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

Survival and prognostic factors of primary retroperitoneal sarcomas after surgery: a single-center experience

PURPOSE

The percentage of retroperitoneal sarcomas (RPS) among all soft tissue sarcomas ranges from 10 to 15%. Surgery remains the gold standard for RPS. In this study, we analyzed the impact of surgical treatment for primary RPS on recurrence and overall mortality at a Chinese institution and identified and evaluated prognostic variables.

METHODS

Data from patients with RPS who underwent surgical treatment were retrospectively analyzed. The patients were treated at a single center from January 2000 to June 2018. Retrospectively collected demographic, clinicopathological, and surgical factors were examined. Overall survival (OS) and disease-free survival (DSF) were used as the primary endpoints. Predicted 5-year survival rates, encompassing both DFS and OS, were derived from the Sarculator prognostic nomogram.

RESULTS

A total of 110 patients met the inclusion criteria. The median follow-up time after surgery for patients with primary RPS was 5.3 years. During this period, 59 patients died. The 5-year OS and DFS estimates were 63.5% and 35.3%, respectively. In a multivariate analysis, poor OS following surgical treatment of primary RPS was independently correlated with FNCLCC grade (p < 0.001) and surgical margin status (p = 0.016). FNCLCC grade (p = 0.001) and surgical margin status (p = 0.002) were also independently associated with poor DFS. The C-indices for 5-year OS and DFS survival utilizing the Sarculator prognostic nomogram were 0.71 and 0.73 respectively.

CONCLUSION

The overall mortality rate of patients with RPS was considered acceptable. OS and DFS prognostic markers were established for primary RPS. Tumor grade and intraregional margins are other factors that affect survival and recurrence.

Advancements in Diagnosis and Multimodal Treatment Strategies for Retroperitoneal Tumors: A Comprehensive Review

Retroperitoneal tumors (RPTs) encompass both benign and malignant entities, constituting ~0.1% to 0.2% of all malignant tumors, of which 70% to 80% manifest malignancy. Predominantly, retroperitoneal sarcomas (RPS) represent the most prevalent subtype among RPT. With over 70 histologic forms identified, liposarcomas and leiomyosarcomas emerge as the primary constituents of RPS. Accurate diagnosis of RPTs necessitates preoperative core-needle biopsy and comprehensive imaging assessment. The current staging protocol for RPS relies on the eighth edition of the American Joint Committee on Cancer/TNM classification. Surgical excision remains the established gold standard for treating RPS. Therapeutic approaches vary according to the underlying pathophysiology. Although chemotherapy and radiotherapy exhibit efficacy in managing metastatic and recurrent unresectable RPS, their role in primary RPS remains unresolved, necessitating further clinical trials for validation. Concurrently, ongoing research explores the potential of targeted therapies and immunotherapy. This literature review aims to provide a comprehensive overview of existing research, delineating diagnostic pathways and optimal therapeutic strategies for RPT.

Radiation therapy for retroperitoneal sarcoma: practice patterns in North America

BACKGROUND

The addition of radiation therapy (RT) to surgery in retroperitoneal sarcoma (RPS) remains controversial. We examined practice patterns in the use of RT for patients with RPS over time in a large, national cohort.

METHODS

Patients in the National Cancer Database (2004-2017) who underwent resection of RPS were included. Trends over time for proportions were calculated using contingency tables with Cochran-Armitage Trend test.

RESULTS

Of 7,485 patients who underwent resection, 1,821 (24.3%) received RT (adjuvant: 59.9%, neoadjuvant: 40.1%). The use of RT decreased annually by < 1% (p = 0.0178). There was an average annual increase of neoadjuvant RT by 13% compared to an average annual decrease of adjuvant RT by 6% (p < 0.0001). Treatment at high-volume centers (OR 14.795, p < 0.0001) and tumor > 10 cm (OR 2.009, p = 0.001) were associated with neoadjuvant RT. In contrast liposarcomas (OR 0.574, p = 0.001) were associated with adjuvant RT. There was no statistically significant difference in overall survival between patients treated with surgery alone versus surgery and RT (p = 0.07).

CONCLUSION

In the United States, the use of RT for RPS has decreased over time, with a shift towards neoadjuvant RT. However, a large percentage of patients are still receiving adjuvant RT and this mostly occurs at low-volume hospitals.

Retroperitoneal Soft Tissue Sarcoma: Emerging Therapeutic Strategies

Retroperitoneal soft tissue sarcoma (RPS) is a rare and heterogenous disease for which surgery is the cornerstone of treatment. However, the local recurrence rate is much higher than in soft tissue sarcoma of the extremities since wide resection is usually unfeasible in RPS due to its large size, indistinct tumour borders, anatomical constraints and the thinness of the overlying peritoneum. Local recurrence is the leading cause of death for low-grade RPS, whereas high-grade tumours are prone to distant metastases. In recent decades, the role of emerging therapeutic strategies, such as more extended surgery and (neo)adjuvant treatments to improve oncological outcome in primary localised RPS, has been extensively investigated. In this review, the recent data on the evolving multidisciplinary management of primary localised RPS are comprehensively discussed. The heterogeneity of RPS, with their different histological subtypes and biological behaviour, renders a standard therapeutic 'one-size-fits-all' approach inappropriate, and treatment should be modified according to histological type and malignancy grade. There is sufficient evidence that frontline extended surgery with compartmental resection including all ipsilateral retroperitoneal fat and liberal en bloc resection of adjacent organs and structures, even if they are not macroscopically involved, increases local tumour control in low-grade sarcoma and liposarcoma, but not in leiomyosarcoma for which complete macroscopic resection seems sufficient. Additionally, preoperative radiotherapy is not indicated for all RPSs, but seems to be beneficial in well-differentiated liposarcoma and grade I/II dedifferentiated liposarcoma, and probably in solitary fibrous tumour. Whether neoadjuvant chemotherapy is of benefit in high-grade RPS remains unclear from retrospective data and is subject of the ongoing randomised STRASS 2 trial, from which the results are eagerly awaited. Personalised, histology-tailored multimodality treatment is promising and will likely further evolve as our understanding of the molecular and genetic characteristics within RPS improves.

Multivisceral resection for retroperitoneal liposarcoma-is it worth it? A 20-year single-center experience

PURPOSE

Soft tissue sarcomas are rare malignant tumors. Liposarcoma constitutes the most frequent histological subtype of retroperitoneal sarcoma. The prognosis of soft tissue sarcomas depends on clinical and histologic characteristics.

OBJECTIVE

Evaluate variables that may be related to the overall and local recurrence-free survival in patients with retroperitoneal liposarcoma and discuss the need for visceral resection en-bloc for tumors.

METHODS

A retrospective analysis was conducted of the medical records of 60 patients seen between 1997 and 2017 who underwent surgical resection of retroperitoneal liposarcoma.

RESULTS

The overall survival rate at 5 years of follow-up was 75.22% (95% confidence interval [CI] 0.58-0.86). The probability of a local recurrence-free survival at 5 years of follow-up was 26.04% (95% CI 0.11-0.44). The multivariate analysis showed that dedifferentiated or pleomorphic tumors and R2/fragmented resection were associated with a shorter time to recurrence. No other characteristics markedly influenced the overall survival (P > 0.05).

CONCLUSION

Patients with dedifferentiated or pleomorphic tumors and incomplete resection were associated with higher local recurrence rates than others. This study reinforces the need for complete and en-bloc resection with organs when there is clear involvement or technical surgical difficulty to maintain the tumor integrity.

Nomogram predicting overall survival after surgical resection for retroperitoneal leiomyosarcoma patients

Background

Surgery is the best way to cure the retroperitoneal leiomyosarcoma (RLMS), and there is currently no prediction model on RLMS after surgical resection. The objective of this study was to develop a nomogram to predict the overall survival (OS) of patients with RLMS after surgical resection.

Methods

Patients who underwent surgical resection from September 2010 to December 2020 were included. The nomogram was constructed based on the COX regression model, and the discrimination was assessed using the concordance index. The predicted OS and actual OS were evaluated with the assistance of calibration plots.

Results

118 patients were included. The median OS for all patients was 47.8 (95% confidence interval (CI), 35.9-59.7) months. Most tumor were completely resected (n=106, 89.8%). The proportions of French National Federation of Comprehensive Cancer Centres (FNCLCC) classification were equal as grade 1, grade 2, and grade 3 (31.4%, 30.5%, and 38.1%, respectively). The tumor diameter of 73.7% (n=85) patients was greater than 5 cm, the lesions of 23.7% (n=28) were multifocal, and 55.1% (n=65) patients had more than one organ resected. The OS nomogram was constructed based on the number of resected organs, tumor diameter, FNCLCC grade, and multifocal lesions. The concordance index of the nomogram was 0.779 (95% CI, 0.659-0.898), the predicted OS and actual OS were in good fitness in calibration curves.

Conclusion

The nomogram prediction model established in this study is helpful for postoperative consultation and the selection of patients for clinical trial enrollment.

Effect of pre-operative radiation therapy on surgical outcome in retroperitoneal sarcoma

Background

A high rate of locoregional recurrence is one of the major difficulties in successful treatment of retroperitoneal sarcoma (RPS). Although pre-operative radiation therapy (RT) is considered a potential way to improve local recurrence, concerns about the associated treatment toxicity and risk of peri-operative complications need to be addressed. Hence, this study investigates the safety of pre-operative RT (preRTx) for RPS.

Methods

A cohort of 198 patients with RPS who had undergone both surgery and RT was analyzed for peri-operative complications. They were divided into three groups according to the RT scheme: (1) preRTx group, (2) post-operative RT without tissue expander, and (3) post-operative RT with tissue expander.

Results

The preRTx was overall well tolerated and did not affect the R2 resection rate, operative time, and severe post-operative complications. However, the preRTx group was associated with higher incidence of post-operative transfusion and admission to intensive care unit (p = 0.013 and p = 0.036, respectively), where preRTx was an independent risk factor only for the post-operative transfusion (p = 0.009) in multivariate analysis. The median radiation dose was the highest in preRTx group, although no significant difference was demonstrated in overall survival and local recurrence rate.

Conclusion

This study suggests that the preRTx does not add significant post-operative morbidity to the patients with RPS. In addition, radiation dose elevation is achievable with the pre-operative RT. However, a meticulous intra-operative bleeding control is recommended in those patients, and further high-quality trials are warranted to evaluate the long-term oncological outcomes.

The Role of Surgery in Oligometastatic Retroperitoneal Sarcoma

Retroperitoneal sarcomas are extremely rare, comprising <15% of primary sarcomas. Distant metastasis occurs in about 20% of cases, with pulmonary and hepatic metastasis as the most common sites of hematogenous spread. Although surgical resection is well established as the main treatment of localized primary disease, there are limited guidelines for the surgical treatment of intra-abdominal and distant metastases. There are inadequate systemic treatment options for patients with metastatic sarcoma, thereby necessitating the consideration of surgical options in carefully selected patients. Key points to consider include tumor biology, patient fitness and co-morbidities, overall prognosis, and goals of care. Multidisciplinary sarcoma tumor board discussion for each case is an essential practice in order to deliver the best care to these patients. The purpose of this review is to summarize the published literature on the past and present role of surgery in the treatment of oligometastatic retroperitoneal sarcoma in order to inform the management of this difficult disease.

Prognostic factors in patients receiving surgery and radiation therapy for retroperitoneal sarcoma: A machine-learning analysis

BACKGROUND

The addition of radiation therapy to surgery for retroperitoneal sarcoma remains controversial. Improved patient selection may help identify optimal candidates for multimodality treatment. The aim of this analysis was to define prognostic factors among patients who receive radiation therapy and surgery to aid in patient selection for multimodal therapy.

METHODS

Patients who received radiation therapy and underwent curative-intent resection for retroperitoneal sarcoma between 2004 and 2016 were identified from a national cohort in the United States (National Cancer Database). A machine-based classification and regression tree model was used to generate similar groups of patients relative to overall survival based on preoperative factors.

RESULTS

A total of 1,443 patients received radiation therapy in addition to surgery. Median age was 61 years old and 55.0% were female. Most patients (66%) received care at an academic or integrated network cancer program. With a median follow-up of 84 months, receipt of radiation therapy was not associated with improved overall survival (P = .81). Classification and regression tree analysis revealed a significant association between overall survival and American Joint Committee on Cancer stage group, age, tumor histology, and Charlson comorbidity score. Application of these parameters via machine learning stratified patients into 5 cohorts with distinct survival outcomes. In the most favorable cohort (Cohort 1: American Joint Committee on Cancer stage group ≤II, age ≤61, histology including fibrosarcoma, well differentiated liposarcoma, myxoid liposarcoma, and leiomyosarcoma), the 5-year overall survival was 81.7% and median overall survival was not reached; in the least favorable cohort (Cohort 6: American Joint Committee on Cancer stage group >II, age >68) where the 5-year survival was 41.3% and median overall survival was 45.2 months (P < .001 versus Cohort 1).

CONCLUSION

In the absence of a defined survival benefit, patients with advanced American Joint Committee on Cancer stage group, older age, and medical comorbidities have relatively unfavorable overall survival after combined modality therapy and therefore stand the least to gain from the addition of radiation therapy to surgery. In contrast, younger patients with good performance status and retroperitoneal sarcoma histologies with a higher propensity for local recurrence may have the greatest opportunity to benefit from radiation therapy.

Superficial soft tissue sarcomas: 10‑year survival outcomes

Cutaneous sarcomas comprise a broad group of rare, heterogeneous mesenchymal tumours. The present report describes a single centre experience regarding the management and the outcomes of patients with superficial soft tissue sarcomas (SSTS). Key prognostic factors in predicting overall survival (OS) and local relapse-free survival were determined. Data from 66 patients with SSTS treated surgically within Edinburgh and Lothian were collected in the context of a service evaluation. Patient demographics, tumour specifics and treatment, as well as 5-year OS and local recurrence, were analysed. Kaplan-Meier analysis was applied for survival curves, and mortality rate estimation and Cox regression were used to establish independent predictors. The mean estimated OS time was 57.2 months, with a 95% CI between 55.0 and 59.5 months. The median OS time could not be estimated because there is no time point during which the survival function has a value <50%. The death risk for a person with SSTS was increased by 7.3% (odds ratio, 1.073; 95% CI, 1.012-1.138) for every additional year of life. The estimated mean local relapse time was 58.5 months, with a 95% CI between 56 and 61 months. The median local relapse time could not be estimated since there is no time point during which the local recurrence function has a value <50%. In conclusion, out of all independent variables considered, none could statistically significantly explicate local relapse recurrence time. It is important that these rare tumours are treated in the context of a multidisciplinary team with consensus guidelines to assist decision-making.

Morbidity and Mortality after Surgery for Retroperitoneal Sarcoma

Retroperitoneal sarcoma (RPS) is a rare disease with over 100 histologic types and accounts for 10-15% of all soft tissue sarcomas. Due to the rarity of RPS, sarcoma centers in Europe and North America have created the Transatlantic RPS Working Group (TARPSWG) to study this disease and establish best practices for its management. Current guidelines dictate complete resection of all macro and microscopic disease as the gold standard for patients with RPS. Complete extirpation often requires a multi-visceral resection. In addition, recent evidence suggests that en bloc compartmental resections are associated with reduced rates of local recurrence. However, this approach must be balanced by the potential for added morbidity. Strategies to mitigate postoperative complications include optimization of the patient through improved preoperative nutrition and pre-habilitation therapy, referral to a high-volume sarcoma center, and implementation of enhanced recovery protocols. This review will focus on the factors associated with perioperative complications following surgery for RPS and outline approaches to mitigate poor surgical outcomes in this patient population.

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.

Retroperitoneal Sarcomas: a Current Review on Management

Retroperitoneal sarcomas are heterogeneous tumours with variable disease biology and outcomes. The prognosis is primarily related to tumour histology and grade as well as the ability to achieve margin negative resection. Surgery involves compartment or contiguous organ resection to achieve the above goal. Careful utilization of neoadjuvant and adjuvant strategies like radiotherapy and/or chemotherapy can lead to improvement in margin status, thereby contributing to better local control and possibly reducing systemic dissemination. Use of targeted therapies has paved newer pathways of treatment integration centred on molecular and genetic targets. The aim of this review is to update the reader on all aspects of retroperitoneal sarcoma management including emphasis on pertinent and landmark trials in this regard.

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.

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.

Role of Radiation Therapy in Retroperitoneal Sarcoma

Retroperitoneal sarcoma comprises a small subset of all soft tissue sarcoma and includes various histopathologic subtypes, each with unique patterns of behavior and differential risks for local recurrence and hematogenous metastatic spread. The primary treatment modality is surgery, although even with complete macroscopic resection, recurrence is common. The rationale for the addition of radiotherapy to resection is to improve local control; however, the use of radiation therapy for retroperitoneal sarcoma is controversial, and existing data are suboptimal to guide management. Treatment decisions should be determined with multidisciplinary input and shared decision-making. When used in selected patients, radiation therapy should be delivered preoperatively; postoperative treatment is not recommended.

Factors associated with disease-free and abdominal recurrence-free survival in abdominopelvic and retroperitoneal sarcomas

Background and Objectives

Retroperitoneal and abdominopelvic sarcomas are rare heterogeneous malignancies. The only therapy proven to improve disease‐free survival (DFS) is R0/R1 surgical resection. We sought to analyze whether additional factors such as radiation and systemic therapy were associated with DFS and abdominal recurrence‐free survival (RFS).

Methods

Retrospective review of adults (≥18) with resectable abdominopelvic and retroperitoneal sarcomas who underwent intent‐to‐cure surgery at a high‐volume tertiary referral center between 1998 and 2015. The main outcome measures were DFS and abdominal RFS.

Results

Overall, 159 patients met the criteria for inclusion. Median follow‐up was 4.8 years (range 0.1–18.9 years). The most common histology was liposarcoma (49%). Systemic therapy was administered to 48% of patients and was not associated with improved outcomes. The neoadjuvant radiotherapy group (11%) had improved adjusted DFS (5.46 years, 95% CI [3.68, 7.24] vs. 3.1 years, 95% CI [2.48, 3.73]) and abdominal RFS (6.14 years, 95% CI [4.38, 7.89] vs. 3.22 years, 95% CI [2.61, 3.84]). The adjuvant radiotherapy group (19%) had no improvement.

Conclusions

In a cohort of patients undergoing resection for retroperitoneal or abdominopelvic sarcoma, neoadjuvant radiation improved DFS and abdominal RFS. A follow‐up of over three years was needed to appreciate a difference in outcomes.

Radiation Therapy for Treatment of Soft Tissue Sarcoma in Adults: Executive Summary of an ASTRO Clinical Practice Guideline

PURPOSE

This guideline provides evidence-based recommendations addressing the indications for radiation therapy (RT), sequencing of local therapies, and appropriate dose and planning techniques for management of primary, operable, localized, soft tissue sarcoma (STS) in adults.

METHODS

The American Society for Radiation Oncology convened a task force to address 5 key questions focused on the use of RT for management of STS. These questions included indications for RT for STS of the extremity and superficial trunk; considerations for sequencing of RT with respect to surgery, dose of RT, appropriate treatment volumes and techniques; and the role of RT in management of retroperitoneal sarcoma. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength.

RESULTS

Multidisciplinary evaluation and decision making are recommended for all cases of STS. RT is recommended for patients in whom there is increased risk of local recurrence of resected STS, particularly if close or microscopically positive margins are anticipated or have occurred. When RT is indicated, preoperative RT is strongly recommended over postoperative RT. Postoperative RT is conditionally recommended in specific clinical circumstances (eg, uncontrolled pain or bleeding) or when the risk of wound complications outweighs that of late toxicity from RT. Routine use of RT in addition to oncologic resection for retroperitoneal sarcoma is conditionally not recommended. When RT is used for retroperitoneal sarcoma, preoperative RT is recommended, whereas postoperative RT is not recommended.

CONCLUSIONS

Based on currently published data, the American Society for Radiation Oncology task force has proposed evidence-based recommendations regarding the use of RT for STS in adults. Future studies will ascertain whether alterations in dosing and sequencing may optimize outcomes and quality of life.

The current management of alveolar soft part sarcomas

OBJECTIVE

Alveolar soft part sarcomas (ASPS) which has high potential ability of metastasis, is a rare and slowly growing malignant tumor, and mainly primary localized in limbs. To date, little is known about the best treatment of ASPS. This study aims to review the current management and advance of ASPS.

METHODS

WANFANG MED ONLINE, CNKI, and NCBI PUBMED were used to search literature spanning from 1963 to 2020, and all cases of ASPS about "ASPS, diagnosis, treatment, surgery, radiotherapy, chemotherapy, target therapy or immune therapy" with detailed data were included.

RESULTS

Complete surgical resection remained the standard management strategy, radiotherapy was reported to be used for the patients of micro- or macroscopical incomplete residue or the surgical margin was questionable. Chemotherapy was controversial. Some target drugs and immune checkpoint inhibitors had produced antitumor activity.

CONCLUSION

Complete surgical resection is the cure treatment for ASPS, and adjuvant chemotherapy is not recommended excepted clinical trials. For the patients with micro- or macroscopical incomplete residue, radiotherapy should be appreciated. Furthermore, for recurrence, distant metastasis, and refractory of ASPS, combination therapy, especially combination with multiple target agents and/or immune checkpoint inhibitors may prolong survival time.

[French ccAFU guidelines - update 2020-2022: retroperitoneal sarcoma]

OBJECTIVE

- To update French urological guidelines on retroperitoneal sarcoma.

MATERIALS AND METHODS

- Comprehensive Medline search between 2018 and 2020 upon diagnosis, treatment and follow-up of retroperitoneal sarcoma. Level of evidence was evaluated.

RESULTS

- Chest, abdomen and pelvis CT is mandatory to evaluate any suspected retroperitoneal sarcoma. MRI sometimes helps surgical planning. Before histological confirmation through biopsy, the patient must be registered in the French sarcoma pathology reference network. The biopsy standard should be an extraperitoneal coaxial percutaneous sampling before any retroperitoneal mass therapeutic decision. Surgery is retroperitoneal sarcoma cornerstone. The main objective is grossly negative margins and can be technically challenging. Multimodal treatment risks and benefits must be discussed in multidisciplinary teams. The relapse rate is related to tumor grade and surgical margins. Reported Negative margins rate thus encourage surgery in high-volume centers.

CONCLUSION

- Retroperitoneal sarcoma prognosis is poor and closely related to the quality of initial management. Centralization through dedicated sarcoma pathology network in a high-volume center is mandatory.

Preoperative Biopsy in Patients with Retroperitoneal Sarcoma: Usage and Outcomes in a National Cohort

INTRODUCTION

Preoperative biopsy (PBx) is often recommended for retroperitoneal sarcoma (RPS), but its utilization rate and impact on perioperative management and outcomes remains undefined.

METHODS

Using the National Cancer Database, patients who underwent resection of non-metastatic RPS were identified (2006-2014). Patients who did and did not undergo PBx of the primary tumor were compared using propensity matching, and factors associated with survival were assessed by multivariable analysis.

RESULTS

Of 2620 patients, 1110 (42.4%) underwent PBx. Factors significantly associated with performance of PBx included male sex [odds ratio (OR) 1.2, P = 0.035], tumor size ≤ 5 cm (OR 1.5, P = 0.012), tumor size > 5 to ≤ 10 cm (OR 1.3, P = 0.009), non-well-differentiated liposarcoma histology (OR 2.0, P ≤ 0.001), and treatment at a high-volume center (OR 1.3, P = 0.021). Receipt of PBx was significantly associated with administration of neoadjuvant radiation (OR 8.8, P < 0.001) or systemic therapy (OR 3.3, P < 0.001), radical surgical resection (OR 1.6, P < 0.001), and complete tumor resection (OR 1.5, P < 0.003). Neoadjuvant radiation [hazard ratio (HR) 0.7, P = 0.003] and complete tumor resection (HR 0.6, P < 0.001) were significantly associated with improved overall survival (OS). Performance of PBx was not associated with OS (HR 1.1, P = 0.070), and following propensity matching, 5-year OS did not differ between the two groups (56.5% PBx vs 58.4% no PBx, P = 0.247).

CONCLUSIONS

A minority of patients with non-metastatic RPS undergo PBx. PBx does not negatively impact survival, but may indirectly improve outcomes in select patients by virtue of receipt of neoadjuvant therapy and attainment of complete tumor resection.

Senolytic Targeting of Bcl-2 Anti-Apoptotic Family Increases Cell Death in Irradiated Sarcoma Cells

Simple Summary

Limited volumetric change after pre-operative radiotherapy (RT) suggests that sarcomas generally do not undergo cell death. Senolytic drugs represent a highly promising field as a new therapy approach to drive senescent cancer cells towards cell death to enhance treatment response. Here, we demonstrate that the Bcl-2 family of anti-apoptotic proteins in irradiated senescent sarcoma cells represents a senotherapeutic target to improve the cell death response in RT. This study paves the way for new treatment options in soft tissue sarcoma management.

Abstract

Radiotherapy (RT) is a key component of cancer treatment. Most of the time, radiation is given after surgery but for soft-tissue sarcomas (STS), pre-surgical radiation is commonly utilized. However, despite improvements in RT accuracy, the rate of local recurrence remains high and is the major cause of death for patients with STS. A better understanding of cell fates in response to RT could provide new therapeutic options to enhance tumour cell killing by RT and facilitate surgical resection. Here, we showed that irradiated STS cell cultures do not die but instead undergo therapy-induced senescence (TIS), which is characterized by proliferation arrest, senescence-associated β-galactosidase activity, secretion of inflammatory cytokines and persistent DNA damage. STS-TIS was also associated with increased levels of the anti-apoptotic Bcl-2 family of proteins which rendered cells targetable using senolytic Bcl-2 inhibitors. As oppose to radiation alone, the addition of senolytic agents Venetoclax (ABT-199) or Navitoclax (ABT-263) after irradiation induced a rapid apoptotic cell death in STS monolayer cultures and in a more complex three-dimensional culture model. Together, these data suggest a new promising therapeutic approach for sarcoma patients who receive neoadjuvant RT. The addition of senolytic agents to radiation treatments may significantly reduce tumour volume prior to surgery and thereby improve the clinical outcome of patients.

Multimodale Therapie primärer, nicht metastasierter retroperitonealer Sarkome

Weichteilsarkome sind eine heterogene Gruppe von Tumoren mesenchymalen Ursprungs, die teilweise ein sehr unterschiedliches biologisches Verhalten zeigen. Retroperitoneale Weichteilsarkome (RSTS) machen 10 – 15% aller Weichteilsarkome aus. Behandlungsempfehlungen für RSTS basieren auf vorrangig retrospektiven Analysen mit geringer Evidenz, die in dieser Übersichtsarbeit dargestellt werden. Zentraler Pfeiler in der Behandlung des lokalisierten, nicht metastasierten RSTS ist die chirurgische Resektion im Sinne einer Kompartment-Resektion. Ziel ist dabei immer die allseitig vollständige Tumorentfernung mit mikroskopisch freien Resektionsrändern. Ist das Erreichen dieses Behandlungsziels mit der alleinigen Kompartment-Resektion fraglich oder besteht eine hohe Wahrscheinlichkeit für eine lokale Tumorrekurrenz bei high-grade Sarkomen, so sollte eine neoadjuvante Bestrahlung, gegebenenfalls mit intraoperativem Boost, im Rahmen eines multimodalen Therapieansatzes durchgeführt werden. Die in Analogie zu den Extremitätensarkomen zu favorisierende Anthrazyklin-basierte Chemotherapie hat ihren Stellenwert vorrangig in der Adjuvanz. Auch wenn ein onkologischer Vorteil durch eine adjuvante Chemotherapie für RSTS bisher nicht nachgewiesen ist, sollte bei high-grade Sarkomen die Indikation diskutiert werden. In Kenntnis der unterschiedlichen Krankheitsverläufe werden zunehmend an die unterschiedlichen histologischen Subtypen adaptierte Therapiekonzepte diskutiert und in Studien untersucht. Valide Empfehlungen lassen sich jedoch bisher nicht ableiten. Die Behandlung von RSTS-Patienten wie überhaupt von Patienten mit Sarkomen in Zentren mit entsprechender Expertise ist mit einer signifikanten Verbesserung der Prognose assoziiert und ist unbedingt anzustreben.

Integrative assessment of clinicopathological parameters and the expression of PD-L1, PD-L2 and PD-1 in tumor cells of retroperitoneal sarcoma

Evidence is limited regarding the immunologic profile and immune microenvironment of soft tissue sarcoma subtypes. The aim of the present study was to describe the clinical significance and prognostic implications of PD-L1, PD-L2, and PD-1 in patients with retroperitoneal sarcoma (RSar). In this retrospective, multicenter, collaborative study, medical charts were reviewed and the immunohistochemical staining results of resected tissue specimens from 51 patients with RSar were examined. Immunohistochemical staining was performed with primary antibodies against PD-L1, PD-L2, PD-1, and Ki-67. The correlations between the baseline clinical parameters and expression levels of the four molecules in sarcoma cells were evaluated, and their prognostic values after tumor resection were assessed. Dedifferentiated liposarcoma (41%), leiomyosarcoma (20%), and undifferentiated pleomorphic sarcoma (16%) were the three major types identified. Dedifferentiated liposarcoma and leiomyosarcoma showed higher levels of PD-L1 expression than did other sarcomas. The Spearman correlation analysis revealed that baseline serum lactate dehydrogenase levels were moderately and positively correlated with PD-L1 (P=0.02, r=0.41) and PD-L2 (P=0.006, r=0.47) expression. The median recurrence-free and disease-specific survival was 58 and 16 months, respectively, during the 29-month median follow-up after surgery. On univariate analysis, a higher expression level of PD-1 was associated with a higher risk of recurrence, whereas multivariate analyses revealed that independent predictors of recurrence-free and disease-specific survival indicated a high expression of Ki-67 (P=0.03; hazard ratio, 2.29 vs. low expression) and prognostic stage IIIB (P=0.04; hazard ratio, 5.11 vs. stage I-II), respectively. Findings of the current study provide novel insights about the prognostic value of PD-L1, PD-L2, and PD-1 expression in RSar. Serum lactate dehydrogenase levels constitute a potential predictor of PD-L1 and PD-L2 expression levels in RSar. Further investigations are needed to determine the immunologic landscape of RSar and provide a foundation for therapeutic intervention using immune checkpoint inhibitors.