Minimally Invasive Surgery for Retroperitoneal Soft Tissue Sarcoma

PAST

Nationally representative observational studies as well as prospective randomized clinical trials have demonstrated that minimally invasive surgery (MIS) is associated with improved postoperative outcomes after pelvic and gastrointestinal operations.¹ Yet, the role of MIS in the treatment of retroperitoneal soft tissue sarcoma (RPS)<AQ1> remains unknown, with existing studies limited to a small number of case reports or case series that lack generalizability and appropriate comparison groups. Given the dearth of data comparing outcomes by operative approach, the authors’ group used data from 3844 patients with histologically confirmed RPS included in the American College of Surgeons (ACS) National Cancer Database (NCDB) to examine the use of MIS for the management of RPS in the United States and sought to compare short- and long-term outcomes by operative approach for this patient population.²

PRESENT

Although current clinical guidelines recommend open resection of RPS at high-volume hospitals, alarmingly, in the authors’ study,² use of MIS was observed to be 10.7 % and increased from 7.4 % in 2010 to 12.0 % in 2015, almost a 50 % increase. ³ Furthermore, nearly one third of the patients underwent surgery at community hospitals, in which the use of MIS was disproportionately higher than in academic medical centers. Importantly, MIS was associated with a shorter hospital stay, but other outcomes including 30- day postoperative readmission, 30- and 90-day mortality, and overall survival were comparable between the operative approaches. To the best of the authors’ knowledge, their study represents the first and largest study to examine the use of MIS for the treatment of RPS.² Taken together with existing literature describing the use of MIS for oncologic surgery as well as epidemiology and survival for RPS, the results of their study suggest that although the use of MIS may confer some improvements in short-term outcomes, additional research is required to evaluate the efficacy and safety of MIS before widespread uptake of MIS for RPS.^4,5 Moreover, given the substantial proportion of patients receiving care at community hospitals and the increasing trend in the use of MIS, the results of this study serve as the “canary in the coal mine,” providing evidence for poor adherence to best practices and evidence-based clinical guidelines for the treatment of RPS.

FUTURE

Management of RPS is complex. Because the tumors are large (often >20 cm), insidious, and invasive of adjacent structures and organs, patients frequently require multi-visceral resections, making the oncologic merits of MIS for the treatment of RPS difficult to justify.⁵ Moreover, given a lack of robust data evaluating local control, disease recurrence, or prospective follow-up assessment, the current study reiterates the need to evaluate the oncologic safety and efficacy of MIS for the treatment of RPS. Until such evidence is available, patients should not receive MIS for the treatment of RPS. Rather, patients should receive care in adherence to current guidelines that recommend referral to high-volume, academic medical centers and use of open surgery to ensure complete surgical resection.⁴