Surgical Principles of Primary Retroperitoneal Sarcoma in the Era of Personalized Treatment: A Review of the Frontline Extended Surgery

Abstract

Surgery is the key treatment in retroperitoneal sarcoma (RPS), as completeness of resection is the most important prognostic factor related to treatment. Compartmental surgery/frontline extended approach is based on soft-tissue sarcoma surgical principles, and involves resecting adjacent viscera to achieve a wide negative margin. This extended approach is associated with improved local control and survival. This surgery must be tailored to tumor histology, tumor localization, and patient performance status. We herein present a review of compartmental surgery principles, covering the oncological and technical basis, and describing the tailored approach to each tumor subtype and localization in the retroperitoneum.

Keywords: compartmental surgery; leiomyosarcoma; liposarcoma; retroperitoneal sarcoma; solitary fibrous tumor.

Figure 1

Abdominal incisions for en bloc extended surgery. Midline laparotomy—red—. Flank extension—yellow—. Subcostal extension—blue—. Inferior oblique incision—orange—.

Figure 2

Illustration of surgical steps of an extended en bloc resection for a right Grade 2 DDLPS. (A) Extended midline incision. (B) Evaluation of a possible intestinal or mesenteric tumor infiltration, with exposure of mesenteric vessels. (C,D) Dissection and division of renal vessels. (E) Dissection and division of distal ureter. (F) Dissection of posterior margin with psoas muscle resection preserving femoral nerve. (G) Lateral right peritonectomy en bloc with right colon, right kidney en bloc with the tumor. (H) Surgical bed.

Figure 3

Resected specimen from Figure 2. This right LPS was resected en bloc with the right colon, right kidney, and right psoas muscle.

Figure 4

Diagram representation of the most common subtypes of primary retroperitoneal sarcoma based on TARPSWG, 2020 series of 1942 RPS patients [19].