Surgical strategies to improve results in retroperitoneal sarcoma. Christoph Kettelhack University Hospital Basel

Transcription

1 Surgical strategies to improve results in retroperitoneal sarcoma Christoph Kettelhack University Hospital Basel

2 Retroperitoneal Sarcoma General considerations Advanced tumor stage Complex anatomy Absence of anatomical barriers Wide resection virtually impossible Limited long term prognosis 000

3 Retroperitoneal Sarcoma Complex Anatomy Curative resection achievable?

4 Retroperitoneal Sarcoma Long-term Prognosis SEER Database USA, patients with surgery 5-year survival 47% 10-year survival 27 % Prognosis Histology Grading Infiltration of other organs Nathan et al, Ann Surg 2009

5 Imaging in Retroperitoneal Sarcoma Diagnostics and Treatment decision NCCN Guideline Multidisciplinary team with expertise in sarcoma NCCN Practice Guidelines in Oncology v

6 Imaging in Retroperitoneal Sarcoma Diagnostics and Treatment decision NCCN Guideline Multidisciplinary team with expertise in sarcoma CT +/- MRI NCCN Practice Guidelines in Oncology v

7 Imaging in Retroperitoneal Sarcoma Requests Anatomy of lesion Displacementand infiltration of organs Tissue qualityof lesion Contrast enhancement 000

8 Imaging in Retroperitoneal Sarcoma Anatomy, Displacement, Organ infiltration, Tumor heterogenity Liposarcoma G1 (WDLS/DDLS) Displacement Mesentery Intestine V. cava Infiltration Kidney Right Colon

9 Imaging in Retroperitoneal Sarcoma Questions to be answered Anatomy of lesion Yes Diagnosis? Malgnancy? Resection possible Yes Surgical margins? 000

10 Imaging in Retroperitoneal Sarcoma Complex Anatomy High-grade Liposarcoma Wide resection not possible Complete resection questionable

11 Imaging in Retroperitoneal Sarcoma Diagnostics and Treatment decision NCCN Guideline Multidisciplinary team with expertise in sarcoma CT +/- MRI Biopsy depending on suspicion of malignancy always beforepreoperativetreatment CT-guided core-needlebiopsy NCCN Practice Guidelines in Oncology v

12 Imaging in Retroperitoneal Sarcoma CT-guided Core Needle Biopsy Biopsy-tract determined by surgeon - radiologist

13 Problems of Biopsy Heterogeneity of tumors

14 Problems of Biopsy Heterogeneity of tumors Liposarcoma G1 G3 Charité Berlin

15 Retroperitoneal Sarcoma Image guided biopsy

16 Retroperitoneal Sarcoma Image guided biopsy

17 Retroperitoneal Liposarcoma Results of Biopsy M D Anderson biopsies (FNP/Core needle) in 120 patients Subtype correct 83/137 WDLS 63/74 DDLS 23/63 Importanceofqualitycontrol for image guided biopsy 37 Ikoma et al, Ann Surg Oncol 2015

18 Biopsy in Retroperitoneal Sarcoma Risk of relapse increased? 90 patients with percutaneous biopsy No influence on relapse rate Wilkinson et al., Ann Surg Oncol

19 Retroperitoneal Sarcoma Quality of Surgery and Results Completenes of resection Surgical Margins Surgical Planning and Strategy 000

20 Retroperitoneal Sarcoma Results in High-volume Centers 7 y OS 7 y DFS Development 50.5 % 35.7 % Validation 58 % 38.4 % Raut et al, Cancer 2016

21 Retroperitoneal Sarcoma Nomogramwith prognosticfactors Patients 7 y OS Development set % Validation set % Raut et al, Cancer 2016

22 Retroperitoneal Sarcoma Influence of resection margins Kirane & Crago, J Surg Oncol 2016

23 Relevance of Surgical Quality Influence of resection margins National Cancer Database Only patients with documented resection margins Patients 4015 R % R % Outcome Analysis 2250 Propensity Score 740 vs 740 Stahl et al, EJSO 2017

24 Relevance of Surgical Quality Influence of resection margins Outcome Analysis Propensity Score n=2250 n= 740 vs 740 Stahl et al, EJSO 2017

25 Retroperitoneal Sarcoma Different Surgical Strategies 1. Simple resection (marginal) Shelling out 2. Resection with macroscopically infiltraded organs en bloc 3. Deliberateresection with neighbouringorgans to achieve clear anatomic boundaryand margins Compartmental Resection

26 Simple tumor resection Shelling out Organ and function sparing marginal resection - often palliative -

27 Surgical planning Marginal Resection Dedifferentiated Liposarcoma, 75-year old man

28 Anatomical boundaries and Surgical Planning Only marginal resection possible

29 Surgery of Retroperitoneal Sarcoma Importance of unfragmented resection Resection margin Resection fragmented 31 Keung et al, J Am Coll Surg. 2014

30 Surgical Planning in Retroperitoneal Sarcoma Vascular infiltration Tumor encloses V. cava and Aorta

31 Surgical Planning in Retroperitoneal Sarcoma Vascular infiltration En-bloc vascular resection and replacement

32 Retroperitoneal Sarcoma Multivisceral en-bloc resection

33 Retroperitoneal Sarcoma Different Surgical Strategies 1. Simple resection (marginal) Shelling out 2. Resection with macroscopically infiltraded organs en bloc 3. Deliberateresection with neighbouringorgans to achieve clear anatomic boundaryand margins Compartmental Resection

34 Anatomical Boundaries and Surgical Planning Dedifferentiated Liposarcoma, 55-year old man Pancreas/Duodenum Right Colon/Small intestine Ureter crosses tumor

35 Anatomical Boundaries and Surgical Planning Dedifferentiated Liposarcoma, 55-year old man Right kidney possibly involved Infiltration of V. cava?

36 Surgical strategy- Compartmental Resection Right Colectomy Dorsal parts of mesenteryfat Nephrectomy with ureter Resektion of psoas muscle Resection of all retropertoneal fat Dorsal abdominal wall muscles Planning of vascular resection (V.cava)

37 Retroperitoneal Sarcoma RadicalResection Strategy 288 Patients, 2 time periods Change of strategy to aggressive multivisceralresection compartmental reseection Organ resection 81 % vs 60 % Locoregional relapse reduced (28 % vs 48 %) Overall survival not improved Gronchi et al, J Clin Oncol 2009

38 Retroperitoneal Sarcoma Agressive Surgical Strategy Deliberate multivisceral resection Simple resection 17 % Organ resection if infiltrated 35 % Compartmental Resection 32 % Incomplete Resection (R2) 10 % 4 Bonvalot et al, J Clin Oncol 2009

39 Retroperitoneal Sarcoma Radical Surgical Strategy Lower rate of positive margins (R1) positive margins Simple resection 40 % Organs resected if infiltrated 36 % Compartmental resection 19 % Locoregional control improved 4 Bonvalot et al, J Clin Oncol 2009

40 Retroperitoneal Sarcoma Radical Resection Strategy Compartmental resection Improvement of locoregional control 4 Bonvalot et al, J Clin Oncol 2009

41 Retroperitoneal Sarcoma Radical Resection Strategy Compartmental resection Improvement of locoregional control 4 Bonvalot et al, J Clin Oncol 2009

42 Compartmental Resection Strategy Preoperative Definition of Surgical Planes Abdominal wall ventral dorsal Psoas Kidney Right colon Dorsal layer of mesentery Negative margin not guaranteed

43 Compartmental Resection Strategy No clear tumor margins in fatty tissue complete removal of retroperitoneal fat - nerve sparing -

44 Anatomical Boundaries and Surgical Planning Dedifferentiated Liposarcoma, 45-year old man

45 Anatomical Boundaries and Surgical Planning Dedifferentiated Liposarcoma, 45-year old man Abdominal wall musculature M. Iliacus /M. psoas Vascular dissection A. iliaca, be prepared for resection/reconstruction Colectomy (ileocoecal) Inguinal canal with spermatic cord

46 Retroperitoneal Sarcoma MultivisceralResection and Organ Infiltration 4 Bonvalot et al, J Clin Oncol 2009

47 Multivisceral Resection Strategy Histological Organ Infiltration Patients with organs resected 99 Inflitration confirmed % Organs resected 302 Infiltration confirmed % Kidney 16 % Kolon 25 % Organ infiltration predictive for overall survival noinfluenceon locoregionalcontrol Fairweather et al, JACS 2017

48 Deliberate Organ Resection Renal function impairment possible Renal function change in113 patients after nephrectomy preop postop Smith et al, Br J Surg 2015

49 Retroperitoneal Sarcoma Radical Resection Strategy Compartmental Resection Morbidity and Mortality n= 259; Villejuif/Milan Complete Resection 93 % Mulitvisceral 90 % > 1 Organ 74 % Complications 18 % Reoperation 12 % Mortality 3 % 33 Bonvalot et al, Ann Surg Oncol. 2010

50 Extended Organ Resection in Sarcoma Surgical Morbidity not increased 156 patients; ACS Database Contiguous organ resection 37 % Morbidity 26 % Severe 11.5 % Mortality 1.3 % Severemorbiditycorrelated to operative time, not to organ resection Tseng et al, J Surg Oncol 2010

51 Radical Resection Strategy Age-dependent Decision Royal Marsden Hospital patients 73 % underwentsurgery (281/385) Age Surgery Morbidity <65 88 % 9.5 % >65 58 % 28.3 % Oncological outcome comparable 37 Smith et al, Eur J Cancer 2016

52 Compartmental Resection Strategy Application limited 149 patients fromrandomised EORTC-trial Hyperthermia Only patients with complete tumor removal (R0/R1) Applied strategy Compartmental 34/ % Wide 106/ % Marginal 9/149 6 % Angele et al, Ann Surg Oncol 2014

53 Radical Resection Strategy and Anatomy Limited influence on surgical margins Kirane & Crago, J Surg Oncol 2016

54 Retroperitoneal Sarcoma MultivisceralResection and Caseload Multicenter Study, 382 patients Cases/Center Multivisceral % % >30 76 % p< Bonvalot et al, J Clin Oncol 2009

55 Retroperitoneal Sarcoma Surgical Quality and Caseload Sarcoma Center Others Patients Incomplete Resection 16 % 33 % p year OS 55 % 43 % p 0.02 van Dalen et al, Ann Surg Oncol 2004

56 Retroperitoneal Sarcoma Results in High-volume Centers 1007 patients - 8 centers Complete 95.3 % Multivisceral 87 % Fragmentation 6.2 % Mortality 30 days 1.8 % 90 days 4.1 % 5 years 10 years Overall survival 67 % 46 % Local recurrence 25.9 % 35 % Metastasis 21 % 21.6 % Gronchi et al, Ann Surg 2016

57 Retroperitoneal Sarcoma Histology and Relapse Gronchi et al, Ann Surg 2016

58 Radical Resection Strategy Locoregional Control and Histology Royal Marsden Hospital Patients 362 complete resection % multivisceral % Locoregional Control (3 years) WDLS 98 % DDLS 57 % LMS 80 % Smith et al, Br J Surg 2015

59 Retroperitoneal Sarcoma Role of Radiotherapy Limited results of Surgeryalone Data on chemotherapy controversial Chemotherapy + Hyperthermia beneficial Radiotherapy essential in limb sarcoma 000

60 Radiotherapy in Retroperitoneal Sarcoma PreoperativeTreatment for Liposarcoma National Cancer Database /2082 patients with preoperative radiotherapy Overall Survival unmatched ns Propensitiy Score 129 vs 84 months Analysis HR 1.54 ( ) p Ecker et al, Br J Surg 2016

61 Radiotherapy in Retroperitoneal Sarcoma PreoperativeTreatment and SurgicalMargins National Cancer Database Patients preop radioth. 696 Negative margins (R0) RT yes 77.5 % RT no 73 % p OS not influenced 37 Nussbaum et al, Ann Surg 2015

62 Radiotherapy in Retroperitoneal Sarcoma Large Database Results National Cancer Database Patients 9068 Radiotherapy preop 563 postop radioth surgery alone 6290 Negative margins 69 % Propensitiy Score Analysis preop vs OP (1:2) postop vs. OP (1:1) 563 vs 1126 patients 2196 vs 2190 patients 37 Nussbaum et al, Lancet Oncol 2016

63 Radiotherapy in Retroperitoneal Sarcoma Survival Benefit for Preoperative Treatment OS HR p 110 vs 66 m 0.78 ( ) < Nussbaum et al, Lancet Oncol 2016

64 Radiotherapy in Retroperitoneal Sarcoma Survival Benefit for Postoperative Treatment OS HR p 89 vs 64 m 0.79 ( ) < Nussbaum et al, Lancet Oncol 2016

65 Retroperitoneal Sarcoma Compartmental Resection Strategy High quality imaging essential Anatomically based surgical planning Preoperative biopsy Deliberate multivisceral resection to enable negative surgical margins Generous application of preop multimodal treatment Always considering patient factors and histology

66 Case Presentation 52 year old male CT scan

67 Case Presentation 52 year old male CT scan

68 Case Presentation 52 year old male CT scan Diagnosis Biopsy Liposarcoma CNB

69 Case Presentation Biopsyresult Well differentiated Liposarcoma

70 Case Presentation 52 year old male CT scan Diagnosis Biopsy Resectable Liposarcoma CNB Yes Surgery

71 Case Presentation 52 year old male CT scan

72 Case Presentation 52 year old male CT scan Diagnosis Biopsy Resectable Surgery Negative Margins Treatment strategy Liposarcoma CNB Yes Pancreas, Spleen, Kidney, Left Colon, Abdominal wall, Psoas Not sure Preop Radiotherapy

73 Case Presentation Dose distribution in Advanced Tumor