Frontline Aggressive Surgical Approach To Primary Retroperitoneal STS:

A Morbidity / MortalityAnalysis From A Multi-Institutional Retrospective

Review.

Marco Fioremarco.fiore@istitutotumori.mi.it

Sylvie Bonvalotsylvie.bonvalot@igr.fr

Connective Tissue Oncology Society 15th Annual Meeting Miami, November 5-7th 2009

Aggressive surgery associated with improved local control

• Liberal en-bloc visceral resections:– Nephrectomy and GI major surgery (with the exception of

pancreato-duodenectomy and major hepatectomy, performed only if infiltrated)

• Loco-regional peritonectomy and miomectomy of the psoas:

– To accomplish better en-bloc resection

• Vascular surgery and bone resection – Feasible but performed only if vessels/bone infiltrated

“Aggressive surgical approach”

Storm, Mahvi – Ann Surg 1990

• Selection of cases / organs (due to expected morbidity): some but not all margins improve

• Data on short- and long-term morbidity not as yet provided

focus on safety

the formal evidence is weak (retrospective)

a randomized study (it will never be done!)

“Aggressive surgical approach” routinely recommended ?

249 primary RSTS (2000-2008)

• Median follow-up: 37 months (IQ range: 16-61)

• Median age: 55 years (IQ range: 45-66)

• Male/Female: 1/1

• Median size: 17 cm (IQ range: 11-26)

• Lipo 57%; Leio 18%; MPNST 6%; SFT 6%; Other 13%

• Median post-operative stay: 13 days (IQ range: 11-16)

Best 5 yr overall survival and local control ever reported

Time (months)

Sur

viva

l Pro

babi

lity

0 12 24 36 48 60

0.0

0.2

0.4

0.6

0.8

1.0 OS LR - DM

Study period

n° of pts

% complete resection

5 yrs overall survival

5 yrs LRFS

Lewis, 1998 1982-1997 231* 80 % 54 % 59%

Stoeckle, 2001 1980-1994 145* 65 % 49 % 42%

Karakousis, 2003 1977-2001 79 99 % 65 % 43%

Kilkenny, 1996 1970-1994 63 78 % 48 % NR

Gronchi, 2004 1982-2001 82 88 % 54 % 63%

Hassan, 2004 1983-1995 97 78% 51% 56%

Van Dalen, 2007 1989-1994 143 55% 39% NR

Lehnert, 2009 1998-2002 71 70% 51% 59%

Current Series 2000-2008 249 93% 65% 78%

78% 51% 57%Previous (median)

Current Series 93% 65% 78%

0

10

20

30

40

50

60

0 1 2 3 4 5 6 7 8

Number of organ resected

Median # of organ resected: 2 (IQ range: 1-3)

Type of organ resected

Morbidity & Mortality

Common Terminology Criteria for Adverse Events (CTCAE) v3.0

https://webapps.ctep.nci.nih.gov/webobjs/ctc/webhelp/welcome_to_ctcae.htm

Grade ≥ 3 Grade ≥ 4 Grade 5

18% 12% 3%

45 pts 30 pts 8 ptsAnastomotic

leakage 23 15 4

Infected collection 10 5 1

Haemorrage 6 6 2Wound

dehiscence 4 4Pulmonary Embolism 1 1Lower limb

compartmental syndrome

1

Number of organs resected > 3 correlate with higher risk of morbidity

organs >3 vs 3 2.75 (1.32-5.74)

OR

p = .007

organs >3 vs 3 2.75 (1.32-5.74)

OR

p = .007

organs >3 vs 3 2.75 (1.32-5.74)

OR

p = .007

# of organs resected

Log

odds

The organs resected correlate with the risk of morbidity

Right Colon Left ColonKidneyPsoasPancreasSpleenUterusOvaryDiaphragmParietal muscleStomachSmall bowelBoneNerveVeinArtery

OR

0.741.101.080.701.571.480.640.791.431.033.572.981.310.982.633.57

0 1 2 3 4 5 10 20

Kidney

PancreasSpleenUterusOvaryDiaphragmParietal muscleStomachSmall bowelBoneNerveVeinArtery

OR

0.741.101.080.701.571.480.640.791.431.033.572.981.310.982.633.57

0 1 2 3 4 5 10 20

Other prognostic factors for morbidity

Patient Age (years): 66 vs 45 1.74 1.00 3.03

0.142

Side: Left vs Right

Middle vs Right 0.98

2.07 0.48 0.53

2.01 8.00

0.550

Preoperative RT: Yes vs no

1.12

0.41

3.07

0.825

Preoperative CT:Yes vs no

1.47 0.64 3.36

0.364

Tumor size (cm): 26 vs 11 1.10 0.57 2.13

0.921

OR 95% C.I. Wald test

Morbidity Mortality

18%(range 9-37%)

3%(range 1-7%)

30%(range 15-50%)

3%(range 1-5%)

10%(range 3-15%)

3%(range 2-4%)

5%(range 2-8%)

3%(range 2-4%)

18% 3%

Morbidity Reoperation Mortality

Lewis, 1998 NR NR 4%

Stoeckle, 2001 NR NR NR

Karakousis, 2003 NR NR 0%

Kilkenny, 1996 NR NR NR

Gronchi, 2004 NR NR 3%

Hassan, 2004 8% 6% 2%

Van Dalen, 2007 NR NR 5%

Lehnert, 2009 24% NR 7%

Current Series 18% 12% 3%

…in brief

• Retroperitoneal STS are a challenging disease more for

their anatomical location than for their biology

• Frontline approach is crucial: need for an aggressive

surgery to minimize positive margins, often including

adjacent uninvolved visceral organs.

• Safety is comparable to other major abdominal

operations, if carried out at high-volume centers

• Need to refer these patients to high-volume centers to

have the best ratio between aggressiveness and

morbidity

marco.fiore@istitutotumori.mi.it