Oncological results of elderly patients undergoing surgery for retroperitoneal sarcomas

As the population ages, more elderly patients are receiving surgery for retroperitoneal sarcoma (RPS). However, high-quality data investigating associations between ageing and prognosis are lacking. Our study aimed to investigate whether ageing is associated with inferior short-term survival outcomes after RPS surgery. Patients undergoing surgery for primary RPS between 2008 and 2019 at two tertiary sarcoma centres were analysed. The primary outcome was 1-year mortality, and the primary explanatory variable was patient age, classified as: < 55, 55-64, 65-74 or 75+ years. The 692 patients undergoing surgery (mean age 60.8 ± 13.8 years) had a 1-year mortality rate of 9.4%, which differed significantly by age (p < 0.001), with rates of 7.2%, 6.9%, 8.7% and 22.8% for the < 55, 55-64, 65-74 and 75+ years groups, respectively. The distribution of causes of death also differed significantly by age (p = 0.023), with 22% and 28% of deaths in the 65-74 and 75+ years groups caused by post-operative complications, versus none in the < 55 and 55-64 years groups. On multivariable analysis, age of 75+ years (versus < 55 years) was a significant independent predictor of 1-year mortality [odds ratio (OR) 7.05, 95% confidence interval (CI) 2.63-18.9, p < 0.001]; no significant increase in risk was observed in the 55-64 (OR 0.72, 95% CI 0.28-1.87) or 65-74 (OR 0.89, 95% CI 0.37-2.15) years groups. Post-operative complications are an important cause of deaths in elderly patients. These findings are relevant to decision-making and counselling when surgery is considered for patients with RPS.

Surgery for primary retroperitoneal sarcomas (RPS) often requires a technically challenging, en bloc multivisceral resection to optimize outcomes. Surgery may also be appropriate for patients with localized recurrent RPS. Anatomic considerations and tumor biology driven by histologic subtype may guide the extent of resection in patients with RPS. This review provides an overview of the current surgical principles for primary and recurrent RPS.

Measuring the impact of complications after surgery for retroperitoneal sarcoma: Is comprehensive complication index better than Clavien-Dindo Classification?

Our study aimed to compare the comprehensive complication index (CCI) to the conventional Clavien-Dindo classification (CDC) in patients undergoing surgery for primary retroperitoneal sarcoma (RPS). Data were collected for patients who underwent surgery from 2008 to 2019 at a tertiary institution. The length of hospital stay (LOS) was used as a surrogate marker for clinical outcomes, and associations with CDC and CCI were assessed. Data were available for 191 patients, with the highest CDC Grade of I, II, III, and IV in 18.3%, 41.9%, 17.8%, and 4.2%, respectively; the 30-day postoperative mortality (CDC Grade V) was 1.6% (N = 3). Whilst both classification systems were significantly correlated with LOS, this association was significantly stronger for CCI (Spearman's ρ: 0.768 vs. 0.648, p < 0.001). Increasing Charlson Comorbidity Index, tumor size, and organ weighted resection scores were independently associated with longer LOS. However, the association between LOS and both the CDC and CCI remained significant, even after adjusting for these factors (both p < 0.001). The CCI is more strongly associated with LOS than the CDC, and represents a useful tool to quantify the total burden of postoperative complications after surgery for RPS.

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

BACKGROUNDEnhanced recovery after surgery (ERAS) programs provide recommendations for an optimized management of patients undergoing surgery. An ERAS program tailored on surgery for retroperitoneal sarcomas (RPS) may improve patient outcomes and it has still not been established.AIMTo determine how an ERAS program tailored to RPS surgery can be agreed upon, structured, and implemented.METHODSTwenty-five candidate items from existing ERAS programs, potentially relevant for RPS surgery, were identified via literature review and expert input. These were included in a questionnaire refined through cognitive interviews and pilot testing. Expert sarcoma surgeons rated each item’s relevance and feasibility on a 6-point scale. The survey was recirculated after one year. Intra-observer reproducibility, inter-observer concordance, and agreement with the modal value of the most experienced participants were analyzed.RESULTSThirteen sarcoma surgeons from 6 centers participated in the survey. Although surgeons agreed on several items, their overall concordance was low. After recirculating the survey, the intra-observer reproducibility was low. Interestingly, the median concordance with the reference increased for relevance and decreased for feasibility.CONCLUSIONDespite interest in ERAS for RPS, surgeon concordance on item relevance and feasibility remains low, underscoring the need for collaborative efforts toward a standardized, consensus-based protocol.

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.

The purpose of this study was to compare the financial burden of surgery for retroperitoneal sarcoma (RPS) and gastric cancer (GC). All patients who underwent surgery for GC or RPS between 2020 and 2021 at Nagoya University Hospital were included. The clinical characteristics, surgical fees per surgeon, and surgical fees per hour were compared between the two groups. The GC and RPS groups included 35 and 63 patients, respectively. In the latter group, 37 patients (59%) underwent tumor resection combined with organ resection; the most common organ was the intestine (n = 23, 37%), followed by the kidney (n = 16, 25%). The mean operative time (248 vs. 417min, p < 0.001) and intraoperative blood loss (423 vs. 1123ml, p < 0.001) were significantly greater in the RPS group than in the GC group. The mean surgical fee per surgeon was USD 1667 in the GC group and USD 1022 in the RPS group (p < 0.001) and USD 1388 and USD 777 per hour, respectively (p < 0.001). The financial burden of surgical treatment for RPS is unexpectedly higher than that for GC.

What is the primary cause of postoperative death after primary retroperitoneal sarcoma surgery in a high-volume center? A nationwide study by the French Sarcoma Group.

BackgroundDefinitive 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.MethodsWe 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).FindingsIn 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.ConclusionsFor 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.

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. 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). 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. 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.

Delayed gastric emptying (DGE) after aggressive resection of retroperitoneal sarcoma (RPS) has rarely been described. This study aimed to determine the incidence and characteristics of DGE after surgery for RPS and explore its potential risk factors. Patients with RPS who had undergone surgery between January 2010 and February 2021 were retrospectively analyzed. DGE was defined and graded according to the International Study Group of Pancreatic Surgery classification and classified as primary or secondary to other complications. Patients with clinically relevant DGE (crDGE, grade B+C) were compared to those with no or mild DGE (grade A). Multivariate logistic regression analysis of clinicopathological and surgical parameters was performed to identify risk factors for crDGE. Of the 239 patients studied, 69 (28.9%) had experienced DGE and 54 (22.6%) had experienced crDGE. Patients with primary and secondary DGE accounted approximately half and half. The most common concurrent complications included abdominal infection, postoperative pancreatic fistula, and abdominal bleeding. Patients with crDGE were more likely to have multifocal tumors and the liposarcoma subtype, with a larger tumor size, longer operating time, more resected organs, and a history of combined resection of the stomach, pancreas, small intestine, and/or colon. In multivariate analysis, the tumor size, operating time, and combined pancreatic resection were independent risk factors for crDGE. In conclusion, the current results indicated that approximately one-fourth of patients experienced DGE after aggressive surgery for RPS and that DGE was primary or secondary to other underlying conditions. A large tumor involving long, difficult surgery and combined pancreatic resection highly predicted the incidence of crDGE. The prevention and management of DGE remain challenging.

Categories of noncurative surgery for retroperitoneal sarcoma include: i) grossly incomplete resection (R2) of primary or locally recurrent tumor; ii) resection in the setting of distant metastatic disease; and iii) true palliative-intent symptom-directed surgery. The value of R2 resection is debatable, since most series do not report initial operative intent. Debulking surgery provides symptom relief in the majority of patients, but relief is generally not durable. Quality of life is poorly studied.

Multivisceral resection of retroperitoneal sarcomas in the elderly

To evaluate short- and long-term results after curative surgery for a retroperitoneal sarcoma (RPS) in elderly patients. We retrospectively analyzed data of all patients operated in our single, tertiary care center for a nonmetastatic RPS and identified patients aged 70years and older. Among 296 patients with an RPS treated between 1994 and 2015, 60 (20%) were aged 70years and older (median age 74years; range 70-85). The median tumor size was 24cm (range 6-46). Forty-six patients (77%) had mass-related symptoms at the time of diagnosis. The most frequent histological subtypes were de-differentiated liposarcoma (53%, n = 32) and well-differentiated liposarcoma (35%, n = 21). Twenty-two patients (37%) had perioperative radiotherapy and/or chemotherapy. Fifty-eight patients (97%) had macroscopically complete resection. The postoperative mortality was 8% and severe morbidity (Dindo/Clavien≥3) was 32%. A reoperation was required for ten patients (17%). After a median follow-up of 20months (range 1-121), the 5-year overall survival (OS) rate was 90% (95% confidence interval [CI] 79-100%), and median OS was not reached. The cancer-specific death rate was 88%. No prognostic factor for disease-specific survival was detected. The 5-year disease-free survival (DFS) rate was 52% (95% CI 33-84%) and 5-year locoregional recurrence-free survival rate was 52% (95% CI 33-84%). Median DFS was 94months (95% CI 35-NA). Reoperation after inappropriate surgery and postoperative morbidity were independent predictive factors of locoregional relapse. No predictive factors of distant metastasis were found. Curative surgery is feasible in selected elderly patients but with higher mortality and morbidity rates than in younger patients. It enables a prolonged survival. Future studies should focus on selection process to minimize postoperative mortality and morbidity.