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Zentralbl Chir 2014; 139(S 02): e72-e78
DOI: 10.1055/s-0032-1315114
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Chirurgische Therapieprinzipien bei retroperitonealen Sarkomen

Principles of Surgery for Retroperitoneal Sarcoma
P. Hohenberger
1   Medizinische Fakultät Mannheim der Universität Heidelberg, Sektion Chirurgische Onkologie und Thoraxchirurgie, Chirurgische Klinik, Mannheim, Deutschland
4   Pathologisches Institut, Georg-August-Universität Göttingen, Göttingen, Deutschland
,
D. Dinter
2   Medizinische Fakultät Mannheim der Universität Heidelberg, Institut für Klinische Radiologie und Nuklearmedizin, Mannheim, Deutschland
,
P. Stroebel
3   Medizinische Fakultät Mannheim der Universität Heidelberg, Sarkomzentrum am Interdisziplinären Tumorzentrum, Mannheim, Deutschland
,
B. Kasper
4   Pathologisches Institut, Georg-August-Universität Göttingen, Göttingen, Deutschland
,
F. Wenz
5   Medizinische Fakultät Mannheim der Universität Heidelberg, Klinik für Strahlentherapie und Radioonkologie, Mannheim, Deutschland
› Author Affiliations
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Publication History

Publication Date:
31 October 2012 (online)

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Zusammenfassung

Die erfolgreiche Therapie retroperitonealer Sarkome erfordert ein erfahrenes Behandlungsteam, in dem neben Chirurgen insbesondere Pathologen und Radiologen gefordert sind. Der entscheidende Schritt in der präoperativen Abklärung dieser häufig spät entdeckten Tumoren ist es, eine zuverlässige Information über die Dignität des Tumors zu haben, ggf. das Grading des Tumors und den Sarkomsubtyp zu kennen und hierauf basierend die Behandlungsrichtung festzulegen. Wesentliche Informationen liefern die bildgebenden Verfahren in Hinblick auf den Nachweis der Infiltration von Nachbarstrukturen und -organen. Hierzu stellt die Kernspintomografie das bestgeeignete Verfahren dar. Für die histologische Sicherung ist eine Stanzbiopsie auf jeden Fall einer Feinnadelaspiration vorzuziehen. Das chirurgische Standardverfahren ist die multiviszerale Resektion aus Prinzip, die in der überwiegenden Mehrzahl der Patienten eine zusätzliche Kolonresektion, Nephrektomie und Resektion der Bauchwandmuskulatur bzw. des M. psoas erfordert, um eine R0-Resektion des retroperitonealen Kompartments zu gewährleisten. Wenn nur minimale Sicherheitsabstände am Resektat zu erwarten sind, ist eine präoperative neoadjuvante Behandlung mit einer Strahlentherapie und/oder einer Chemotherapie, ggf. auch in Kombination mit einer Tiefenhyperthermie bei hochmalignen Sarkomen überlegenswert. Eine adjuvante postoperative Strahlentherapie kann meist nicht komplett appliziert werden, da die durch den Tumor verdrängten Abdominalorgane das ehemalige Tumorbett insbesondere mit dem bestrahlungsempfindlichen Dünndarm auffüllen. Die optimale Behandlungsstrategie für diese Patientengruppe sollte in einem multidisziplinären Tumorboard vor jeglicher diagnostischen oder therapeutischen Maßnahme festgelegt werden.

Abstract

The successful treatment of retroperitoneal soft tissue sarcomas requires an experienced team consisting of not only surgeons but also pathologists and radiologists with a high case load in these tumours. The decisive step in the preoperative work-up of these, often late detected, tumours is their reliable grading as well as, if necessary, recognition of the sarcoma subtype as a basis for determining the direction of treatment. Imaging methods provide essential information with regard to the detection of infiltration of neighbouring structures and organs. Magnetic resonance imaging (MRI) is the most suitable method for this purpose. Punch needle biopsy is to be preferred over fine-needle biopsy in all cases for histological confirmation. The surgical standard procedure for the majority of the patients comprises multivisceral resection as principle, with additional colon resection, nephrectomy, and resection of abdominal wall musculature or, respectively, the psoas muscle in order to achieve an R0 resection of the retroperitoneal compartment. If only small margins of clearance are to be expected, a preoperative (neoadjuvant) treatment with radiation and/or chemotherapy even in combination with deep wave hyperthermia for high grade sarcomas should be strongly considered. Adjuvant postoperative radiation therapy often cannot be adequately applied due to the occupation of the former tumour bed by abdominal organs that were displaced by the mass effect, especially the radiation-sensitive small bowel. The optimal treatment strategy for these patients must be discussed in a multidisciplinary tumour board prior to any diagnostic or therapeutic procedure.

Schlüsselwörter

retroperitoneales Sarkom - multiviszerale Resektion - multimodale Therapie

Key words

retroperitoneal sarcoma - multivisceral resection - multimodal treatment
 

  • Literatur

  • 1 Porter GA, Baxter NN, Pisters PW. Retroperitoneal sarcoma: a population-based analysis of epidemiology, surgery, and radiotherapy. Cancer 2006; 106: 1610-1616
    CrossrefPubMedGoogle Scholar
  • 2 Lewis JJ, Leung D, Woodruff JM et al. Retroperitoneal soft-tissue sarcoma: analysis of 500 patients treated and followed at a single institution. Ann Surg 1998; 228: 355-365
    CrossrefPubMedGoogle Scholar
  • 3 Stoeckle E, Coindre JM, Bonvalot S et al. Prognostic factors in retroperitoneal sarcoma: a multivariate analysis of a series of 165 patients of the French Cancer Center Federation Sarcoma Group. Cancer 2001; 92: 359-368
    CrossrefPubMedGoogle Scholar
  • 4 Hassan I, Park SZ, Donohue JH et al. Operative management of primary retroperitoneal sarcomas: a reappraisal of an institutional experience. Ann Surg 2004; 239: 244-250
    CrossrefPubMedGoogle Scholar
  • 5 Youssef E, Fontanesi J, Mott M et al. Long-term outcome of combined modality therapy in retroperitoneal and deep-trunk soft-tissue sarcoma: analysis of prognostic factors. Int J Radiat Oncol Biol Phys 2002; 54: 514-519
    CrossrefPubMedGoogle Scholar
  • 6 Stojadinovic A, Yeh A, Brennan MF. Completely resected recurrent soft tissue sarcoma: primary anatomic site governs outcomes. J Am Coll Surg 2002; 194: 436-447
    CrossrefPubMedGoogle Scholar
  • 7 Edge SB, Byrd DR, Compton CC. Soft Tissue Sarcoma. AJCC Cancer Staging Manual. 7. Aufl. New York, NY: Springer; 2010: 291-296
    Google Scholar
  • 8 van Doorn RC, Gallee MP, Hart AA et al. Resectable retroperitoneal soft tissue sarcomas. The effect of extent of resection and postoperative radiation therapy on local tumor control. Cancer 1994; 73: 637-642
    CrossrefPubMedGoogle Scholar
  • 9 Ballo MT, Zagars GK, Pollock RE et al. Retroperitoneal soft tissue sarcoma: an analysis of radiation and surgical treatment. Int J Radiat Oncol Biol Phys 2007; 67: 158-163
    CrossrefPubMedGoogle Scholar
  • 10 Pisters PW. Retroperitoneal sarcomas – an SOS to colleagues in Europe. Ann Surg Oncol 2007; 14: 1787-1789
    CrossrefPubMedGoogle Scholar
  • 11 Gronchi A, Pollock R. Surgery in retroperitoneal soft tissue sarcoma: a call for a consensus between Europe and North America. Ann Surg Oncol 2011; 18: 2107-2110
    CrossrefPubMedGoogle Scholar
  • 12 Russo P, Kim Y, Ravindran S et al. Nephrectomy during operative management of retroperitoneal sarcoma. Ann Surg Oncol 1997; 4: 421-424
    CrossrefPubMedGoogle Scholar
  • 13 Bonvalot S, Rivoire M, Castaing M et al. Primary retroperitoneal sarcomas: a multivariate analysis of surgical factors associated with local control. J Clin Oncol 2009; 27: 31-37
    CrossrefPubMedGoogle Scholar
  • 14 Gronchi A, Casali PG, Fiore M et al. Retroperitoneal soft tissue sarcomas: patterns of recurrence in 167 patients treated at a single institution. Cancer 2004; 100: 2448-2455
    CrossrefPubMedGoogle Scholar
  • 15 Bonvalot S, Miceli R, Berselli M et al. Aggressive surgery in retroperitoneal soft tissue sarcoma carried out at high-volume centers is safe and is associated with improved local control. Ann Surg Oncol 2010; 17: 1507-1514
    CrossrefPubMedGoogle Scholar
  • 16 Seinen J, Almquist M, Styring E et al. Delays in the management of retroperitoneal sarcomas. Sarcoma 2010; 2010: 702573
    PubMedGoogle Scholar
  • 17 Griffin JH, Waters WB. Primary leiomyosarcoma of the ureter. J Surg Oncol 1996; 62: 148-152
    CrossrefPubMedGoogle Scholar
  • 18 Anaya DA, Lev DC, Pollock RE. The role of surgical margin status in retroperitoneal sarcoma. J Surg Oncol 2008; 98: 607-610
    CrossrefPubMedGoogle Scholar
  • 19 Francis IR, Cohan RH, Varma DG et al. Retroperitoneal sarcomas. Cancer Imaging 2005; 5: 89-94
    CrossrefPubMedGoogle Scholar
  • 20 Lahat G, Anaya DA, Wang X et al. Resectable well-differentiated versus dedifferentiated liposarcomas: two different diseases possibly requiring different treatment approaches. Ann Surg Oncol 2008; 15: 1585-1593
    CrossrefPubMedGoogle Scholar
  • 21 Dimitrakopoulou-Strauss A, Strauss LG, Schwarzbach M et al. Dynamic PET 18F-FDG studies in patients with primary and recurrent soft-tissue sarcomas: impact on diagnosis and correlation with grading. J Nucl Med 2001; 42: 713-720
    PubMedGoogle Scholar
  • 22 Cantin J, McNeer GP, Chu FC et al. The problem of local recurrence after treatment of soft tissue sarcoma. Ann Surg 1968; 168: 47-53
    CrossrefPubMedGoogle Scholar
  • 23 Storm FK, Mahvi DM. Diagnosis and management of retroperitoneal soft-tissue sarcoma. Ann Surg 1991; 214: 2-10
    PubMedGoogle Scholar
  • 24 Gronchi A, Bonvalot S, Le Cesne A et al. Resection of uninvolved adjacent organs can be part of surgery for retroperitoneal soft tissue sarcoma. J Clin Oncol 2009; 27: 2106-2107 (author reply 2107–2108)
    PubMedGoogle Scholar
  • 25 Bonvalot S, Raut CP, Pollock RE et al. Considerations in surgery for retroperitoneal sarcomas: position paper from e-surge, a master class in sarcoma surgery, and EORTC-STBSG. Ann Surg Oncol 2012; 19: 2981-2991
    CrossrefPubMedGoogle Scholar
  • 26 Gronchi A, Miceli R, Colombo C et al. Frontline extended surgery is associated with improved survival in retroperitoneal low- to intermediate-grade soft tissue sarcomas. Ann Oncol 2011; 23: 1067-1073
    PubMedGoogle Scholar
  • 27 Mussi C, Colombo P, Bertuzzi A et al. Retroperitoneal sarcoma: is it time to change the surgical policy?. Ann Surg Oncol 2011; 18: 2136-2142
    CrossrefPubMedGoogle Scholar
  • 28 Schwarzbach MH, Hohenberger P. Current concepts in the management of retroperitoneal soft tissue sarcoma. Recent Results Cancer Res 2009; 179: 301-319
    PubMedGoogle Scholar
  • 29 Teo MC, Chow PK, Soo KC. Surgery for retroperitoneal sarcoma requiring major vascular resection and reconstruction. Asian J Surg 2005; 28: 312-315
    CrossrefPubMedGoogle Scholar
  • 30 Schwarzbach MH, Hormann Y, Hinz U et al. Clinical results of surgery for retroperitoneal sarcoma with major blood vessel involvement. J Vasc Surg 2006; 44: 46-55
    CrossrefPubMedGoogle Scholar
  • 31 Italiano A, Toulmonde M, Stoeckle E et al. Clinical outcome of leiomyosarcomas of vascular origin: comparison with leiomyosarcomas of other origin. Ann Oncol 2010; 21: 1915-1921
    CrossrefPubMedGoogle Scholar
  • 32 Issels RD, Lindner LH, Verweij J et al. Neo-adjuvant chemotherapy alone or with regional hyperthermia for localised high-risk soft-tissue sarcoma: a randomised phase 3 multicentre study. Lancet Oncol 2010; 11: 561-570
    CrossrefPubMedGoogle Scholar
  • 33 Gronchi A, Bui BN, Bonvalot S et al. Phase II clinical trial of neoadjuvant trabectedin in patients with advanced localized myxoid liposarcoma. Ann Oncol 2012; 23: 771-776
    CrossrefPubMedGoogle Scholar
  • 34 Alektiar KM, Hu K, Anderson L et al. High-dose-rate intraoperative radiation therapy (HDR-IORT) for retroperitoneal sarcomas. Int J Radiat Oncol Biol Phys 2000; 47: 157-163
    CrossrefPubMedGoogle Scholar
  • 35 Zagar TM, Shenk RR, Kim JA et al. Radiation therapy in addition to gross total resection of retroperitoneal sarcoma results in prolonged survival: results from a single institutional study. J Oncol 2008; 2008: 824036
    PubMedGoogle Scholar
  • 36 Sindelar WF, Kinsella TJ, Chen PW et al. Intraoperative radiotherapy in retroperitoneal sarcomas. Final results of a prospective, randomized, clinical trial. Arch Surg 1993; 128: 402-410
    CrossrefPubMedGoogle Scholar
  • 37 Thomas DM, OʼSullivan B, Gronchi A. Current concepts and future perspectives in retroperitoneal soft-tissue sarcoma management. Expert Rev Anticancer Ther 2009; 9: 1145-1157
    CrossrefPubMedGoogle Scholar
  • 38 Moran EA, Porterfield Jr. JR, Nagorney DM. Duodenocaval fistula after irradiation and resection of a retroperitoneal sarcoma. J Gastrointest Surg 2008; 12: 776-778
    CrossrefPubMedGoogle Scholar
  • 39 Heslin MJ, Lewis JJ, Nadler E et al. Prognostic factors associated with long-term survival for retroperitoneal sarcoma: implications for management. J Clin Oncol 1997; 15: 2832-2839
    CrossrefPubMedGoogle Scholar
  • 40 Jones JJ, Catton CN, OʼSullivan B et al. Initial results of a trial of preoperative external-beam radiation therapy and postoperative brachytherapy for retroperitoneal sarcoma. Ann Surg Oncol 2002; 9: 346-354
    CrossrefPubMedGoogle Scholar
  • 41 Pawlik TM, Pisters PW, Mikula L et al. Long-term results of two prospective trials of preoperative external beam radiotherapy for localized intermediate- or high-grade retroperitoneal soft tissue sarcoma. Ann Surg Oncol 2006; 13: 508-517
    CrossrefPubMedGoogle Scholar