Morbidity and Mortality after Surgery for Retroperitoneal Sarcoma

Survivorship Considerations and Management in the Adolescent and Young Adult Sarcoma Population: A Review

Soft tissue sarcoma (STS) has an 2-8% incidence for all malignant tumors in the adolescent and young adult (AYA) population, which are patients from ages 15 to 39. As most STS tumors are aggressive, they require multimodal management with surgery, radiation and chemotherapy. This article discusses the survivorship considerations in this young population of cancer patients who complete therapy. The lasting side effects include surgical and radiation-related morbidity, chemotherapy toxicity, early and late secondary effects on other organ systems, such as cardiac and endocrine dysfunction, and the development of secondary cancers. The long-term psychologic and practical impacts for those who have received a sarcoma diagnosis in the prime of their life include fertility, mental health, relationship, education and career implications. Although there is a paucity of data in some of these areas, we present existing management guidelines as available. This article serves as a comprehensive review of this wide array of treatment effects intended for all providers participating in the care of AYA sarcoma survivors, to include oncologists, primary care providers and therapists.

A comprehensive approach to the surgical management of a complex abdominal sarcoma utilizing advanced imaging and 3D printing technology: a case report

This case report presents the surgical management of a complex abdominal sarcoma in a 33-year-old female patient, emphasizing the pivotal role of advanced imaging and three-dimensional (3D) printing technology in optimizing surgical outcomes. The study aimed to explore the clinical value of integrating computed tomography, magnetic resonance imaging, and patient-specific 3D-printed models for preoperative planning, intraoperative navigation, and postoperative evaluation. A multidisciplinary team utilized Mimics23 software to generate a detailed 3D reconstruction of the tumor and its intricate anatomical relationships with the ileocecal region, appendix, and colon. This model guided the precise resection of a 15 × 10 × 10 cm high-grade sarcoma, minimizing damage to adjacent critical structures. The technology-enhanced approach resulted in complete tumor excision with clear margins, and postoperative no complications. This case underscores the potential of 3D visualization and printing to address the challenges of complex abdominal sarcomas, offering a paradigm for personalized surgical strategies in oncology.

Preoperative Platelet/Albumin Ratio Predicts Morbidity and Mortality in Patients with Retroperitoneal Liposarcoma

Retroperitoneal sarcomas are a rare and heterogeneous group of malignant neoplasms. The most frequent sarcoma in this location is liposarcoma; complete resection is the gold standard of treatment. To achieve this, a multivisceral resection is often necessary to reduce local recurrence. However, this approach must be balanced by the potential for added morbidity. This study aims to evaluate the platelet-albumin ratio as a predictor of morbidity risk. A retrospective review of the medical records of patients with retroperitoneal liposarcomas operated with curative intent at our institution between January 2010 and December 2020 was performed. The platelet-albumin ratio was calculated, and a cutoff point of 78.86 was determined to predict morbidity by receiver operating characteristic (ROC) curve analysis, divided into high-risk and low-risk groups with a sensitivity of 83% and a specificity of 71.6%. These risk groups were contrasted with the different demographic and evolution variables. One hundred thirty-six patients were analyzed, and 91 met the inclusion criteria; age at presentation was 52.55 years (SD 12.96), tumor size was 29.31 (SD 12.43), and 40.7% underwent multivisceral resections, identifying a difference between the presence of a high platelet/albumin ratio and the appearance of complications at 30 days with an OR of 8 (CI 1.0052 to 63.6698, p 0.0494). The platelet-albumin ratio is an easy-to-use test that could help clarify the group of patients who require preoperative prehabilitation to reduce significant complications.

Role of Microsurgery in Organ-Preserving Surgeries in Uro-oncology

Organ preservation surgery is the need of the hour in cancer management whenever it is feasible. Vascular continuity is a must for organ preservation. We found such same in this article. We retrospectively collected the data of all cases which operated for either salvage of organs such as kidney or iatrogenic injury to renal pedicle or any kind of salvage procedure done in uro-oncological cases from June 2022 to January 2023 in our hospital. Data were analysed and presented using descriptive analysis. In a total of five such cases, two required end-to-end primary repair of the renal artery and vein, and one required vein graft for renal artery. In one case, we had to flip the inferior mesenteric artery to anastomose it to the renal artery. One case of renal autotransplant was done. All cases have good outcomes in the form of renal function and oncological safety. Although a lot of urologists are trained in renal transplants and arteriovenous fistula formations, the results can further be improved with good microvascular surgeons in the team in uro-oncology settings too.

Comprehensive treatment strategy for improving surgical resection rate of retroperitoneal sarcomas: a histology-specific approach narrative review

Retroperitoneal sarcoma (RPS) represents a rare and heterogeneous group of malignancies, posing significant challenges in evaluation and management. Surgery, the cornerstone of RPS treatment, critically depends on complete resection for a favorable prognosis. The extent of resection is a crucial determinant of local control and survival. This review delves into the evolution of multidisciplinary management of localized RPS, highlighting the imperative to adapt surgical strategies to tumor histology, location, and patient functional status. We explore the principles of compartmental surgery-an extended first-line approach that involves resecting adjacent viscera for wide negative margins-and its effectiveness across different histological subtypes of RPS and more limited resections for other types. Particular emphasis is placed on the heterogeneity of the disease, as various histological subtypes exhibit distinct biological behaviors. This necessitates a shift away from a one-size-fits-all treatment approach. The review analyzes the role of different surgical strategies, focusing on histological type and location. Additionally, the potential benefits of (neo)adjuvant treatments, such as radiotherapy and chemotherapy, are examined, recognizing their specific histological indications and limitations. This comprehensive review consolidates recent data on surgical strategies and complementary therapies, advocating for a personalized approach tailored to histology. As understanding of the molecular and genetic underpinnings of RPS continues to evolve, so will strategies for its effective management, underscoring the need for global collaboration among specialists in this field to enhance our collective knowledge and treatment methodologies.

3D-SARC: A Pilot Study Testing the Use of a 3D Augmented-Reality Model with Conventional Imaging as a Preoperative Assessment Tool for Surgical Resection of Retroperitoneal Sarcoma

BACKGROUND

Retroperitoneal sarcomas (RPSs) present a surgical challenge, with complex anatomic relationships to organs and vascular structures. This pilot study investigated the role of three-dimensional (3D) augmented reality (3DAR) compared with standard imaging in preoperative planning and resection strategies.

METHODS

For the study, 13 patients who underwent surgical resection of their RPS were selected based on the location of their tumor (right, left, pelvis). From the patients' preoperative computed tomography (CT) scans, 3DAR models were created using a D2P program and projected by an augmented-reality (AR) glass (Hololens). The 3DAR models were evaluated by three experienced sarcoma surgeons and compared with the baseline two-dimensional (2D) contrast-enhanced CT scans.

RESULTS

Three members of the surgical team evaluated 13 models of retroperitoneal sarcomas, resulting in a total of 26 responses. When the surgical team was asked to evaluate whether the 3DAR better prepared the surgeon for planned surgical resection, 10 responses favored the 3DAR, 5 favored the 2D CT scans and 11 showed no difference (p = 0.074). According to 15 (57.6 %) of the 26 responses, the 3DAR offered additional value over standard imaging in the preoperative planning (median score of 4; range, 1-5). The median stated likelihood that the surgeons would consult the 3DAR was 5 (range, 2-5) for the preoperative setting and 3 (range, 1-5) for the intraoperative setting.

CONCLUSIONS

This pilot study suggests that the use of 3DAR may provide additional value over current standard imaging in the preoperative planning for surgical resection of RPS, and the technology merits further study.

Prognostic Nutritional Index (PNI): A More Promising Nutritional Predictor for Patients Undergoing Surgery for Retroperitoneal Liposarcoma

Background

Extended surgery with multi-visceral resection is the standard treatment for retroperitoneal liposarcoma (RLPS). Malnutrition tends to result in increased surgical complications and reduced survival. The aim of this study was to identify the prognostic role of nutritional status in patients with RLPS.

Patients and methods

Data from 189 consecutive patients with RLPS who underwent surgical treatment at the Peking University Cancer Hospital Sarcoma Center between April 2011 and August 2022 were retrospectively reviewed. The following nutritional parameters were calculated: nutritional risk index, prognostic nutritional index (PNI) and Nutrition Risk Screening 2002. Time-dependent receiver operating characteristic (time-ROC) curve analysis was conducted to compare the prognostic utility of nutritional indicators. The associations between nutritional indicators and major complications, local recurrence-free survival (LRFS) and overall survival (OS) were investigated.

Results

Based on the time-ROC curve analysis, the PNI was superior to other nutritional indices at predicting OS. The optimal cut-off value of PNI was 41.2. The PNI was significantly inversely associated with tumor size, tumor grade, and histological subtype. Patients in the low PNI group (< 41.2) had significantly shorter LRFS and OS than those in the high PNI (≥ 41.2) group, with higher major morbidity and mortality rates. The PNI was found to be a unique nutritional predictor that independently predicted LRFS and OS in the multivariate analysis.

Conclusion

The PNI is an effective tool for nutritional assessment in patients with RLPS. A low PNI value in patients with RLPS predicts worse survival outcomes.

Short- and long-term post-nephrectomy outcomes for retroperitoneal liposarcoma from a high-volume sarcoma center: a propensity score matching analysis

BACKGROUND

Multivisceral en bloc resection with the ipsilateral kidney is commonly performed in patients with retroperitoneal liposarcoma (RLPS). We evaluated the effect of nephrectomy on short- and long-term outcomes in patients with RLPS.

METHODS

Data from a prospectively maintained database of the Peking University Cancer Hospital Sarcoma Center between April 2011 and August 2022 were analyzed. We classified the RLPS patients who underwent surgery into nephrectomy group (NP) and non-nephrectomy group (non-NP). Patients were matched using a 1:1 propensity score to eliminate baseline differences between groups. Postoperative renal function outcomes, major morbidity, and mortality were analyzed to compare short-term outcomes after nephrectomy. Differences in local recurrence-free survival (LRFS) and overall survival (OS) were compared by Kaplan-Meier analysis with respect to oncological benefits.

RESULTS

In the matched cohort, patients in the NP group had significantly higher postoperative eGFR and CKD stages, but none required dialysis. Patients between NP and non-NP had a comparable major morbidity (p = 0.820) and 60-day mortality (p = 0.475). Patients in the NP group had a higher 5-year LRFS rates than those in the non-NP group (34.5 vs. 17.8%, p = 0.015), and similar 5-year OS rates (52.4 vs. 47.1%, p = 0.401). Nephrectomy was an independent risk factor for LRFS, but not for major morbidity or OS.

CONCLUSIONS

RLPS resection with nephrectomy is related to a mild progression of renal impairment; however, dialysis is rare. En bloc nephrectomy for complete resection of RLPS is safe and improves local control.

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.

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.