Download - Frontline Aggressive Surgical Approach To Primary Retroperitoneal STS: A Morbidity / Mortality
Frontline Aggressive Surgical Approach To Primary Retroperitoneal STS:
A Morbidity / MortalityAnalysis From A Multi-Institutional Retrospective
Review.
Marco [email protected]
Sylvie [email protected]
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