarcoma (RPS) is often difficult due to its huge dimensions and irregular shape; thus, it often requires manual segmentation, which is time-consuming and operator-dependent. This study aimed to evaluate two fully automated deep learning networks (ENet and ERFNet) for RPS segmentation. This retrospective study included 20 patients with RPS who received an abdominal computed tomography (CT) examination. Forty-nine CT examinations, with a total of 72 lesions, were included. Manual segmentation was performed by two radiologists in consensus, and automatic segmentation was performed using ENet and ERFNet. Significant differences between manual and automatic segmentation were tested using the analysis of variance (ANOVA). A set of performance indicators for the shape comparison (namely sensitivity), positive predictive value (PPV), dice similarity coefficient (DSC), volume overlap error (VOE), and volumetric differences (VD) were calculated. There were no significant differences found between the RPS volumes obtained using manual segmentation and ENet (p-value = 0.935), manual segmentation and ERFNet (p-value = 0.544), or ENet and ERFNet (p-value = 0.119). The sensitivity, PPV, DSC, VOE, and VD for ENet and ERFNet were 91.54% and 72.21%, 89.85% and 87.00%, 90.52% and 74.85%, 16.87% and 36.85%, and 2.11% and -14.80%, respectively. By using a dedicated GPU, ENet took around 15 s for segmentation versus 13 s for ERFNet. In the case of CPU, ENet took around 2 min versus 1 min for ERFNet. The manual approach required approximately one hour per segmentation. In conclusion, fully automatic deep learning networks are reliable methods for RPS volume assessment. ENet performs better than ERFNet for automatic segmentation, though it requires more time.

Role of Radiation Therapy for Newly Diagnosed Retroperitoneal Sarcoma

OPINION STATEMENT

Soft tissue sarcomas (STS) are rare, aggressive, and heterogenous tumors, comprising approximately 1% of adult cancers with over 50 different subtypes. The mainstay of treatment for retroperitoneal sarcomas (RPS) includes surgical resection. The addition of radiation therapy (RT), either preoperatively or postoperatively, has been used to potentially decrease the risk of local recurrence. The recently published results from STRASS (EORTC-STBSG 62092-22092), which randomized patients to receive or not receive preoperative radiation, indicate no abdominal recurrence-free survival benefit (primary endpoint) nor overall survival benefit to date from the addition of preoperative RT prior to surgical resection in patients with RPS. Keeping in mind caveats of subgroup analyses, the data show a significant reduction in local recurrence with radiation therapy in resected patients and non-significant trends toward improved abdominal recurrence-free survival in all patients and improved local control and abdominal recurrence-free survival in patients with liposarcoma and low-grade sarcoma. Given the high rate of local failure with surgery alone, it is possible that higher RT dose and/or selective RT dose painting may improve outcomes. Prior to treatment, the authors encourage multidisciplinary review and discussion of management options at a sarcoma center for patients with RPS. Selective use of RT may be considered for patients at high risk of local recurrence.

Surgical Diagnosis and Treatment of Primary Retroperitoneal Liposarcoma

Background: Primary retroperitoneal liposarcoma (PRPLS) is the most common soft tissue sarcoma of the retroperitoneum with high recurrence rate and short overall survival (OS).

Methods: A retrospective review of 51 patients with PRPLS, treated between September 1, 2009 and November 30, 2020, was conducted to evaluate clinical outcomes of PRPLS resection. Patient demographics, histopathologic subtypes, overall survival (OS), progression-free survival (PFS), disease recurrence rate, and tumor stage were reviewed and analyzed. Univariate analysis was done to identify factors potentially affecting OS and PFS of PRPLS patients. Multivariate Cox proportional hazards analysis was used to evaluate the impact of various clinicopathological factors on OS and PFS of PRPLS patients.

Results: Fifty-one PRPLS patients (28 Males, 23 Females; mean age 56.25 years) were evaluated. There was no significant effect of age, gender, contiguous organ resection, degree of differentiation and tumor size on the OS and PFS of the patients. Univariate analysis showed that negative surgical margin and early tumor stage significantly correlated with OS and PFS (all P < 0.001). Multivariate analysis showed that tumor stage [hazard ratio (HR) = 1.177, P = 0.001] was an independent predictors of poor progression-free survival, and surgical margins [HR = 4.0674 P = 0.038] and tumor stage [HR = 1.167 P = 0.001] were identified as independent predictors of poor overall survival.

Conclusion: Negative surgical margin is a prognostic factor of OS, and can prolong the postoperative survival time of PRPLS patients. Tumor stage is a prognostic factor for OS and PFS, and can influence the survival of PRPLS patients. Earlier tumor stages of PRPLS are associated with significantly better outcomes.

Renal liposarcoma: case report and review of systemic treatment

Liposarcomas are malignant mesenchymal tumours usually located in the retroperitoneum, rarely occurring as a single lesion in the kidney. We present a case of a 59-year-old male patient with a left renal mass detected by computed tomography scan. He underwent radical nephrectomy and the histopathological study reported a primary undifferentiated liposarcoma of the kidney without nodal involvement. After 15 months of surgery, he remained asymptomatic and without evidence of disease recurrence. The objective of this report is to present a case and literature review with current evidence of treatment options and prognostic factors for survival.

Primary upper pole liposarcoma of the kidney with invasion to inferior vena cava: A case report

Genitourinary tract liposarcoma is considered as the second most commonly reported type of sarcomas. Renal liposarcoma with tumor invasion to inferior vena cava (IVC) is distinctly rare. This tumor has a relatively indolent clinical course with risk of local recurrences (20%–85% rate) after surgery. Angiomyolipomas (AML) are the most important differential diagnosis because both are large fat-containing lesions. Herein, a patient with upper pole kidney liposarcoma with tumor invasion to renal vein and IVC is presented. The optimal management is radical nephrectomy and IVC tumor resection. Chemotherapy and radiotherapy have not shown significant survival benefit.

The Vanderbilt staging system for retroperitoneal sarcoma: a validation study of 6857 patients from the National Cancer Database

The Vanderbilt staging system for retroperitoneal sarcoma incorporates information regarding the histologic subtype of sarcoma and outperforms the 7th and 8th editions of the AJCC staging systems by several different statistical criteria. The current study was performed using an independent patient cohort from the National Cancer Database (n = 6857) to validate this proposed staging system. Each staging system was assessed for degree of discrimination by pairwise comparisons of adjacent stage categories. Predictive accuracy of 5-year overall survival was performed by comparison of areas under receiver operating characteristic curves generated from logistic regression. Three different concordance indices (Harrell's c, Somers' D, and Gönen and Heller's K) were calculated using bootstrap methods. Amount of variation in observed outcomes explained by each staging system was assessed using O'Quigley's ρ²k and Royston's R². Bayesian information criteria were also assessed as measures of model fit. The revised AJCC 8th edition T categories were not effective in categorizing risk of death. The Vanderbilt staging system showed the best discrimination between adjacent tumor stages, highest predictive accuracy for 5-year overall survival, a higher degree of concordance with and explained variation of clinical outcomes, and resulted in the best fitting regression model. These results obtained with an independent dataset validate the Vanderbilt staging system for retroperitoneal sarcoma and demonstrate its superiority in risk stratification over current and prior editions of the AJCC staging system.

Incisions and reconstruction approaches for large sarcomas

Large intraabdominal, retroperitoneal, and abdominal wall sarcomas provide unique challenges in treatment due to their variable histology, potential considerable size at the time of diagnosis, and the ability to invade into critical structures. Historically, some of these tumors were considered inoperable if surgical access was limited or the consequential defect was unable to be closed primarily as reconstructive options were limited. Over time, there has been a greater understanding of the abdominal wall anatomy and mechanics, which has resulted in the development of new techniques to allow for sound oncologic resections and viable, durable options for abdominal wall reconstruction. Currently, intra-operative positioning and employment of a variety of abdominal and posterior trunk incisions have made more intraabdominal and retroperitoneal tumors accessible. Primary involvement or direct invasion of tumor into the abdominal wall is no longer prohibitive as utilization of advanced hernia repair techniques along with the application of vascularized tissue transfer have been shown to have the ability to repair large area defects involving multiple quadrants of the abdominal wall. Both local and distant free tissue transfer may be incorporated, depending on the size and location of the area needing reconstruction and what residual structures are remaining surrounding the resection bed. There is an emphasis on selecting the techniques that will be associated with the least amount of morbidity yet will restore and provide the appropriate structure and function necessary for the trunk. This review article summarizes both initial surgical incisional planning for the oncologic resection and a variety of repair options for the abdominal wall spanning the reconstructive ladder.

Solitary fibrous tumor

Solitary fibrous tumor (SFT) is a rare tumor of mesenchymal origin that account for less than 2% of all soft tissue masses. Initially identified in the pleura, SFT has been identified in multiple anatomic locations and can arise anywhere in the body. The varying histologic features along with non-specific means of identification have led SFT to be associated with several different names. Over the last several decades, sustained advances through research and technology have led to more reliable methods for differentiating this distinct soft tissue tumor. Advances specifically in immunohistochemistry and molecular diagnostics have identified CD34 as the most consistent marker in SFT, however even this lacks specificity to conclusively narrow down the broad differential for exact identification. More recently the discovery of the NAB2-STAT6 fusion gene has led to more precise diagnosis of SFT. Like many other soft tissue tumors, surgical management is the mainstay of treatment for SFT with emphasis on obtaining tumor-negative margins. Radiation therapy and chemotherapy regimens have not demonstrated global effectiveness, and thus no standardized treatments have been identified. Given the rarity of SFT and current supportive evidence for therapies, management should be focused on tumor extirpation. Nonetheless, individualized therapy, determined within a multidisciplinary setting should be considered.

Coexistence of gastric gastrointestinal stromal tumor, intro-abdominal and retroperitoneal liposarcomas -a case report

Background

Gastric gastrointestinal stromal tumor (GIST), intro-abdominal and retroperitoneal neoplasms are distinct tumors arising from different cell layers; therefore, coexistence of such tumors is relatively rare.

Case presentation

A man complained of early satiety for 2 mouths, whose upper gastrointestinal (GI) endoscopy showed a tumor arising from the greater curvature of gastric body and extending into the lumen. Abdominal computed tomography (CT) revealed coexistence of gastric, intro-abdominal and retroperitoneal masses. Wedge resection for gastric tumor, resection for intro-abdominal and retroperitoneal tumors were done. The postoperative histological examination suggested simultaneous development of a gastric GIST, intro-abdominal and retroperitoneal myxoid liposarcomas.

Conclusion

Although both GISTs and liposarcomas originate from mesenchymal tissues, simultaneous development of a gastric GIST, intro-abdominal and retroperitoneal liposarcomas is the first such case to be reported in the literature.

Perioperative chemotherapy is not associated with improved survival in high-grade truncal sarcoma

BACKGROUND

The treatment benefit of perioperative chemotherapy (CTX) for truncal soft tissue sarcoma (STS) is not well established. This study evaluates the association of CTX with survival for patients with resected primary high-grade truncal STS.

MATERIALS AND METHODS

Adult patients with high-grade truncal STS who had curative-intent resection from 2000 to 2016 at seven U.S. institutions were evaluated retrospectively. Patients were stratified by receipt of CTX. Kaplan-Meier curves with log-rank tests were used to compare overall survival (OS) and recurrence-free survival. Logistic regression models were used to evaluate characteristics associated with OS.

RESULTS

Of patients with primary high-grade truncal STS, 235 underwent curative-intent resections. The most common histology was undifferentiated pleomorphic sarcoma and mean tumor size was 7.8 cm. Thirty percent of the patients received CTX (n = 70). Among patients receiving CTX, 34% (n = 24) had neoadjuvant CTX, 44% (n = 31) adjuvant CTX, and 21% (n = 15) had neoadjuvant and adjuvant CTX. Patients receiving CTX were more likely to receive radiation (51% versus 34%, P = 0.01), have deep tumors (86% versus 73%, P = 0.037) and solid organ invasion (14% versus 3%, P = 0.001). On univariate analysis, patients who received CTX had worse OS (P < 0.01) and a trend toward worse recurrence-free survival (P = 0.08). Margin status was the only variable associated with improved OS on multivariate analysis (odds ratio 4.36, 95% confidence interval 1.56, 12.13, P < 0.01).

CONCLUSIONS

In this multi-institutional retrospective analysis of resected high-grade truncal STS, receipt of perioperative CTX was not associated with improved OS, which may be related to selection bias. Microscopically negative margin status was the only independent factor associated with OS.

[LEIOMYOSARCOMA OF THE OVARIAN VEIN WITH THE RENAL VEIN INVASION: A CASE REPORT]

A 56-year-old woman had complained of two year's consecutive left-side abdominal pain. Retroperitoneal tumor was diagnosed and the patient was referred to our institute in December 2014. Laboratory data including endocrinological activity and serological markers were within the normal ranges. Imaging studies showed that the solid tumor measuring 5 cm in diameter was uncovered in the retroperitoneum, between the abdominal aorta and left kidney. The patient underwent surgical removal of the tumor with the left kidney because the mass was highly adhesive to the left ovarian vessels and left renal vein. Histological examination showed proliferating spindle cells in the tumor, and immunoreactivity for desmin and alfa-smooth muscle actin in tumor cells confirmed the diagnosis of leiomyosarcoma originated in left ovarian vein with left renal vein invasion. The patient has been free of disease 21 months after the surgery. Ovarian vein leiomyosarcoma is extremely rare and we have found 18 cases in literature. Furthermore, only three cases of leiomyosarcoma arising from the ovarian vein with the renal vein invasion were reported including our case.

Looking for answers: the current status of neoadjuvant treatment in localized soft tissue sarcomas

PURPOSE

Sarcomas are a rare and heterogeneous variant of cancer. The standard of care treatment involves surgical resection with radiation in high-risk patients. Despite appropriate treatment approximately 50 % of patients will suffer and die from recurrent disease. The purpose of this article is to review the current evidence concerning the use of neoadjuvant chemotherapy with or without radiation in soft tissue sarcomas.

METHODS

An in-depth literature search was conducted using Ovid Medline and PubMed.

RESULTS

The most active chemotherapeutic agents in sarcoma are anthracyclines and ifosfamide. Adjuvant chemotherapy trials show only minimal benefit. Neoadjuvant chemotherapy offers the potential advantage of reducing the extent of surgery, increasing the limb salvage rate, early exposure of micrometastatic disease to chemotherapy, and assessment of tumor response to chemotherapy. Some retrospective and phase II trials suggest a benefit to neoadjuvant chemotherapy. Unfortunately, no clearly positive phase III prospectively randomized trials exist for neoadjuvant therapy in soft tissue sarcomas.

CONCLUSIONS

The current neoadjuvant chemotherapy trials that do exist are heterogeneous resulting in conflicting results. However, neoadjuvant chemotherapy with or without radiation can be considered in patients with high-risk disease in an attempt to improve long-term outcomes.

Practical Issues for Retroperitoneal Sarcoma

Background

Retroperitoneal sarcoma is rare. Using initial specimens on biopsy, a definitive diagnosis of histological subtypes is ideal but not always achievable.

Methods

A retrospective institutional review was performed for all cases of adult retroperitoneal sarcoma from 1996 to 2015. A review of the literature was also performed related to the distribution of retroperitoneal sarcoma subtypes. A meta-analysis was performed.

Results

Liposarcoma is the most common subtype (45%), followed by leiomyosarcoma (21%), not otherwise specified (8%), and undifferentiated pleomorphic sarcoma (6%) by literature review. Data from Moffitt Cancer Center demonstrate the same general distribution for subtypes of retroperitoneal sarcoma. A pathology-based algorithm for the diagnosis of retroperitoneal sarcoma is illustrated, and common pitfalls in the pathology of retroperitoneal sarcoma are discussed.

Conclusions

An informative diagnosis of retroperitoneal sarcoma via specimens on biopsy is achievable and meaningful to guide effective therapy. A practical and multidisciplinary algorithm focused on the histopathology is helpful for the management of retroperitoneal sarcoma.

High-grade Primary Renal Leiomyosarcoma

Objectıve

To investigate the clinical characteristics, prognosis, survival and diagnosis of high-grade primary renal leiomyosarcoma.

Materıals and Methods

From January 2003 to April 2013, 10 cases of high-grade primary renal leiomyosarcoma were retrospectively reviewed. We analyzed clinical manifestations, treatment and prognosis of our group and correlated to the literature.

Results

Ten cases (five male and five female patients; age range 43–77 years, mean=57±std d:12.3 ) were enrolled. The mean diameter of the tumor masses was 9.35±4.5 cm (range 3-18 cm). 40% of the patients were asymptomatic while the major symptom of 60% patients was lumbar pain. Nephrectomy was performed in 90% of patients. Partial nephrectomy surgery was preferred for only one patient. Pleomorphism and necrosis with high-grade, pink spindle cell cytoplasm were viewed in all patients. All patients were high-grade, pink spindle cell cytoplasm and pleomorfism and necrosis were observed in all. In an immunohistochemical examination, vimentin was seen in 100%, desmin in 90% and smooth muscle actin in 80% of the patients. CD117 was negative in all patients. All of the cases were followed-up, and the time of survival varied from 6 to 68 months (mean 23.9±std d:20.1). No patient received adjuvant CTx and/or RTx.

Conclusıon

High-grade primary renal leiomyosarcomas (LMSs) are rare and highly malignant and the prognosis is poor. Early diagnosis and radical nephrectomy can prolong the patient’s life. Surgery is the main treatment modality for renal (leiomyosarcoma) LMS.

Prognostic factors in patients with recurrent or metastatic retroperitoneal leiomyosarcoma

AIMS

Factors that predict the prognosis of patients with recurrent or metastatic retroperitoneal leiomyosarcomas after treatment are uncertain.

MATERIALS & METHODS

Clinical and pathological data on 22 patients with retroperitoneal leiomyosarcomas who were treated by a multidisciplinary abdominal soft-tissue tumor group were analyzed retrospectively to identify prognostic factors for their progression-free survival (PFS).

RESULTS & CONCLUSION

The median PFS in the 22 patients was 9 months. Microvessel density in tumor tissues, which was evaluated via CD34 expression in 16 cases, and the presence of metastasis on admission were both found to be correlated with PFS in a Kaplan-Meier analysis, but not in a multivariate analysis. The multivariate analysis did, however, show that complete resection of tumors and the FNCLCC (Fédération Nationale des Centres de Lutte Contre Le Cancer) disease grade were independent factors predicting PFS.

Management of retroperitoneal liposarcoma: A case report and review of the literature

Retroperitoneal liposarcoma is a rare tumor with an incidence of 2.5 per million individuals. Early diagnosis is difficult as there is an absence of specific clinical presentations. The present case study reports a patient diagnosed with retroperitoneal liposarcoma who was treated by complete surgical resection and relapsed 3 months following the surgery. In addition, the clinical data of 14 patients with retroperitoneal liposarcoma were reviewed and analyzed. The mean age of the 14 patients at presentation was 54.1 (range, 36-73 years) and 5/14 patients experienced recurrence, ranging between 1 and 10 times. Of the 12 cases that reported histological subtypes, 7 were well-differentiated liposarcoma, 2 were dedifferentiated liposarcoma, 2 were myxoid liposarcoma and 1 was mixed subtype. All the patients underwent complete resection and 5 received combined multiple organs resection (3 nephrectomy, 1 sigmoid colon and 1 multiple visceral organs). However, no patients received chemotherapy or radiotherapy. In conclusion, retroperitoneal liposarcoma is a rare disease with a high rate of recurrence. Complete resection is the predominant treatment and combined resection of adjacent organs is occasionally necessary.

Effectiveness of regional hyperthermia with chemotherapy for high-risk retroperitoneal and abdominal soft-tissue sarcoma after complete surgical resection: a subgroup analysis of a randomized phase-III multicenter study

OBJECTIVE

To determine whether regional hyperthermia (RHT) in addition to chemotherapy improves local tumor control after macroscopically complete resection of abdominal or retroperitoneal high-risk sarcomas.

BACKGROUND

Within the prospectively randomized EORTC 62961 phase-III trial, RHT and systemic chemotherapy significantly improved local progression-free survival (LPFS) and disease-free survival (DFS) in patients with abdominal and extremity sarcomas. That trial included macroscopically complete and R2 resections.

METHODS

A subgroup analysis of the EORTC trial was performed and long-term survival determined. From 341 patients, 149 (median age 52 years, 18-69) were identified with macroscopic complete resection (R0, R1) of abdominal and retroperitoneal soft-tissue sarcomas (median diameter 10 cm, G2 48.3%, G3 51.7%). Seventy-six patients were treated with EIA (etoposide, ifosfamide, doxorubicin)+RHT (≥5 cycles: 69.7%) versus 73 patients receiving EIA alone (≥5 cycles: 52.1%, P=0.027). LPFS and DFS as well as overall survival were determined.

RESULTS

RHT and systemic chemotherapy significantly improved LPFS (56% vs 45% after 5 years, P=0.044) and DFS (34% vs 27% after 5 years, P=0.040). Overall survival was not significantly improved in the RHT group (57% vs 55% after 5 years, P=0.82). Perioperative morbidity and mortality were not significantly different between groups.

CONCLUSIONS

In patients with macroscopically complete tumor resection, RHT in addition to chemotherapy resulted in significantly improved local tumor control and DFS without increasing surgical complications. Within a multimodal therapeutic concept for abdominal and retroperitoneal high-risk sarcomas, RHT is a treatment option beside radical surgery and should be further evaluated in future trials.

[Operative therapy of abdominal and retroperitoneal sarcoma]

Retroperitoneal soft tissue sarcomas are characterized by a high rate of local recurrence. Complete tumor resection is the only potentially curative therapeutic option. The concept of a systematic compartmental resection is to remove the tumor en bloc with a margin of uninvolved tissue and organs. This is frequently only achieved by multivisceral resection which often includes kidney, colon, pancreas and parts of the diaphragm or the psoas muscle. The adoption of such a policy of multivisceral organ resection improves the proportion of curative resections and, ultimately, results in lower local recurrence rates. The present article comprehensively describes the operative procedures, perioperative treatment and the oncological results of surgery for retroperitoneal sarcomas. The role of surgery in oncological treatment plans and the importance of specialized centres are outlined in detail.

Hispanic mortality paradox: a systematic review and meta-analysis of the longitudinal literature

To investigate the possibility of a Hispanic mortality advantage, we conducted a systematic review and meta-analysis of the published longitudinal literature reporting Hispanic individuals' mortality from any cause compared with any other race/ethnicity. We searched MEDLINE, PubMed, EMBASE, HealthSTAR, and PsycINFO for published literature from January 1990 to July 2010. Across 58 studies (4 615 747 participants), Hispanic populations had a 17.5% lower risk of mortality compared with other racial groups (odds ratio = 0.825; P < .001; 95% confidence interval = 0.75, 0.91). The difference in mortality risk was greater among older populations and varied by preexisting health conditions, with effects apparent for initially healthy samples and those with cardiovascular diseases. The results also differed by racial group: Hispanics had lower overall risk of mortality than did non-Hispanic Whites and non-Hispanic Blacks, but overall higher risk of mortality than did Asian Americans. These findings provided strong evidence of a Hispanic mortality advantage, with implications for conceptualizing and addressing racial/ethnic health disparities.

Prognostic factors and survival in pediatric and adolescent liposarcoma

Purpose. Liposarcoma is extremely rare in the pediatric population. To identify prognostic factors and determine treatment outcomes, we reviewed our institutional experience with pediatric liposarcoma. Methods. We retrospectively reviewed all pediatric patients (age <22 years) with confirmed liposarcoma treated at Memorial Sloan-Kettering Cancer Center. Histologic subtype, tumor location, margin status, recurrence, and adjuvant therapy were analyzed and correlated with overall survival. Results. Thirty-four patients (56% male) with a median age of 18.1 years were identified. Twenty-two (65%) had peripheral tumors and 12 (35%) had centrally located tumors. Histologically, 29 (85%) tumors were low grade, and 5 (15%) were high grade pleomorphic. Eleven (32%) had recurrent disease, 9 patients with central tumors and 2 patients with peripheral lesions. Eight deaths occurred, all in patients with central disease. Five-year overall survival was 78%, with a median follow-up time of 5.4 years (range, 0.3–30.3 years). Tumor grade (P = .003), histologic subtype (P = .01), and primary location (P < .001) all correlated with survival, as did stage (P < .001) and margin status (P = .001). Conclusions. Central location of the primary tumor, high tumor grade, and positive surgical margins are strongly correlated with poor survival in pediatric patients with liposarcoma.

Prognostic factors and clinical outcomes of urological soft tissue sarcomas

Purpose

The purpose of this study was to elucidate prognostic factors for survival and clinical outcomes of rological soft tissue sarcomas (STSs).

Materials and Methods

This was a retrospective review of the medical records of 48 patients with urological STS treated from January 1982 to July 2009. Demographic and pathological characteristics were compared. Patients' demographics, clinico-pathological parameters, overall survival, and the factors expected to predict survival, such as sex, age at diagnosis, primary organ, surgical resection, metastasis, and mass size, were analyzed. We evaluated differences in survival on the basis of histological subtype by Kaplan-Meier analysis and multivariate Cox proportional hazards regression.

Results

The study included 34 males (70.8%) and 14 females (29.1%). The mean age at diagnosis was 47.1 years (range, 3 to 80). The most common site was the retroperitoneum (n=16), followed by the kidney (n=12), prostate (n=10), bladder (n=7), ureter (n=1), and paratesticular region (n=1). Nineteen patients (39.5%) had other organ metastases at diagnosis. The most common subtypes of sarcoma were leiomyosarcoma (50%), rhabdomyosarcoma (18.7%), and liposarcoma (8%). The remaining 11 cases had other histological subtypes (22.9%). Mean tumor size was 9.5 cm (range, 2.2 to 24). Thirty-three patients (68.7%) underwent surgical resection. The overall survival rate at 5 years was 51.4%. In the univariate and multivariate analysis, surgical resection, primary tumor site, and metastasis at diagnosis remained significant predictors of prognosis. Patients with retroperitoneal sarcoma had a higher overall survival rate by 5 years compared with patients with other organ sarcoma.

Conclusions

The overall survival rate at 5 years was 51.4%. Surgical resection, primary tumor site, and metastasis at diagnosis remained significant predictors of prognosis.

Giant Retroperitoneal Mucinous Tumor Supportively Diagnosed as a Dedifferentiated Liposarcoma by Fluorescence In Situ Hybridization of MDM2 Gene

Surgical resection was performed on a 47-year-old woman for a retroperitoneal mass that weighed 8.5 kg. Histological examination revealed a myxoid sarcomatous tumor. Because diagnosis could not be determined by immunohistochemistry, attention was focused on MDM2 (murine double minute) gene amplification by fluorescence in situ hybridization (FISH) analysis. The tumor was finally determined to be a dedifferentiated liposarcoma. We experienced a case of a giant retroperitoneal dedifferentiated liposarcoma. FISH analysis was useful for the diagnosis and determination of the therapeutic strategy.

Rhabdomyosarcoma in children: a SEER population based study

OBJECTIVE

To examine incidence and outcomes for pediatric rhabdomyosarcoma (RMS).

METHODS

The SEER registry was examined for patients with RMS < 20 y old.

RESULTS

Overall, 1544 patients were identified for an incidence of 0.4414/100,000 per year. Males outnumbered females 3:2. Tumors were classified as embryonal (67%), alveolar (32%), and pleomorphic (1%). Alveolar and pleomorphic RMS were more common in adolescents, whereas embryonal type was more common in younger children (P = 0.0001). Pleomorphic (47%) and alveolar (39%) RMS commonly presented with distant disease, in contrast to embryonal (25%). Most patients had surgical resection (81%) and radiotherapy (63%). Overall, 5- and 10-y survival was 60% and 57%, respectively. Univariate analysis identified higher survival for age < 10 y, local stage, favorable site, embryonal type, <5 cm tumor size, and surgical resection. Multivariate analysis identified non-embryonal type (HR 1.451), non-favorable site (HR 1.570), no surgery (HR 1.726), age ≥ 10 y (HR 1.734), 1973-1978 diagnosis year (HR 1.730), and distant disease (HR 3.456) as independent predictors of mortality.

CONCLUSIONS

Embryonal histology, the most common type of pediatric RMS, presents in young children and has better prognosis than alveolar or pleomorphic types. Patients with embryonal tumors, favorable tumor location, age < 10 y, localized disease, and surgical resection have improved survival.

Retroperitoneal leiomyosarcoma presenting as lower gastrointestinal bleeding: a case report and review of the literature

We report the first known case of a retroperitoneal leiomyosarcoma that presented with an endoscopically defined source of gastrointestinal bleeding in the colon. A 68-year-old male with a history of diverticulosis, hypertension, and hypercholesterolemia who complained of a 3-month history of abdominal pain, nausea, and intermittent hematochezia presented for evaluation of large volume hematochezia and lightheadedness. Colonoscopy revealed left-sided diverticulosis and rectal varices without stigmata of recent bleed. CT scan showed a 26 × 20 × 13 cm heterogeneous retroperitoneal mass and multiple hypodense hepatic lesions. Liver biopsy revealed leiomyosarcoma. In summary, although surgery is the mainstay of treatment, resectability has not improved significantly. Early recognition and aggressive surgery are keys to long-term survival.

Surgery for retroperitoneal soft tissue sarcomas: aggressive re-resection of recurrent disease is possible

INTRODUCTION

Retroperitoneal soft tissue sarcomas represent a relatively rare and complex therapeutic problem where surgery forms the mainstay of treatment and is technically demanding. In this study, we review a single UK centre's experience with the surgical management of retro-peritoneal soft tissue sarcoma.

PATIENTS AND METHODS

We present analysis of data on patients treated between 1997 and 2006, our first 75 patients. Data collected from the Access database, included patient demographics, staging modalities, peri-operative details, treatment, outcome, pathological diagnosis and subsequent complications.

RESULTS

A total of 75 patients (M:F, 44:31) underwent 115 resectional procedures as part of the management of retroperitoneal soft-tissue sarcoma. There were 12 major complications for the 115 procedures (morbidity of 8.69%). The 30-day operative mortality was zero and the 90-day mortality rate was 1.33% (1/75). Follow-up ranged from 16-131 months. The median disease-free survival was 69 months (range, 59-78 months). Recurrences developed in 46 patients; median time to overall recurrence was 13 months (range, 3-71 months). Of these 46, 22 developed localised recurrence, which was amenable to further resection. In the cohort of patients with recurrent disease, median survival in those who underwent surgery was 53 months (range, 30-76 months) and median survival in those who did not undergo surgery was 30 months (range, 18-41 months) and this difference was statistically significant (log rank, P = 0.01).

CONCLUSIONS

Extensive resectional surgery with minimal morbidity, devoid of mortality is feasible in the treatment of retroperitoneal sarcoma. Development of recurrent disease is a significant factor influencing survival; however, localised recurrences are amenable to surgery and this can lead to improved survival.

Retroperitoneal giant liposarcoma

Retroperitoneal liposarcoma is an infrequent, locally aggressive malignancy. We report two cases of huge retroperitoneal liposarcomas. The presence of a palpable abdominal mass was a common symptom of the two patients. Preoperative imaging study showed huge retroperitoneal tumors. Both patients underwent complete surgical resections, and a negative microscopic margin was achieved in both cases. The histopathologic diagnosis was a well-differentiated retroperitoneal liposarcoma. Neither of the two patients developed a recurring tumor during the 1.5 years of follow-up.

Retroperitoneal soft tissue sarcomas: experience at a single institution in Mexico

BACKGROUND

Retroperitoneal soft tissue sarcomas (RSTS) are a rare and uncommon entity with a poor 5-year overall survival (OS) of approximately 50%, even though they rarely metastasize. The aim of the present study was to analyze the survival of patients with RSTS treated at our institution.

PATIENTS AND METHODS

Patients with RSTS treated between 1990 and 2008 were included. Variables analyzed were age, sex, histological type, TNM stage, tumor size, grade of differentiation, and treatment (surgery, chemotherapy only, radiotherapy only, adjuvant radiotherapy, and best supportive care). R0, R1, and R2 resection were analyzed. Overall survival, recurrence-free survival (RFS), cancer-specific survival (CSS), and survival comparison by stage, grade, and type of resection were analyzed.

RESULTS

Data for 46 patients were analyzed, 20 men and 26 women. Median age was 51.1 years. Surgery with a curative intent was performed in 32 patients, and R0 resection was feasible in 19 (59.4%). The 5- and 10-year OS rates were 47 and 30%, respectively, for the entire group. The median CSS for resected patients was 102 months; the 5-year OS for stages I, III, and IV was 83, 37, and 0%, respectively; the 5-year OS for low histological grade disease and high histological grade disease was 82 and 35%, respectively; and for R0, R1, and R2 resection, the 5-year OS was 81, 56, and 14%, respectively. Median RFS was 79 months.

CONCLUSIONS

Incomplete surgical resection, unresectable disease, high histological grade, and advanced TNM stage are associated with a poor survival in patients with RSTS. Complete resection is still the treatment of choice.

Predictors of survival after resection of retroperitoneal sarcoma: a population-based analysis and critical appraisal of the AJCC staging system

OBJECTIVE

To identify predictors of survival after resection of retroperitoneal sarcoma (RPS) and to evaluate the performance of the American Joint Committee on Cancer (AJCC) staging system for RPS.

SUMMARY BACKGROUND DATA

Previous studies of survival after RPS resection are restricted to at most several institutions, yet the current AJCC staging system for RPS is based entirely on these relatively small studies.

METHODS

Patients undergoing resection of primary RPS from 1988 to 2005 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Cox proportional hazards models were used to analyze survival and evaluate AJCC staging.

RESULTS

In 1365 patient undergoing resection of primary RPS, the most prevalent histologies were liposarcoma (50%), leiomyosarcoma (26%), and malignant fibrous histiocytoma (11%). Median, 5-year, and 10-year survival after resection were 55 months, 47%, and 27%. Histological subtype (P < 0.001), histological grade (grade 3-4 vs. grade 1; HR, 2.42; P < 0.001), and tumor invasion of adjacent structures (HR, 1.37; P < 0.001) were associated with survival on multivariable analysis. However, tumor size had no prognostic value. Consequently, the AJCC T classification system demonstrated poor discriminatory ability (c = 0.50). The AJCC stage grouping system demonstrated moderate discriminatory ability (c = 0.66) but performed no better than a much simpler system that omits information on tumor size and lymph node metastasis (c = 0.67).

CONCLUSIONS

Indicators of tumor aggressiveness (histological grade and invasion of adjacent structures) as well as histological subtype predict survival after RPS resection. Tumor size, however, does not impact survival. The AJCC staging system for RPS is in need of revision.

Primary orbital liposarcoma

PURPOSE

To describe 6 new cases of primary orbital liposarcoma and provide a review of the relevant literature.

DESIGN

Noncomparative consecutive case series and literature review.

PARTICIPANTS

Six patients with primary orbital liposarcoma.

METHODS

Review of patient charts, imaging, and histopathology; literature review.

MAIN OUTCOME MEASURES

Patient demographics; clinical presentations; results of radiologic imaging; histopathology; surgical techniques used and their complications; other treatment modalities; outcomes and recurrences.

RESULTS

Six cases of primary orbital liposarcoma were identified, 5 of which were primary presentations and 1 of which was a recurrence. In 4 cases, exenteration was deferred, resulting in recurrence of disease in all 4. All cases were exenterated, and 2 cases had local recurrence despite exenteration. Two cases were associated with the Li-Fraumeni syndrome and other malignancies. Literature review identified 34 other cases of primary orbital liposarcoma, which, partly because of its rarity, is frequently initially misdiagnosed. The most common subtype is myxoid (56.8%); other types are pleomorphic (10.8%) and well differentiated (29.7%). Well-differentiated tumors have the best prognosis. Non-exenterating surgery was associated with recurrence, although recurrence post-exenteration also occurred. Although radiotherapy has an established role in the treatment of nonorbital liposarcoma, the role of both radiotherapy and chemotherapy in the management of primary orbital liposarcoma is still unclear.

CONCLUSIONS

Orbital liposarcoma remains a diagnostic and surgical challenge. Exenteration remains the treatment of choice, but clinicians must also be aware that liposarcoma may herald the diagnosis of the Li-Fraumeni familial cancer syndrome.

Metastatic gastrointestinal stromal tumors in the era of imatinib: improved survival and elimination of socioeconomic survival disparities

BACKGROUND

Imatinib was approved in 2002 for unresectable and metastatic gastrointestinal stromal tumors. Our objective was to determine if the introduction of imatinib coincided with improved survival from metastatic gastrointestinal stromal tumor in the U.S. population and in specific socioeconomic groups.

METHODS

Query of the Surveillance, Epidemiology, and End Results registry identified 552 patients with metastatic gastrointestinal stromal tumor between 1995 and 2004. Year of diagnosis was categorized into two periods, 1995 to 2000 and 2001 to 2004, to account for the effect of imatinib. Kaplan-Meier and multivariate Cox regression analyses were used to examine differences in survival between periods and among socioeconomic groups.

RESULTS

Median survival increased from 12 to 33 months from 1995 to 2000 to 2001 to 2004 (P < 0.001); survival at 47 months increased from 21% to 41%, respectively (P < 0.001). Median survival times for White, Black, Hispanic, and Asian or Pacific Islander, and for low-, middle-, and high-income groups increased significantly in the era of imatinib (all P < 0.05). On multivariate analysis, Black race [hazard ratio, 1.96; 95% confidence interval (95% CI), 1.15-3.32; P = 0.013], Hispanic race (hazard ratio, 2.11; 95% CI, 1.14-3.88; P = 0.017), and low income (hazard ratio, 1.81; 95% CI, 1.13-2.89; P = 0.014) were associated with the poorest survival during the 1995 to 2000 period. During 2001 to 2004, these disparities in survival were no longer statistically apparent.

CONCLUSIONS

Survival from metastatic gastrointestinal stromal tumor has improved significantly in the era of imatinib. This improvement has been uniform across all socioeconomic groups, with concomitant elimination of socioeconomic survival disparities potentially due to an assistance program intended to provide universal access to imatinib therapy.

Retroperitoneal Mixed-Type Liposarcoma Showing Features of Four Different Subtypes

Mixed-type liposarcoma is a rare soft tissue tumor. This report describes a 50-year-old man with retroperitoneal mixed-type liposarcoma that consisted of four pathologically different components. Preoperative CT and MRI showed a giant retroperitoneal mass composed of several nodules with various attenuation and signal intensity. At laparotomy, the tumor appeared to be composed of four components. Pathologic examination revealed that each component was of a histologically different subtype. Mixed-type liposarcoma containing four different subtypes is extremely rare. Its clinical and pathologic features are briefly reviewed.

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.

Outcomes for Soft-Tissue Sarcoma in 8249 Cases from a Large State Cancer Registry

BACKGROUND AND OBJECTIVES

To date, outcome reports for soft-tissue sarcoma (STS) have largely been limited to single or paired institutional series. To more accurately elucidate population-based outcomes and prognostic factors associated with STS, a large cancer registry was examined.

METHODS

STS arising in the Florida Cancer Data System were examined (1981-2004).

RESULTS

A total of 8249 patients were identified, the calculated annual incidence of sarcoma being approximately 38 cases per million in 2003. The tumor histologies among these patients were leiomyosarcoma and gastrointestinal stromal tumor (LMS/GIST) (43.5%), malignant fibrous histiocytoma (MFH) (31.5%), liposarcoma (19.0%), and fibrosarcoma (6.0%). Tumors were situated in the extremities (30.7%), truncal or visceral locations (50.4%), retroperitoneum (11.7%), and head or neck (7.2%). Thirty-three percent of lesions were over 10 cm in greatest dimension, while 50.2% were classified as high grade. Median overall survival was 25 months. Superior survival was observed for liposarcomas and fibrosarcomas as compared to MFH and LMS/GIST (P < 0.001). Retroperitoneal and truncal sarcomas had a more ominous prognosis than did other sites (P < 0.001). Multivariate analysis of pretreatment variables demonstrated that increasing age, male gender, non-Caucasian race, advanced stage, and a truncal or retroperitoneal location were each independently associated with lower survival. Histological subtype was also an independent predictor of outcome. Surgical resection and radiation therapy were the only treatment variables shown to improve survival.

CONCLUSIONS

Histological subtype, tumor site, and stage are independent prognostic factors in STS. Surgical resection and radiotherapy are unique among treatment modalities in association with a significant survival benefit.