Surgery at specialised sarcoma centres improves patient outcomes - A systematic review by the Australia and New Zealand sarcoma association clinical practice guidelines working party

ASO Practice Guidelines Series: Multidisciplinary Management of Retroperitoneal Sarcomas

Retroperitoneal sarcomas (RPS) represent a rare and biologically diverse group of malignancies, distinct from soft tissue sarcomas arising in other anatomic regions. Their deep-seated location, large size at presentation and proximity to critical structures contribute to diagnostic delays, treatment challenges, and variable oncologic outcomes, particularly when managed outside high-volume referral centers. Current international guidelines emphasize the importance of preoperative biopsy, review by a sarcoma pathologist, management in a referral center, multidisciplinary case discussion, consideration for clinical trials enrollment, and prospective database inclusion as standards of care. Given that the quality of the initial surgical resection-achieving complete macroscopic resection with margins tailored to the histologic type-remains the most important modifiable prognostic factor, adherence to international best practices in surgical and multimodal treatment is crucial to optimize patient outcomes. This article reviews contemporary management strategies for adult-type RPS, emphasizing the importance of multidisciplinary expertise.

Histology-driven tailoring of surgical approaches in retroperitoneal soft tissue sarcoma: retrospective cohort study

BACKGROUND

Histology-driven tailoring of surgical approaches for retroperitoneal soft tissue sarcoma is currently under debate. Compelling evidence assessing the role of histology-dependent extent of resection is lacking. The aim of this study was to assess outcomes of patients with primary retroperitoneal liposarcoma (LPS) or leiomyosarcoma (LMS) according to whether comprehensive (formerly 'compartmental') resection (CR) was performed.

METHODS

A retrospective study was conducted on data from patients undergoing surgical resection for LPS and LMS at Heidelberg University Hospital (2002-2019). Parameters were compared between groups with and without CR, with subgroup analyses for grading (LPS). Kaplan-Meier and Cox regression analyses were used to identify predictors of disease-specific survival (DSS), local recurrence-free survival, and distant metastasis-free survival.

RESULTS

In total, 119 patients with primary LPS and 46 patients with primary LMS were identified. DSS was improved in patients with LPS with CR (P = 0.049), and both DSS (P = 0.040) and distant metastasis-free survival (P = 0.041) were improved in the subgroup of patients with primary G3 LPS. In contrast, CR in patients with LMS was not associated with improved DSS, local recurrence-free survival, or distant metastasis-free survival. CR was associated with more severe postoperative complications (P = 0.021) and a longer hospital stay (P = 0.013) in patients with LPS, longer operation times (P < 0.010) in both patients with LPS and LMS, and increased blood loss (P = 0.008) in patients with LMS.

CONCLUSION

CR is associated with improved DSS in patients with primary LPS, which is not the case in patients with primary LMS. Given the association between CR and increased perioperative morbidity, surgical strategies for retroperitoneal soft tissue sarcoma should be individualized according to the underlying histology.

Travel distance to tertiary sarcoma centres does not influence oncological presentation or outcomes

Aims

Soft-tissue sarcomas (STSs) are rare cancers with centralized care advocated to consolidate resources and expertise. However, geographical challenges, particularly in countries like Canada, can increase travel distances for patients. The impact of travel distance on sarcoma presentation and outcomes remains unclear, particularly in single-payer healthcare systems with centralized care.

Methods

A retrospective cohort analysis was conducted on 1,570 patients with STS who underwent surgical resection at a Canadian tertiary referral centre between January 2010 and January 2021. Patients were divided into those living ≤ 50 km and > 50 km from the centre. Demographics, tumour characteristics, treatment methods, and survival outcomes were analyzed. A Cox regression model was constructed to evaluate predictors of overall survival.

Results

Patients living > 50 km from the centre (n = 700) travelled a mean of 176 km (SD 250), while those ≤ 50 km (n = 870) travelled a mean of 24.8 km (SD 13.8). There were no significant differences in disease presentation, time to definitive treatment, use of systemic therapies, or functional outcomes between the two groups. The two-year and five-year overall survival rates were similar between the groups (83.1% (95% CI 80.1% to 86.1%) vs 83.8% (95% CI 81.8% to 85.8%) and 72.1% (95% CI 69.1% to 75.1%) vs 72.5% (95% CI 69.5% to 75.5%), respectively). The regression model demonstrated that age, higher tumour grade, depth, and lower income were predictive of worse overall survival, while distance travelled was not an independent predictor of survival.

Conclusion

Contrary to previous studies, our findings suggest that travel distance did not influence disease presentation or survival outcomes in STS patients treated at a centralized sarcoma centre. This challenges previous notions regarding the impact of travel distance on cancer outcomes, and supports the effectiveness of centralized care models, even in geographically vast regions.

SPARC - A multi-disciplinary team program for retroperitoneal sarcoma: the Royal Prince Alfred Hospital and Chris O'Brien Lifehouse Collaboration

BACKGROUND

The Royal Prince Alfred Hospital (RPAH) and Chris O'Brien Lifehouse (COBLH) established a formal Sarcoma of the Pelvic and Abdominal Retroperitoneum Collaboration (SPARC) in November 2020. An established multidisciplinary team (MDT) with the aims to centralise patient referrals and treatment, establish database and research, coordinate surgical resections is critical in improving patient outcomes and quality of life.

METHODS

A prospective database was established in October 2021. Clinical, pathological and radiological data points were recorded for all patients since the inception of SPARC. Quality of Life questionnaires were included and follow-up planned regularly for 5 years.

RESULTS

From November 2020 to Feb 2024, 294 new referrals were discussed at the MDT meeting. Majority were from the metropolitan area (182) followed by regional NSW (87), interstate (20) and five internationals. 141 operations were performed during this period compared to 119 operations from 2010 to November 2020 in RPAH. The inception of the SPARC program has resulted in exponential growth in operations, improving from the previous rate of 15 cases annually to 35. Liposarcomas followed by leiomyosarcomas are the most common types of sarcomas resected. The majority were extended resections (81.6%) and 22% were pelvic exenterations. Overall R0 rate is 54.6%, R1 38.3% and R2 1.4% (131 (92.9%) had R0/R1 resections. Overall complication rate is 35.5% with one in-hospital mortality.

CONCLUSION

Success and expansion of a robust retroperitoneal sarcoma program requires a collaborative surgical approach, an MDT meeting, centralized referral process, and a research team in specialized tertiary institutions.

What is the association of preoperative biopsy with recurrence and survival in retroperitoneal sarcoma? A systematic review by the Australia and New Zealand Sarcoma Association clinical practice guidelines working party

Preoperative biopsy for retroperitoneal sarcoma (RPS) enables appropriate multidisciplinary treatment planning. A systematic review of literature from 1990 to June 2022 was conducted using the population, intervention, comparison and outcome model to evaluate the local recurrence and overall survival of preoperative biopsy compared to those that had not. Of 3192 studies screened, five retrospective cohort studies were identified. Three reported on biopsy needle tract seeding, with only one study reporting biopsy site recurrence of 2 %. Two found no significant difference in local recurrence and one found higher 5-year local recurrence rates in those who had not been biopsied. Three studies reported overall survival, including one with propensity matching, did not show a difference in overall survival. In conclusion, preoperative core needle biopsy of RPS is not associated with increased local recurrence or adverse survival outcomes.

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.

The role of radiation therapy in the management of primary retroperitoneal sarcoma: A systematic review and clinical practice guidelines from the Australia and New Zealand Sarcoma Association

While surgery is the mainstay of treatment for localised retroperitoneal sarcoma, the use of radiotherapy (RT) remains controversial. This systematic review aimed to evaluate the role of RT for retroperitoneal sarcoma. A systematic review using the population, intervention, comparison, and outcome model from 1990 to 2022 identified 66 studies (a mixture of preoperative and postoperative RT); one randomised controlled trial (RCT) with two publications, 18 registry studies, and 46 retrospective studies. In the RCT of preoperative RT, there was no difference in local/abdominal recurrence. The pooled analysis of this RCT and a retrospective study showed a significant abdominal recurrence free survival benefit with preoperative RT in low grade liposarcoma. The RCT and the majority of retrospective series found RT did not improve recurrence free survival (11 of 16 no difference in combined local and distant RFS, 11 of 13 no difference in distant metastasis free survival), disease specific survival (9 of 12 studies) or overall survival (33 of 49 studies). The majority of studies found no association between RT and perioperative morbidity. In summary, preoperative RT may improve local control for low grade (well-differentiated or grades 1-2 dedifferentiated) liposarcoma, but not other histological subtypes. There is no strong evidence that perioperative RT provides an overall survival benefit. Patients with low grade retroperitoneal liposarcoma can be considered for preoperative RT to improve abdominal recurrence free survival. The rationale and level of evidence in this scenario should be carefully discussed by the multidisciplinary team with patients. RT should not be routinely recommended for other histological subtypes.