Quality of Local Treatment or Biology of the Tumor: Which are the Trump Cards for Loco-regional Control of Retroperitoneal Sarcoma?

Abstract

Surgery remains the mainstay of curative therapy for retroperitoneal sarcoma (RPS). Local control is critical to achieve this objective, yet is not possible to achieve even initially in as many as 50 % of patients. Unlike sarcoma arising at other sites, anatomical constraints in the retroperitoneum limit the ability to achieve wide resection margins. As a consequence, local recurrences in RPS are more frequent than in extremity sarcoma and comprise the leading cause of death especially for low-to-intermediate grade tumors, e.g., liposarcoma, the histopathological subtype of approximately one-half of sarcomas arising at this site. Conceptually, adjuvant radiation therapy (RT) is attractive, but this modality also is limited by anatomical constraints as well as the typically large size of these tumors at presentation. RT benefits in RPS remain to be conclusively demonstrated; its application is reserved for selected cases. In the report by McBride et al.1 an interesting approach is proposed, consisting of external preoperative therapy followed by intraoperative dose escalation with brachytherapy. This is an appealing concept, with the caveat that the justification for this strategy is tempered by the retrospective nature of their analysis and the small numbers of patients in their series. Moreover, patients presenting with recurrent tumor whose outcome is usually worse and less likely to be affected by any treatment modalities were nonetheless included in this study. With recurrence, the likelihood of definitive local control reduces to the anecdotal; therefore, the initial therapeutic intervention is critical if durable control (let alone cure) is to result. McBride and colleagues used this opportunity to investigate possible predictors of survival, identifying multifocality as the only determinant of outcome. This finding is not surprising in that multifocality may be a reflection of an especially unfavorable underlying biology of RPS, with obvious prognostic impact, as we and others also have reported.2 Understanding the relative contributions of the effectiveness of local therapy against the inherent biology of specific RPS subtypes will be critical if we are to move a new set-point in RPS, in which specifically useful treatment options can be tailored to the individual patient. QUALITY OF LOCAL THERAPY Surgical StrategySome authors have advocated for the widest possible surgical resection at presentation, a strategy at variance with past recommendations advocating grossly complete extirpation in which the need or utility of resecting adjacent organs was limited to unequivocal direct tumor involvement.3,4 These retrospective analyses have favored a more aggressive adjacent organ resection approach, reporting greater than 75 % local control at 5 years. The need to standardize these seemingly disparate surgical strategies has been addressed recently by a panel of European and North American experts who have described how these tumors might be optimally approached. In essence, this surgical strategy consists of l...

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