Received: 3 November 2017
Accepted: 3 November 2017
The role and outcomes of palliative surgery for retroperitoneal sarcoma
Siham Zerhouni MD, MSc
Frits Van Coevorden MD
Carol J. Swallow MD, PhD
Department of Surgery, University of
Toronto, Toronto, Ontario, Canada
Department of Surgical Oncology, Princess
Margaret Cancer Centre and Mount Sinai
Hospital, Toronto, Ontario, Canada
Department of Surgical Oncology,
Netherlands Cancer Institute, Amsterdam,
North Holland, Netherlands
Carol Swallow, MD, PhD, Department of Surgery
Mount SInai Hospital, 600 University Avenue,
#1225, Toronto, Ontario, Canada, M5G 1X5.
Categories of noncurative surgery for retroperitoneal sarcoma include: i) grossly
incomplete resection (R2) of primary or locally recurrent tumor; ii) resection in the
setting of distant metastatic disease; and iii) true palliative-intent symptom-directed
surgery. The value of R2 resection is debatable, since most series do not report initial
operative intent. Debulking surgery provides symptom relief in the majority of patients,
but relief is generally not durable. Quality of life is poorly studied.
palliative, R2 resection, retroperitoneal sarcoma, surgery
In a sense, the majority of surgical procedures performed in patients
with retroperitoneal sarcoma (RPS) could be regarded as “palliative.”
Large surgical series with long-term follow-up have shown that while
the recurrence rate is highest within the first two years following
complete resection of primary RPS, recurrences continue to occur 15-
20 years later, with no apparent plateau.
The very long-term
recurrence-free survival rate is less than 25% in such series. For
recurrent RPS, whether local or distant, the disease-specific survival
rates following resection are worse still.
However, recent improve-
ments in the quality of surgical resection may translate to improved
long-term outcomes. In keeping with the latter expectation, a
consensus statement by the Trans-Atlantic RPS working group
emphasizes that the best chance of curative resection
is at time of primary presentation, with discussion of every patient at a
multidisciplinary sarcoma conference where adjuvant therapies can be
considered as the optimal approach to “curative-intent” management
is developed for the individual patient. By contrast, the role of surgery
in patients who are not eligible for a curative approach is fraught with
uncertainty and controversy.
The term “palliative care” was first coined in 1975 by Balfour
Mount, a Canadian urologist who started a palliative care ward in
Montreal after visiting the first hospice established by Dame Cicely
Saunders in the UK.
It took 2-3 decades before principles of palliative
care were finally integrated in the Institute of Medical Science address
on “Improving Palliative Care for Cancer”
and in the American
College of Surgeons' “Principles of Guiding Care at the End of Life.”
The World Health Organization defines palliative care as “an approach
that improves the quality of life of patients and their families facing the
problems associated with life-threatening illness, through the preven-
tion and relief of suffering by means of early identification and
impeccable assessment and treatment of pain and other problems,
physical, psychosocial and spiritual.”
The assessment of outcomes in palliative care is challenging. Since
death is inevitable, survival differences may be considered irrelevant.
Self-reported morbidity and quality of life differences do not lend
themselves easily to quantitative assessment, rendering comparison of
Randomized clinical trials in this setting are hard to
conduct due to challenges with randomization, blinding, patient
selection, ethical informed consent, and measurement of outcomes.
Efforts are being made to better define goals of palliative surgery. In a
recent survey of surgical oncologists, pain and symptom relief have
been identified as the most important goals of palliative surgery.
It would be fair to say that the role of palliative surgery for
patients with RPS is at present incompletely understood. In the
primary setting, amongst patients who are explored with curative
intent, approximately 85% will have a complete gross (R0/R1)
resection. In patients with recurrent sarcoma, fewer than 50% will be
deemed to be “resectable.” Among those with local recurrence, each
successive recurrence is associated with a shorter disease-free
interval until the next recurrence, a lower rate of complete resection,
and an increased morbidity rate when resection is attempted.
Repeated extensive resections may seriously hamper and diminish
the quality of life after surgery. In this review, we explore the role of
non-curative surgery in RPS.
J Surg Oncol. 2018;117:105–110. wileyonlinelibrary.com/journal/jso © 2017 Wiley Periodicals, Inc.