In a patient with a large left sided retroperitoneal mass involving the stomach, pancreas and vascular pedicles of spleen and the left kidney. In addition to these 'disposable' organs, the mass is involving the celiac axis, SMA, 3rd part of duodenum and root of the small bowel mesentery. There seems a high likelihood of R2 resection with upfront surgery.
Is preoperative XRT in an attempt to downsize or to achieve negative margins followed by extensive resection an appropriatee management option in this situation?
Is upfront extensive R2 resection with clips to residual tumor for postoperative XRT justified in this situation?
Regards, raza
It seems it is such a huge and infiltrating mass that cannot be removed upfront and I am in doubt if radiation could be also feasible in this particulat portal. I would go for chemotherapy induction, histology-driven if possible (1). Chemoradiation seems to be to toxic in this particular case; interdisciplinary approach is mandatory.
Vote for chemo induction/neoadjuvant (2); surgery and radiotherapy (in sequence). Also would consider the possibilty of intraoperatory radiotherapy.
1. Histology- and non-histology-driven therapy for treatment of soft tissue sarcomas.
Casali PG. Ann Oncol. 2012. http://www.ncbi.nlm.nih.gov/m/pubmed/22987955/
2. One possibility if not histology-driven: Short, full-dose adjuvant chemotherapy in high-risk adult soft tissue sarcomas: a randomized clinical trial from the Italian Sarcoma Group and the Spanish Sarcoma. Gronchi A, et al. J Clin Oncol. 2012. http://www.ncbi.nlm.nih.gov/m/pubmed/22312103/?i=2&from=frustaci%20sarcoma%20adjuvant
I would first try to down size the tumour after discussing in the Tumour board,presuming it is a sarcoma.As suggested multi diciplinary team approach.Application of clips to the margins do help.At the end we are going to only palliate the disease !!!
Thank you very much Drs Zakaria, Dettino and Reddy. I am grateful for your opinions.
ESMO guidelines suggest grossly incomplete resection to be of questionable oncologic benefit and regards it as potentially palliative in certain settings only.
ESMO guidelines additionally support selective use of neoadjuvant therapies, especially for unresectable/borderline resectable retroperitoneal sarcomas.
Which form of neoadjuvant therapy for retroperitoneal sarcomas do you use in your practice. XRT, chemoradiation, or chemotherapy? How effective do you find it?
I think we can start with no adjuvant therapy according to CT guided biopsy then we do resection that can be upgraded from R2 to Ro resection
I agree with DrEmad as the effect of adjuvant radiation may not help,but in a case scinario like this as mentioned nicely Disposable organs can be resected but non resectable ares it is difficult ,leads to incomplete resection and recurrence.Our aim in these cases is margin free resection and recurrence free interval.
I agree.. A margin negative resection (R0) is one of the most important prognostic factors determining outcomes for RPS. preop radiation has shown to help achieve negative margins and should be considered in such situations.
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