ASO Author Reflections: Every Step Counts: Improved Survival of Retroperitoneal Sarcoma Patients During the Past 15 Year
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Every Step Counts: Improved Survival of Retroperitoneal Sarcoma Patients During the Past 15 Years Dario Callegaro, MD1,2,3, and Carol J. Swallow, MD, PhD1,2 1
Department of Surgical Oncology, Princess Margaret Cancer Centre/Mount Sinai Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada; 3Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
2
PAST Surgical resection is the cornerstone of treatment for patients with localized primary retroperitoneal sarcoma (RPS). The ability to achieve complete resection of all the macroscopic tumor has long been recognized as a dominant prognostic factor for patients with this disease. In the 1950s and 1960s, the rate of complete resection was as low as 40%, and the perioperative mortality rate was higher than 10%. During the 1980s and 1990s, both the resection rate and the perioperative mortality rate improved, with associated 5-year survival rates in the 40% to 50% range according to major series published in the early 2000s. This was the state-of-the-art of RPS surgery about 20 years ago, at the beginning of the period examined in the current study.1 The last 20 years have brought significant shifts in the approach to management of RPS, which can be clustered into three main themes. First, the role of surgical technique in the resection of primary RPS received increased attention. The sarcoma surgical teams at the Istituto Nazionale Tumori in Milan and the Gustave Roussy in Villejuif adopted a standardized technical approach that included en bloc resection of involved and adherent structures. These two groups published large retrospective series suggesting that this ‘‘extended’’ approach was associated with impressive local
control and potentially improved long-term survival.2,3 Ongoing dialogue and interaction with more ‘‘conservative’’ sarcoma surgeons at other major centers have culminated in the creation of consensus documents that describe shared principles of RPS resection. Second, the Transatlantic Australasian Retroperitoneal Sarcoma Working Group (TARPSWG, www.tarpswg.org) was established in 2013 with the purpose of sharing experience and promoting rigorous cooperative prospective data collection on an international level. This allowed the creation of large series of patients treated in major referral centers, and thereby the exploration of topics such as histology-specific outcomes, post-relapse outcomes, and personalized prognostication. Third, the first phase 3 randomized controlled trial (RCT) specifically analyzing patients with RPS began enrolling patients in 2012, with accrual completed in 2017. The STRASS trial (EORTC 62092) compared short- and long-term outcomes after preoperative radiotherapy plus surgery versus surgery alone for patients with primary RPS. Although several centers have consistently championed the use of preoperative radiotherapy, its application has been highly variable across institutions and not evidence-based. The
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