The management of retroperitoneal soft tissue sarcoma: a single institution experience with a review of the literature

Retroperitoneal undifferentiated pleomorphic sarcoma with total nephrectomy: a case report and literature review

Background

Undifferentiated pleomorphic sarcoma (UPS) is a highly malignant soft tissue sarcoma with a poor prognosis and no clear effective clinical means for treatment, and there has been no significant progress in research within this field in recent years. This study aimed to investigate the epidemiology, etiology, clinical features, diagnostic modalities, various treatment modalities, and prognosis of retroperitoneal undifferentiated pleomorphic sarcoma and to contribute to the clinical management of this type of disease. In this study, we report a case of undifferentiated pleomorphic sarcoma with a primary origin in the retroperitoneum. Undifferentiated pleomorphic sarcoma occurring in the retroperitoneum is rarely reported.

Case description

A 59-year-old man with abdominal distension and pain for 4 months presented to our hospital after the failure of conservative treatment. A 9.6 cm by 7.4 cm mass in the left retroperitoneum was found on a CT scan of the whole abdomen with three degrees of enhancement. After surgical treatment, the tumor and the left kidney were completely removed, and pathological examination and genetic sequencing showed an apparent undifferentiated pleomorphic sarcoma. The patient subsequently declined follow-up treatment and is currently alive and well.

Conclusions

At the current level of clinical technology, the treatment of undifferentiated pleomorphic sarcoma is still in the exploratory stage, and the scarcity of clinical cases of this disease may have hindered the acquisition of clinical trials and research data for this disease. At present, the first choice of treatment for undifferentiated pleomorphic sarcoma is still radical resection. In the existing clinical studies, there are no strong data to support the effect of preoperative neoadjuvant chemoradiotherapy and adjuvant chemoradiotherapy in clinical practice. Similar to other diseases, the use of radiotherapy and chemotherapy before and after surgery may be a potential treatment for this disease in the future. Targeted therapy for this disease still needs further exploration, and we need more reports on related diseases to promote future treatment and research on this disease.

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

Background

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

Methods

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

Results

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

Conclusion

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

[RETROPERITONEAL LIPOSARCOMA WITH MULTIPLE RECURRENCE OF LUNG METASTASES TREATED BY MULTIMODAL THERAPY CENTERING ON THE OPERATION: A CASE REPORT]

A 34-year-old man presented with scrotal pain and slight fever. The scrotal pain was improved by the treatment of antibiotics, but the slight fever remained and an abdominal protuberance appeared. Computed tomography showed a 22 cm abdominal tumor with lipid density. He was then referred to our hospital. He was diagnosed as retroperitoneal liposarcoma and a surgical resection was performed for retroperitoneal tumor and surrounding organs. Histopathological diagnosis was dedifferentiated liposarcoma. 3 months after surgery, a PET/CT scan showed multiple lung metastases. We treated the patient with AI therapy by doxorubicin and ifosfamide. After 6 courses were performed, a complete response was achieved. 30months after the initial surgery, a PET/CT scan showed there was just one metastasis which was in the left lung. Thoracoscopic lung tumor resection was performed. Histopathological diagnosis was metastatic dedifferentiated liposarcoma. As adjuvant therapy, we treated with IE therapy by ifosfamide and VP-16. 3 courses were performed. 3 years and 6 months after the first surgery, he has had no recurrence up to the present day.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in seven patients with peritoneal sarcomatosis from uterine sarcoma

Peritoneal sarcomatosis from uterine sarcoma is a rare disease with no effective treatment and poor prognosis. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has successful results in peritoneal carcinomatosis from gastrointestinal/gynecological origins. We show that CRS/HIPEC is safe, feasible, and may benefit selected patients with peritoneal sarcomatosis from uterine sarcoma.

Retroperitoneal Soft Tissue Sarcoma: Prognostic Factors and Therapeutic Approaches

Aims and Background

Retroperitoneal sarcomas are a rare group of malignant soft tissue tumors with a generally poor prognosis. The aim of the study was to assess clinical, pathological and treatment-related factors affecting prognosis in patients with retroperitoneal sarcomas.

Methods and Study Design

The hospital records of 73 patients who underwent surgical exploration at our unit for primary retroperitoneal sarcomas between 1984 and 2003 were reviewed. Factors influencing overall and disease-free survival were analyzed for all patients and for those who underwent complete surgical resection.

Results

The complete resectability rate was 69.8% (51/73). Operative mortality and morbidity rates were 2.7% and 21.9%, respectively. For patients who underwent complete resection, the 5-year survival rate was 58.3%, whereas it was 0% in cases of incomplete or no resection (P <0.001). Local recurrence rate was 37.2%. Incomplete gross surgical resection and microscopic infiltration of margins were the most important independent predictors of a poor prognosis.

Conclusions

The present study confirmed the importance of an aggressive surgical management for retroperitoneal sarcomas to offer these patients the best chance for long-term survival.

Retroperitoneal Sarcomas

BACKGROUND

The evaluation and treatment of retroperitoneal sarcomas are challenging because the tumors are relatively rare and frequently present with advanced disease in an anatomically complex location.

METHODS

We reviewed the literature on experience in the management of retroperitoneal sarcomas, and we present our own experience in the treatment of these tumors.

RESULTS

The identification of prognostic factors other than the adequacy of resection has been inconsistent. Due to a lack of associated symptoms, retroperitoneal sarcomas smaller than 5 cm are rare. Computed tomography is the most useful tool in the evaluation of retroperitoneal tumors. Surgery, radiation therapy, and chemotherapy are treatment options, but the most important factor in the treatment of primary tumors is complete surgical resection. The role of neoadjuvant and adjuvant therapies is not defined and should be considered within the context of clinical trials.

CONCLUSIONS

Early referral of patients with retroperitoneal soft tissue tumors will help to ensure that they will receive the benefits of multidisciplinary evaluation and treatment of their disease and ready access to clinical trials.

Retroperitoneal Sarcomas

Retroperitoneal sarcomas are rare tumors, representing only 15% of all sarcomas. The mainstay of therapy is surgical resection with negative margins. However, this is challenging because of the late presentation of many of these tumors and involvement with adjacent structures. Decisions on radiation therapy and chemotherapy should be made in a multidisciplinary setting at a tertiary referral center.

Nonrhabdomyosarcomatous abdominopelvic sarcomas: Analysis of prognostic factors

BACKGROUND

Data concerning treatment outcome and prognostic factors in sarcomas of abdomen and pelvis are sparse in literature.

METHODS AND RESULTS

Of 696 patients with nonrhabdomyosarcomatous soft tissue sarcoma registered at our center between June 2003 and December 2012, 112 (16%) patients of sarcomas arising from abdomen and pelvis were identified, of which 88 patients were analyzed for treatment outcome and prognostic factors. The median age was 40 years (range: 1-78 years) with a male: female ratio of 0.7:1. Twenty-one (24%) patients were metastatic at baseline. The most common tumor sites were retroperitoneum in 70% patients and abdominal wall in 18% patients. Leiomyosarcoma was the most common histological subtype in 36% patients followed by liposarcoma in 17% patients. Thirty-five (40%) patients had Grade III tumors. Forty-six (52%) patients underwent surgical resection. At a median follow-up of 43 months (range: 2-94 months), the 5-year event-free survival (EFS) and overall survival (OS) were 35% and 42%, with a median of 22 months and 43 months, respectively. Multivariate analysis identified male gender (P - 0.03, hazard ratio [HR] - 0.46, 95% confidence interval [CI] - 0.23-0.92), baseline metastatic disease (P - 0.01, HR - 2.98, 95% CI - 1.27-6.98) and Grade III tumors (P - 0.02, HR - 1.84, 95% CI - 1.08-3.13) as factors associated with poor EFS, whereas baseline metastatic disease (P < 0.001, HR - 5.45, 95% CI - 2.31-12.87) and unresectability (P - 0.01, HR - 2.72, 95% CI - 1.27-5.83) were associated with poor OS.

CONCLUSION

This is a single-institutional study of patients with abdominopelvic sarcomas where gender was identified as a new factor affecting survival apart from baseline presentation, histologic grade, and surgical resection.

Neoadjuvant radiotherapy for retroperitoneal sarcoma: A systematic review

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Preoperative intensity modulated radiation therapy for retroperitoneal sarcoma

The use of intensity modulated radiation therapy (IMRT) has allowed for the administration of high doses to retroperitoneal sarcomas (RSTS) while limiting toxicity to adjacent organs. The purpose of our study is to assess the outcome and toxicities of patients with RSTS treated with neo-adjuvant external beam radiation (EBRT) therapy using IMRT. This is a retrospective study of 21 patients treated with preoperative IMRT for primary or recurrent RSTS between 2005 and 2011. Overall survival (OS) and local recurrence free survival (LRFS) were computed using the Kaplan-Meier method (log-rank test). Acute and chronic toxicities were assessed using the CTCAE v. 3 criteria. The actuarial 2 and 3-year OS was 66% for both and the 5-year OS was 51%. As for LRFS it was 57% at 2 and 3-year and 51% for the 5-year LRFS. Factors predictive for local control were microscopically negative margins (p = 0.022), a median tumor diameter <15 cm (p = 0.007) and pathology of liposarcoma (p = 0.021). Furthermore, patients treated for recurrent disease fared worse (p = 0.04) in local control than patients treated for primary disease. As for OS, patients treated for Grade 1 histology had a better outcome (p 5 0.05). EBRT was generally well tolerated. Acute gastrointestinal (GI) Grade 1 or 2 toxicities occurred in 33% of patients and one patient had unexplained post-radiation Grade 2 fever that resolved after tumor resection. As for chronic toxicities 24% of our patients presented Grade 1 GI toxicity and one patient presented Grade 3 small bowel stenosis not clearly due to radiation toxicity. Despite the location and volume of the tumors treated, preoperative IMRT was very well tolerated in our patients with retroperitoneal sarcoma. Unfortunately local recurrences remain common and dose escalation is to be considered.

The management of retroperitoneal giant schwannomas in AIDS patients: A case report

Retroperitoneal schwannomas are a rare disease. During the potent antiretroviral therapy era, the incidence of AIDS-defining cancers has decreased, while the incidence of non-AIDS defining cancers has increased; however, the existence of a relationship between benign or malignant schwannomas and AIDS remains unclear. Although a case of ethmoid malignant schwannoma in an AIDS patient was first reported in 1993, no additional reports of schwannomas associated with AIDS have been published since. In the current study, the case of a 30-year-old male AIDS patient with a large benign retroperitoneal schwannoma is presented. The ideal treatment of retroperitoneal schwannomas is complete excision. However, controversy exists over the necessity of negative soft tissue margins, particularly when adjacent tissue or viscera must also be removed. In the current case study, due to the immune dysfunction in AIDS patients, the incidence of malignancy could not be completely excluded prior to surgery and a significant risk of short-term relapse or malignancy following partial tumor resection was present. The patient underwent complete resection with partial superior mesenteric artery excision in order to attain negative margins, and recovered well. A follow-up was performed 1 year after the procedure and the patient was well and a CT scan demonstrated no evidence of recurrence. However, the long term efficacy of this procedure requires continued observation in this patient.

Imaging of the retroperitoneum

The retroperitoneum is the compartmentalized space bounded anteriorly by the posterior parietal peritoneum and posteriorly by the transversalis fascia. It extends from the diaphragm superiorly to the pelvic brim inferiorly. This article discusses clinically relevant anatomy of the abdominal retroperitoneal spaces, their cross-sectional imaging evaluation with computed tomography and magnetic resonance imaging, and the imaging features of common retroperitoneal pathologic processes.

Surgical experience with retroperitoneal liposarcoma in a single korean tertiary medical center

Purpose

This is a report of the surgical treatment and prognosis of retroperitoneal liposarcoma (RPLS) in Koreans.

Materials and Methods

Nineteen patients treated for RPLS between July 1, 1984, and March 31, 2009, were included. Patient demographics, histopathologic subtypes, survival rate, disease recurrence rate and interval, and adjuvant therapy were reviewed and analyzed.

Results

Of the 19 patients diagnosed with RPLS, 26.3% presented with well-differentiated RPLS, 10.5% with dedifferentiated RPLS, 15.8% with myxoid/round cell type, and 47.4% with mixed-type liposarcoma. The mean follow-up period was 66.8 months (range, 6 to 165 months). Primary RPLS was treated in 17 patients. Nine patients (52.9%) had recurrent disease, and recurrence developed at a mean of 47.7 months after primary or repeated surgical treatment. The overall survival rate was 84.2% during a mean follow-up of 66.8 months. The 3- and 5-year survival rates were 86.9%, and the 10-year survival rate was 69.5%. The recurrence interval was significantly shorter in recurrent RPLS cases (p=0.023). The mean growth rate of locally recurrent tumors was 0.34 cm per month.

Conclusions

The survival rates reported here were higher than in previous studies. Locally recurrent tumors presented with a low growth rate, which may have contributed to the relatively high survival rate. A high prevalence of mixed-type RPLS was also noted, and its cause and prognosis require further research.

Soft tissue paraspinal inflammatory malignant fibrous histiocytoma presenting as a lumbar abscess

The rarest subtype of malignant fibrous histiocytoma (MFH) is the inflammatory type, which due to its peculiar clinical presentation may mimic an infectious process such as an abscess. The rarity of this disease and the unique features of its presentation may mislead the surgeon with consequent catastrophic results for the patient. In this study, a case report of a 65-year-old female patient with a soft-tissue inflammatory MFH presenting as a lumbar abscess and a review of the current literature are presented.

Retroperitoneal sarcoma: a rare cause of intestinal perforation in two cases

Retroperitoneal sarcoma is a rare malignancy often insidious in onset. At initial presentation, abdominal mass, pain or obstructive symptoms are the most common complaints. Here we present two patients who presented with abdominal discomfort and were discovered to have retroperitoneal sarcomas with secondary intestinal perforation. Perforation is a rare complication of retroperitoneal sarcoma, but one with the potential to significantly affect patient outcomes. Both patients underwent surgical resection and pathological characterization of their malignancies. The discovery of intestinal perforation during workup necessitates initiation of empirical antibiotic coverage and prompt surgical intervention.

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

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

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.

Recurrent retroperitoneal Schwannomas displaying different differentiation from primary tumor: case report and literature review

Background

Retroperitoneal Schwannomas are uncommonly found in the retroperitoneum and few of them show malignant transformation and invasion. Local recurrence are common in malignant Schwannomas with very few reports of tumor distinct differentiation at recurrences.

Case presentation

We report here a rare case of retroperitoneal schwannoma with multiple origins from retroperitoneum and pelvic wall. Pathological examination confirmed the case as a schwannoma with malignant transformation. Radical dissection of the tumors along with the sacrifice of adjacent sigmoid colon and left kidney failed to provide a cure for this patient. Due to tumor recurrence, a second and a third surgery of radical excision were performed 6 months and 17 months later after the first surgery, respectively. Histopathologic analysis identified that the recurrent tumors were different from the original schwannoma because of their smooth muscle-like differentiation.

Conclusion

Malignant schwannomas are uncommon sarcomas with a high incidence of local recurrence. Distinct immunohistochemical staining results of the tumors at recurrence indicate their potential of smooth-muscle like differentiation. Radical excision of the tumors may provide benefit for their local recurrences.

Primary adult soft tissue sarcomas: analysis of 294 patients

We retrospectively analyzed 294 patients with primary soft tissue sarcoma followed between 1996 and 2002 in Ankara Oncology Hospital. There were 170 male and 124 female patients with the age range of 16-80 years. The primary tumor was in the extremity in 72.9% of the patients. We determined lung metastasis in 102 (85%) out of the 120 patients as distant metastasis. The most common adult sarcomas were liposarcoma (16.3%), malignant mesenchymal tumor (MMT) (13.9%), malignant fibrous histiocytoma (MFH) (11.2%), rhabdomyosarcoma (10.2%) and synovial sarcoma (10.2%). Seventeen patients (5.3%) had grade 1 tumor, 143 patients (52.2%) had grade 2 tumor, and 112 patients (41.4%) had grade 3 tumor. In 45 patients (15.3%), the grade of the tumors is unknown. The tumor size was 0 to <5 cm in 54 cases (19.4%), 5-10 cm in 117 cases (41.9%) and >10 cm in 108 cases (38.7%). In 15 cases (5.1%), tumor size was unknown. Ninety-five patients (32.4%) were treated with adjuvant chemotherapy, and 125 patients (42.7%)) were treated with palliative chemotherapy. Prognostic factors influencing the overall survival were tumor size, grade, adjuvant radiotherapy and chemotherapy. Adjuvant radiotherapy had influence on disease-free survival. While tumor grade and size showed a significant value for predicting local recurrence, grade, localization of tumor, adjuvant chemotherapy and radiotherapy had an impact on metastasis development. The 1-year overall survival for all patients was 73.4%, 3-year overall survival was 51.8%, and 5-year overall survival was 45.1%.

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.

[Retroperitoneal sarcomas. Report of five new cases and review of the current situation]

INTRODUCTION

Soft-tissue sarcomas represent a heterogeneous group of rare tumors arising from the mesenchymal cells of the connective tissue. Approximately 15% of these tumors arise in the retroperitoneum. These neoplasms are locally aggressive and the only curative treatment is surgical resection "en-bloc". The main cause of mortality is locoregional recurrence. Five-year survival is 3-58%, depending on the histologic subtype and grade.

PATIENTS AND METHOD

Over a 5-year period (2001 to 2006), we performed surgery in five patients with retroperitoneal sarcomas. The mean age was 59 years (range, 46-76) with a male-to-female ratio of 3:2. The most frequent signs were abdominal pain and the appearance of a mass. In 2 patients, an incidental diagnosis was made during the surgical intervention.

RESULTS

Surgical resection was performed in 5 patients but was incomplete in two patients. We removed 2 liposarcomas, 1 leiomyosarcoma, 1 chondrosarcoma and 1 fusocellular sarcoma arising in the kidney. Locoregional recurrence occurred in four patients, requiring between 1 and 2 new relaparotomies (using the retroperitoneal approach in 2 patients). There was one death.

CONCLUSIONS

Retroperitoneal sarcomas are a heterogeneous group of tumors, in which the only common factor is the anatomical location. New randomized, prospective, multicenter trials are required to apply different therapeutic options according to the subtype of retroperitoneal sarcoma.

Complete surgical resection of retroperitoneal leiomyosarcoma in pregnancy: a case report

Retroperitoneal soft tissue sarcoma (RPS) is extremely rare in pregnancy, so there has been little experience in dialing with this condition. We report our experience of a pregnant patient with a retroperitoneal soft tissue sarcoma, which was treated by complete surgical resection at 17 weeks gestation. After regular follow-up, the patient admitted to our hospital in labor, in the 38th gestational week and vaginally delivered a male fetus weighing 3,200 g with Apgar score of 8 and 10 at 1 and 5 min respectively. Adjuvant radiotherapy and chemotherapy is controversial in RPS and due to postoperative continuation of pregnancy in our case, the adjuvant therapy was not practiced. The patient had an uneventful recovery, and no recurrence was detected for 20 months in the follow-up period.

Primary malignant retroperitoneal tumors: Analysis of a single institutional experience

AIMS

In order to achieve complete resection in the surgical management of retroperitoneal tumors, it is crucial to know the tumor's anatomical location relative to neighboring organs.

METHODS

Forty-nine patients with primary malignant retroperitoneal tumors were divided by tumor location into two groups [upper abdomen (group 1) or lower abdomen (group 2)], and clinicopathological features, tumor recurrence, and patient survival were assessed.

RESULTS

No significant differences in preoperative clinical characteristics existed between two groups, and liposarcoma was the most frequently observed tumor type. The difference in the rates of complete resection between the two groups was not statistically significant (75.9% for group 1 and 85% for group 2). En-bloc combined resection was performed in 52% and 30% of patients in groups 1 and 2, respectively. The local recurrence rate in group 2 (31.3%) was higher than that in group 1 (9.5%), despite the fact that the differences in rates of complete resection and distant recurrence rates (14.3% in group 1 and 12.5% in group 2) between the two groups were not statistically significant. The overall 5-year survival rates were 67.9% for group 1 and 43.2% for group 2 (p=0.038). The 5-year survival rate of patients with tumors smaller than 10 cm was 78.4%, while that of patients with tumors larger than 10 cm was 38.1% (p=0.017). The 5-year survival rate after complete excision was 61%, whereas that after incomplete resection or biopsy only was 40.0% (p<0.0001).

CONCLUSIONS

An upper abdominal tumor location is a positive prognostic factor even if small tumor size (<10 cm) and complete resection of the tumor are still more important factors to improve outcome in patients with malignant primary retroperitoneal tumors. Because complete resection was shown to be the most important prognostic factor, an aggressive and careful surgical approach is recommended for the treatment of such tumors.

Intensity modulated radiation-therapy for preoperative posterior abdominal wall irradiation of retroperitoneal liposarcomas

PURPOSE

Preoperative external-beam radiation therapy (preop RT) in the management of Retroperitoneal Liposarcomas (RPLS) typically involves the delivery of radiation to the entire tumor mass: yet this may not be necessary. The purpose of this study is to evaluate a new strategy of preop RT for RPLS in which the target volume is limited to the contact area between the tumoral mass and the posterior abdominal wall.

METHODS AND MATERIALS

Between June 2000 and Jan 2005, 18 patients with the diagnosis of RPLS have been treated following a pilot protocol of pre-op RT, 50 Gy in 25 fractions of 2 Gy/day. The Clinical Target Volume (CTV) has been limited to the posterior abdominal wall, region at higher risk for local relapse. A Three-Dimensional conformal (3D-CRT) and an Intensity Modulated (IMRT) plan were generated and compared; toxicity was reported following the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events v3.0.

RESULTS

All patients completed the planned treatment and the acute toxicity was tolerable: 2 patients experienced Grade 3 and 1 Grade 2 anorexia while 2 patients developed Grade 2 nausea. IMRT allows a better sparing of the ipsilateral and the contralateral kidney. All tumors were successfully resected without major complications. At a median follow-up of 27 months 2 patients developed a local relapse and 1 lung metastasis.

CONCLUSIONS

Our strategy of preop RT is feasible and well tolerated: the rate of resectability is not compromised by limiting the preop CTV to the posterior abdominal wall and a better critical-structures sparing is obtained with IMRT.

Intensificación terapéutica intraoperatoria en el tratamiento de los sarcomas abdominales localmente avanzados

INTRODUCTION

Sarcomas are rare tumors that develop from mesenchymal cells. Their management is difficult due to their changing histology, location, and behavior. In this article, we discuss the use of two intraoperative therapeutic intensification techniques, intraoperative radiotherapy (IORT) and hyperthermic intraoperative intraperitoneal chemotherapy (HIIC), in the treatment of locally advanced abdominal sarcomas and peritoneal sarcomatosis.

MATERIAL AND METHODS

We analyzed a series of 20 consecutive patients diagnosed with advanced abdominal sarcoma and 5 patients with a diagnosis of peritoneal sarcomatosis who were evaluated and treated in our department from December 1996 to October 2005. In advanced abdominal sarcoma, we performed complete or maximal resection followed by IORT. In peritoneal sarcomatosis we performed massive cytoreduction followed by HIIC.

RESULTS

The survival rate in advanced abdominal sarcomas without sarcomatosis was 65% at 26 months. Among the 5 patients diagnosed with peritoneal sarcomatosis, 3 were alive, and 2 were without recurrence at 20 months of follow-up.

CONCLUSIONS

IORT associated with radical surgery seems to improve local control and survival in advanced abdominal sarcomas. Maximal cytoreduction plus HIIC used as treatment of peritoneal sarcomatosis is a feasible technique that offers a therapeutic option with curative intent.

Major Vascular Resection and Prosthetic Replacement for Retroperitoneal Tumors

INTRODUCTION

Involvement of major vascular structures has been considered a limiting factor for resecting advanced tumors. The objective of this study was to evaluate the outcome after concomitant retroperitoneal tumor and vascular resection with prosthetic replacement of the aorta/vena cava.

METHODS

The authors reviewed a 5-year series of eight patients with a median age of 50 years (range 11-68 years) who had undergone resection of a retroperitoneal tumor and concomitant resection and replacement of the abdominal aorta, inferior vena cava, or both. The histologic diagnoses were sarcoma (five patients), teratoma (one), transitional cell carcinoma (one), and ganglioneuroma (one). The main outcome measures were early (<30 days) and late (>or=30 days) surgical morbidity and mortality. Secondary endpoints were vascular graft patency and tumor-free survival. Two patients underwent combined graft replacement of the aorta and vena cava. Single aortic and vena cava graft replacement were each done in three patients.

RESULTS

Two patients showed early surgical morbidity necessitating reoperation for a thrombotic graft occlusion. No patient died during the early course of the follow-up. During a median follow-up of 14 months (range 1-56 months), two patients had late surgical morbidity. The median tumor-free survival for patients with malignancy was 14 months (range 1-54 months). One patient developed locoregional tumor recurrence, and two developed distant metastases. The median survival for patients with malignancy was 14 months (range 1-60 months).

CONCLUSIONS

An aggressive surgical approach for otherwise unresectable retroperitoneal tumors with vascular resection and prosthetic vascular replacement is justified in selected cases and has acceptable morbidity and mortality.

EFFECT OF RESECTION AND OUTCOME IN PATIENTS WITH RETROPERITONEAL SARCOMA

BACKGROUND

A consecutive series of 47 patients with retroperitoneal sarcoma (RPS) were resected and prospectively followed.

METHOD

Between July 1994 and March 2005, 47 patients (24 men, 23 women; mean age, 56 years; range, 17-82 years) were evaluated.

RESULTS

A total of 23 patients had primary RPS and 24 patients had recurrent RPS. A total of 30 out of 47 patients (64%) underwent removal of contiguous intra-abdominal organs. The peroperative mortality was nil and significant preoperative complications occurred in eight cases only (17%). High tumour grade and incomplete resection were significant variables for a worse survival in all 47 patients, both in the univariate and multivariate analyses (P = 0.008 and P = 0.016, respectively). Among 28 radically resected patients, only histological grade affected overall survival (90% 5-year survival for low-grade tumour vs 26% 5-year survival for high-grade tumour; P = 0.006) with a similar effect noted for disease-free survival.

CONCLUSIONS

Histological grade was the only factor that affected overall and disease-free survival for RPS tumours. An aggressive surgical approach in both primary and recurrent RPS is associated with long-term survival.

Adult soft tissue sarcomas: Conventional therapies and molecularly targeted approaches

The therapeutic approach to soft tissue sarcomas (STS) has evolved over the past two decades based on the results from randomized controlled trials, which are guiding physicians in the treatment decision-making process. Despite significant improvements in the control of local disease, a significant number of patients ultimately die of recurrent/metastatic disease following radical surgery due to a lack of effective adjuvant treatments. In addition, the characteristic chemoresistance of STS has compromised the therapeutic value of conventional antineoplastic agents in cases of unresectable advanced/metastatic disease. Therefore, novel therapeutic strategies are urgently needed to improve the prognosis of patients with STS. Recent advances in STS biology are paving the way to the development of molecularly targeted therapeutic strategies, the efficacy of which relies not only on the knowledge of the molecular mechanisms underlying cancer development/progression but also on the personalization of the therapeutic regimen according to the molecular features of individual tumours. In this work, we review the state-of-the-art of conventional treatments for STS and summarize the most promising findings in the development of molecularly targeted therapeutic approaches.

Intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: current status and future directions

Natural history studies have shown that peritoneal carcinomatosis is uniformly fatal, with a median survival in the range of approximately 6 months. For more than a decade, a handful of centers have pursued aggressive intraperitoneal cytoreductive surgery combined with intraperitoneal hyperthermic chemotherapy as an alternative approach to this disease. Strict selection criteria, variation in intraperitoneal chemotherapy, and the vagaries of what represents "cytoreductive surgery" make many of our colleagues, particularly those in medical oncology, reticent to refer patients for such an aggressive therapy. This article establishes a conceptual framework for understanding the role of intraperitoneal hyperthermic chemotherapy in the treatment of peritoneal surface malignancy. This procedure continues to make advancements in the oncological community despite formidable challenges. The advancement of centers of excellence and the initiation of further phase II trials will help to define the optimal treatment approach for peritoneal carcinomatosis.

Adjuvant Radiation Therapy for Resectable Retroperitoneal Soft Tissue Sarcoma

BACKGROUND

In the management of retroperitoneal sarcomas it is necessary to achieve local control to ensure survival. The role of adjuvant radiation therapy (RT), either pre- or postoperative, remains controversial.

METHODS

Outcomes for 40 patients with retroperitoneal sarcoma treated with surgery and postoperative RT (n = 25) or preoperative RT (n = 15) were analyzed for variables prognostic for local control, survival, and associated complications.

RESULTS

Patterns of failure for patients treated by resection and postoperative RT were local (n = 4), local and distant (n = 3), and distant (n = 3). The failure patterns for preoperative RT cases were local (n = 2), local and distant (n = 2); and distant (n = 4). Median time to local recurrence in the postoperative and preoperative RT series were 1 year and 2.5 years respectively. The margin status was predictive for local control (P = 0.0065) and survival (P = 0.0012), regardless of treatment sequence. Absolute 5-year survival was 12% with positive margins versus 69% if negative. Histologic grade was indicative of the risk for distant metastasis (low grade 8% vs high grade 64%; P = 0.1373), and significantly predicted 5-year absolute survival (low grade 77% vs high grade 34%; P = 0.0267). Postoperative RT was associated with significant complications (infection, hemorrhage, and bowel obstruction--2 cases each).

CONCLUSION

Compared with the surgery-alone series, adjuvant RT appears to improve the probability of local control. Preoperative RT may be the preferred sequence potentially to improve tumor resectability and local-regional control with less risk of complications than with postoperative RT.

Retroperitoneal sarcoma: 25 years of experience with aggressive surgical treatment at the Institute of Oncology, Ljubljana

BACKGROUND AND OBJECTIVES

Retroperitoneal sarcomas are rare malignant tumors with an aggressive course of disease and high local recurrence rate. Local disease is the main cause of death. A retrospective study was undertaken to evaluate the results of aggressive surgical treatment in a series of patients of primary and recurrent retroperitoneal sarcomas.

PATIENTS AND METHODS

From 1975 to 2000, 155 patients with retroperitoneal tumors were operated on at the Institute of Oncology, Ljubljana. Patients with fibromatosis and children less than 16 years were excluded from further calculation. Out of the rest 139 patients, 102 patients had localized retroperitoneal sarcoma, and 37 patients had retroperitoneal sarcoma with distant metastases Leiomyosarcoma was the most common type of histology, followed by liposarcoma and schwannoma. Their referral status was as follow: 56 had primary sarcoma, 20 residual sarcoma after operation elsewhere and 26 already recurrent sarcoma. Our treatment approach was aggressive. We removed surgically primary tumor, recurrent sarcoma and metastases, whenever possible. To this end, we performed, 235 operations for retroperitoneal sarcomas on 139 patients (up to 8 operations on 1 patient).

RESULTS

Complete resection was done in 97 of 102 patients with localized sarcoma (resectability rate 95%); in 55 patients, R0 resection was made, in 42 patients, R1 resection, in 3 patients, debulking procedure, and in 2 patients biopsy alone. In 118, patients at least one organ was resected completely or partially en bloc with tumor. The 5-, 10-, and 15-year survivals of patients with localized sarcoma were 52%, 36%, and 22%, respectively. The 5-year survival of patients with metastases was 12% (P = 0.0002), the 5- and 10-year survival rates of patients with R0 resection were 75% and 64%, respectively, and of those with R1 resection, 25% and 8%, respectively (0 < 0.00001). High tumor grade was associated with poor survival. The 5-year local recurrence rate of patients with primary sarcoma and of those with locally recurrent sarcoma was 37% and 71%, respectively (P = 0.04). After the first local recurrence, the 5- and 10-year survival rates were 42% and 26%, after the second local recurrence 45% and 22%, after the third local recurrence 43% and 11%, and after the fourth local recurrence 51% and 17%, respectively.

CONCLUSION

Complete surgical resection without microscopic residuum and contamination is likely to offer the best chances for long-term survival. Until there are no other treatment modalities, aggressive surgery for recurrent sarcoma is recommended.

Hyperthermic intraperitoneal intraoperative chemotherapy after cytoreductive surgery for the treatment of abdominal sarcomatosis: clinical outcome and prognostic factors in 60 consecutive patients

BACKGROUND

Abdominal sarcomatosis is a rare nosologic entity with a poor prognosis. After a Phase I study on cytoreductive surgery combined with hyperthermic intraperitoneal intraoperative chemotherapy (HIIC), the authors reported the results of the treatment of 60 patients using this novel multimodal approach.

METHODS

Twenty-nine patients had multifocal primary disease and 31 patients had recurrent abdominal sarcoma. Tumor histology was represented by visceral (n = 26 [43%]) and retroperitoneal (n = 34 [57%]) sarcoma. All patients underwent cytoreductive surgery (with no or minimal residual disease) and 90-minute HIIC with doxorubicin (15.25 mg/L of perfusate) and cisplatin (43 mg/L). The clinical outcome and the prognostic value of 11 clinicopathologic variables were analyzed.

RESULTS

No postoperative deaths occurred. The morbidity rate was 33% and the moderate to severe locoregional toxicity rate was 15%. The median time to local disease progression and the median overall survival were 22 months and 34 months, respectively. Using multivariate analysis, histologic grading and completeness of surgical cytoreduction predicted patient prognosis, indicating that both local progression-free and overall survival were affected significantly by tumor aggressiveness and local disease control.

CONCLUSIONS

Although these results were encouraging, there was no definitive conclusion reached regarding the therapeutic activity of this locoregional treatment. In addition, the toxicity rate was substantial. In the absence of effective systemic agents, the therapeutic potential of cytoreductive surgery plus HIIC should be explored further in comparative trials.

Surgical management of retroperitoneal sarcomas associated with external and intraoperative electron beam radiotherapy

AIMS

To report outcomes of adults with retroperitoneal sarcoma (RS) treated by surgery, external beam radiotherapy (EBRT) and intraoperative electron beam radiotherapy (IORT).

METHODS

From July 1988 to February 2001; 24 patients with primary and recurrent RS were diagnosed and treated. The median dose and energy of IORT delivered was 15 Gy/9meV. EBRT dose varies between 45-50 Gy.

RESULTS

There were five primary and 19 recurrent tumours. One primary and five recurrent tumours underwent R0 resection. There were 12 liposarcomas and 19 grade I tumours; 13 patients developed local recurrence and three developed distant metastases.Twenty-two patients received IORT associated with EBRT: 11 developed recurrences. Six patients developed Neurotoxicity (4 grade II and 2 grade III). Disease free survival and overall survival at 5 years was 28 and 56% respectively.

CONCLUSIONS

EBRT with IORT treatment is a promising technique for local control. Lower recurrence rates are associated with radical (R0) surgical procedures.

The management of retroperitoneal liposarcoma with synchronous intra-duodenal sarcoma

Intra-abdominal (as opposed to extremity or limb and limb-girdle) soft tissue sarcomas (STS) are rare and account for less than 1% of all diagnosed neoplasms. These tumours are usually associated with a poor prognosis and are often locally invasive and metastatic at the time of presentation. Retroperitoneal sarcomas with synchronous or metachronous different histological types are rare and intra-duodenal sarcomas extremely unusual. A case of a giant retroperitoneal STS weighing approximately 15 kg consisting of two histologically different types is presented. Intra-duodenal involvement with sarcoma was found intra-operatively. We discuss the management of this condition in the context of an illustrative case in our recent experience.