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10.1245/ASO.2006.03.026
Annals of Surgical Oncology 13:245-252 (2006)
© 2006 Society of Surgical Oncology
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Original Article

Surgery Combined With Intraoperative Brachytherapy in the Treatment of Retroperitoneal Sarcomas

Wirginiusz Dziewirski, MD1, Piotr Rutkowski, MD1, Zbigniew I. Nowecki, MD1, Maciej Salamacha1, Tadeusz Morysinski, MD1, Anna Kulik, MD2, Maria Kawczynska, PhD2, Anetta Kasprowicz, MD2, Jaroslaw Lyczek, MD2 and Wlodzimierz Ruka, MD1

1 Department of Soft Tissue/Bone Sarcoma, M. Sklodowska-Curie Cancer Center and Institute of Oncology, W.K. Roentgena Str. 5, 02-781, Warsaw, Poland
2 Department of Brachytherapy, M. Sklodowska-Curie Cancer Center and Institute of Oncology, W.K. Roentgena Str. 5, 02-781, Warsaw, Poland

Correspondence: Address correspondence and reprint requests to: Piotr Rutkowski, MD; E-mail: rutkowskip{at}coi.waw.pl.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The purpose of this study was to analyze the results of treatment of retro-peritoneal soft tissue sarcomas (RSTS) by surgery combined with intraoperative brachytherapy (IOBRT).

Methods: Seventy adult patients with RSTS were considered for combined treatment (surgery plus IOBRT) between June 1998 and February 2004. There were 64 (91%) recurrent tumors, and 93% of tumors exceeded 5 cm. IOBRT was performed with high-dose-rate Gammamed 12 with iridium 192 (IOBRT time range, 20–87 minutes; median, 56 minutes).

Results: After intraoperative re-evaluation, 24 patients (34%) were found to be ineligible for IOBRT because of multiple intraperitoneal recurrences, macroscopically nonradical resection, poor general condition, and technical aspects. Thirty-seven patients underwent IOBRT immediately after surgery during the same general anesthesia procedure. Nine patients underwent delayed IOBRT within 1 to 3 days after the primary operation. Ten (21.5%) of 46 patients underwent reoperation because of surgical complications. One patient died in the postoperative period. After IOBRT, 24 patients (52%) underwent adjuvant external beam radiotherapy (EBRT) to a total dose of 50 Gy. Over a median follow-up time of 20 months, the estimated 5-year overall survival and local recurrence–free survival rates in IOBRT patients were 55% and 51%, respectively. Application of adjuvant EBRT showed a favorable local control rate.

Conclusions: The scheduled combined treatment (surgery plus IOBRT) was possible to perform in 66% of RSTS cases that received surgical treatment. The complication rate was high, but we consider it acceptable because of the necessity for extensive aggressive surgical treatment in regionally advanced RSTS. EBRT seems to be an indispensable part of treatment that provides better local control.

Key Words: Sarcoma • Retroperitoneal • Soft tissue • Recurrence • Brachytherapy • Radiotherapy


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Surgery is the mainstay of treatment for soft tissue sarcomas, but retroperitoneal soft tissue sarcomas (RSTS) are often diagnosed as very advanced cases, and the resection outcomes are rather unfavorable.1,2 Microscopically complete resection (R0) is one of the main predictors of recurrence of the disease. Anatomical localization, lack of true surgical compartments, asymptomatic growth of large masses, and frequent invasion of adjacent organs make the surgical procedure difficult, often necessitating the excision of other structures but also resulting in problems with microscopic radicality. All these technical challenges cause the high recurrence rate when surgery is used as the sole treatment modality.

Adjuvant external beam radiotherapy (EBRT) decreases the recurrence rate in soft tissue sarcomas of the extremities,3,4 but obtaining an adequate therapeutic dose (≥60 Gy) in RSTS is difficult because of anatomical restrictions, and EBRT is accompanied by a high risk of postradiation complications.5 The application of intraoperative brachytherapy (IOBRT) at the site of sarcoma removal is one of the alternative approaches6–14 that may allow an increased total radiotherapy dose. The aim of this study was to analyze the results of surgical treatment of RSTS combined with intraoperative high-dose brachytherapy performed in one institution and the effect of postoperative adjuvant EBRT in this group of patients.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
We analyzed 70 consecutive adult patients with RSTS (pediatric and gynecological sarcomas were excluded) considered for surgery with curative intent combined with IOBRT at the Department of Soft Tissue/Bone Sarcoma of the M. Sklodowska-Curie Cancer Center and Institute of Oncology in Warsaw, Poland, from June 1998 to February 2004. There were 26 male (median age, 45 years) and 44 female (median age, 51 years) patients. Sixty-four cases (91%) were recurrent locoregional tumors primarily treated (with multiple surgical resections; range one to five) outside our center, and only six cases (9%) were primarily diagnosed and treated in our department. Informed consent was obtained from all patients, and the study was approved by the local bioethics committee.

Patient characteristics are listed in Table 1Go. All pathologic results were confirmed at the Department of Pathology of the M. Sklodowska-Curie Cancer Center and Institute of Oncology: we reviewed the pathologic characteristics of recurrent cases, and biopsies were performed for all primary tumors before surgery in our center. The largest diameter of most treated tumors (93%) exceeded 5 cm (6–23 cm; median tumor size, 15 cm). Histological grade 2 or 3 was found in 76% of cases. Histologically the tumors were liposarcomas (51%), leiomyosarcomas (14%), malignant schwannomas (4%), gastrointestinal stromal tumors (4%), hemangiopericytomas (4%), and others (24%).


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  		TABLE 1. Patient characteristics
 
The clinicopathologic features of RSTS were determined by physical examination, pathologic examination of the tumor, and routine preoperative imaging examinations (chest radiograph, computed tomography of the abdominal cavity and the pelvis, and ultrasonography of the abdominal cavity). The clinical and pathologic parameters examined for prognostic value in the group undergoing IOBRT were tumor size (dichotomized into two groups: <10 and >10 cm), tumor grade (low grade [grade 1] vs. high grade [grade 2 or 3]), histological type (liposarcoma vs. others), sex, contiguous organ resection (zero additional organs, one organ, and more than one organ), number of previous operations (zero, one, or more than one), and subsequent EBRT. We did not include the microscopic status of resection margins (R0 vs. R1) in this analysis because the reliable determination of the margin status in large, mostly recurrent retroperitoneal sarcomas is doubtful.

Intraoperative Brachytherapy
The operation was performed in a theater situated in the direct vicinity of the bunker containing the high-dose-rate unit. The preferable operative access was as follows: abdominoinguinal incision for complete retroperitoneal access for tumors of the lower abdominal quadrants or longitudinal median laparotomy for tumors of the median part of abdomen with the possibility of extending the incision to perform thoracophrenolaparotomy in the upper quadrants when necessary. After careful exploration and removal of the tumor, the patient was reevaluated for eligibility for IOBRT (good general condition, hemoglobin level >9 g/dL, absence of multifocal disease, macroscopically radical surgery, and absence of technical contraindications, such as the presence of large vessels in the potential irradiation field). If the patient met these criteria, he or she underwent high-dose IOBRT with the application of high-dose-rate afterloader Gammamed 12i (Varian Medical Systems, Charlottesville, VA) with iridium 192 as the radiation source with a nominal activity of 10 Ci. The flap applicator (Harrison Anderson Mick) was introduced into the tumor bed, and other structures were separated during surgery. The irradiated area was marked with titanium clips. After the applicator was fixed, its localization was ascertained on radiograph by using the C-arm Philips BV212 unit. Two orthogonal films were taken in the isocentric position, and both were exported to the Treatment Planning System Abacus 1.6 (Varian Medical Systems, Charlottesville, VA) as basic information for planning isodoses. The tumor volume was described on the basis of computed tomographic and magnetic resonance imaging scan, ultrasonography, and clinical examination during surgery. Margins from the clips were increased by 1 to 2 cm to obtain a safety margin; thus, the tumor volume and the margins were defined as the treatment volume with a 100% treatment dose. A total of 20 Gy in a single dose was delivered to the treatment volume. The depth of IOBRT was 1 cm. The positions of the catheters were carefully checked with the aid of radiograph just before the treatment session. The duration of the treatment sessions ranged from 20 to 87 minutes (median, 56 minutes), depending on the treatment volume and the actual activity of the source. In some cases of patients in poor intraoperative condition, but without other contraindications for IOBRT, delayed IOBRT was performed within 1 to 3 days after the primary operation, when their general status improved. Blood transfusions resulted in hemoglobin levels >9 g/L, and packing of the tumor site (if required for hemostasis control) was removed. After IOBRT completion, the applicators were removed, the operating field was rinsed, and the wound was primarily closed.

Since 2000, we have introduced the protocol of adjuvant EBRT in eligible patients (EBRT beginning 30 days after the operation; total dose, 50 Gy). In 24 patients (52%) after IOBRT, we applied adjuvant EBRT to a total dose of 50 Gy. All but two patients received the intended dose of 50 Gy (one patient received 42 Gy because of neurological side effects, pain, and refusal of further therapy, and one received 36 Gy because of refusal of further treatment, without any obvious side effects). Chemotherapy was not given as adjuvant treatment with the exception of two patients with the diagnosis of primitive neuroectodermal tumor.

Follow-Up and Statistical Analysis
Postoperative follow-up consisted of physical examination and routine imaging investigations (computed tomography and sonography of the abdominal cavity). Routinely, surveillance was recommended every 3 months for the first 2 years, every 6 months for years 3 to 5, and annually thereafter.

The median follow-up time was 20 months for survivors (range, 7–76 months). Overall survival (OS) time was calculated from the date of operation at the study institution to the date of the most recent follow-up or death. Similarly, the local recurrence–free survival (LRFS) time was estimated from the date of tumor excision to the date of the most recent follow-up or local disease recurrence.

For prospective data collection, the hospital system Oncosys and database Sarcoma were applied. Statistical computations were performed by using Statistica software (StatSoft, Tulsa, OK). For survival analysis, the Kaplan-Meier method in combination with the log-rank test was used for univariate analysis. We did not perform multivariate analysis because of relatively small numbers of patients in some subgroups. Differences were considered statistically significant if P values were <.05.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
After intraoperative reevaluation, 46 patients underwent IOBRT. Of these, 37 (80%) were irradiated immediately after tumor excision during the same course of general anesthesia. The remaining nine patients (20%) underwent delayed brachytherapy. The characteristics of patients who underwent IOBRT are listed in Table 1Go. Twenty-four patients (34%) were ineligible for IOBRT. The reasons for their disqualification were as follows: multiple intra-peritoneal recurrences undetected during preoperative imaging evaluations (n = 11), macroscopically nonradical (R2) surgical removal of the tumor (n = 5), poor general condition (n = 3), and technical aspects—mainly the presence of large vessels in the potential irradiation field (n = 5).

Obtaining radical margins during surgery necessitated the removal of other organs in 55 (78.5%) of 70 cases of the entire group (1 organ in 20 patients and ≥2 organs in another 35 cases) and in 38 (82.5%) of 46 cases in the IOBRT group (excision of 1 or >1 organs was performed in 10 patients [21.5%] and 28 patients [61%], respectively). In the IOBRT group, the resections margins were estimated pathologically as R0 in 30 cases (65%) and R1 in 16 cases (35%).

One patient died after surgery. Postoperative complications that necessitated surgery occurred in 10 patients (21.7%) after IOBRT and included intraperitoneal abscess (2 cases), stercoral fistula (2 cases), wound dehiscence (2 cases), ileus (1 case), duodenal fistula (1 case), hemorrhage (1 case), and massive hydroperitoneum (1 case). In the group of patients undergoing adjuvant EBRT, the most common chronic complaint was chronic subileus (5 [21%] of 24). Two patients underwent operation because of ileus symptoms (in one case with accompanying intestinal fistula) 15 and 26 months after the primary operation. One patient died of complications, and two patients (8%) complained of peripheral neuropathy.

The estimated 5-year OS in the entire cohort of 67 patients (gastrointestinal stromal tumor patients were excluded from the survival analysis because of the distinct natural history of this subtype of abdominal sarcomas) was 44%, and the median survival time was 38 months. During follow-up, 28 patients (61%) from the IOBRT group were alive. Twelve patients (26%) died of disease progression, and six patients (13%) died of non–sarcoma-related reasons (four from medical conditions, mainly cardiovascular, and two from treatment complications in the postoperative period). The estimated 5-year OS in the IOBRT group was 55% (Fig. 1Go), and the median OS has not yet been reached. In univariate analysis, the important negative factors influencing the prognosis were a higher tumor grade (P = .009), operation of recurrent disease (one or more previous operations; P = .03), and a histological type other than liposarcoma (P = .007). The actuarial 3-year OS was 78% for grade 1 tumors versus 46% for grade 2 or 3 tumors, 100% for primary tumors, 53% for recurrent tumors, 73% for liposarcoma, and 33% for other histological types. No significant correlations were found between OS and tumor size, contiguous organ resection, adjuvant EBRT, or sex (Table 2Go).


Figure 1
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  		FIG. 1. Overall survival of patients after intraoperative brachytherapy.

 

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  		TABLE 2. Predictive factors that influenced the OS and LRFS of patients undergoing IOBRT according to univariate analysis
 
The median LRFS time after IOBRT was 45 months, and the estimated 5-year LRFS rate was 51% (Fig. 2Go). The following factors significantly influenced poor LRFS in univariate analysis: operation of recurrent disease (P = .03) and lack of adjuvant EBRT (P = .04). The actuarial 3-year LRFS was 100% in primary tumors versus 68% in recurrent tumors and was 88% in patients undergoing adjuvant EBRT versus 58% in patients with IOBRT alone. We did not observe an influence of the following factors on LRFS: tumor size, tumor grade, contiguous organ resection, pathologic tumor type, or sex (Table 2Go).


Figure 2
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  		FIG. 2. Local recurrence–free survival of patients after intraoperative brachytherapy.

 
Patients after IOBRT demonstrated the following pattern of disease recurrences (a total of 18): local or intraperitoneal recurrences (n = 13; 72%), liver metastases (n = 2; 11%), lung metastases (n = 2; 11%), and bone metastases (n = 1; 6%). In the IO-BRT-only group, the pattern of recurrences showed a higher rate of local recurrences (9 [41%] of 22) and a rate of distant recurrences (2 [9.1%] of 24) similar to that in the IOBRT plus adjuvant postoperative EBRT group: the local recurrence rate was 17% (4 of 24; P = .07), and the distant recurrence rate was 12.5% (3 of 24).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
RSTS comprise a group of rare neoplasms that usually have a poor prognosis. Several series of patients with RSTS may be found in the literature that provide differing data regarding the treatment outcome.1,15–23 Complete surgical resection at the time of primary presentation seems to offer the best chance for long-term survival.1,23–25 However, it is not common to perform such an excision because RSTS often present as large (>10 cm), deeply located masses. Only a small group of RSTS patients develop distant metastases.24 In most cases, the reasons for treatment failure depend on locoregional recurrence. This was confirmed in our patient series: >75% of recurrences could be assessed as locoregional failure. It implies that improvements in local treatment may increase the curability rate. There is strong evidence that adjuvant radiotherapy improves the local control rate in combination with conservative surgery in the treatment of soft tissue sarcomas of the extremities and trunk in patients with negative, marginal, or minimal microscopic positive surgical margins.3,4 Similarly, studies with EBRT combined with surgical resection of retroperitoneal tumors have shown a reduction of local recurrences.26–28 The results of several studies with EBRT in adult soft tissue sarcomas indicate a strong dependence of local failure rates on the radiation dose.3,29 Tepper et al.30 observed local failure rates of 67% in patients with retroperitoneal sarcomas who underwent postoperative radiation at doses <50 Gy, as compared with 17% for those who received postoperative radiation doses of >60 Gy. This effective, adequate dose of ≥60 Gy is difficult to obtain in RSTS because of the intimacy of the tumor with radiosensitive healthy organs, such as the bowel, the kidney, or the great vessels.

IOBRT (used as electron beam or high-dose-rate radiation31; the latter is used in our center) is an alternative method, the results of which are comparable to EBRT for local control for high-grade sarcomas.4,17 IOBRT allows delivery of a high dose of radiotherapy to the high-risk area while sparing healthy tissue irradiation as a result of the intraoperative placement of catheters in the retroperitoneal tumor bed.8,14,17,26 The theoretical advantages of IOBRT comprise direct visualization of the treatment field, thus allowing for greater control over the dose prescription and distribution, and delivery of higher doses of radiation (with the biologic efficacy of a high dose given in a single fraction estimated to be two to five times stronger than the equivalent dose given in traditional fractions) to a field that conforms more closely to the tumor bed. Thus, the doses applied to the surrounding tissues can be limited more effectively than in preoperative or postoperative EBRT (high-dose-rate IOBRT has sources with a rapid dose-rate falloff). It may be combined with EBRT, and such a combination (which seems efficient for decreasing local failure) may allow increasing the total dose of radiation given to the tumor bed to at least 60 to 65 Gy.20,29

Taking into account the entire group of patients considered for these methods in our series, IOBRT was feasible to perform in 66% of patients, and approximately half of them subsequently underwent EBRT. It is difficult to determine the reliable profile of toxicity of these methods, considering that some of the complications are related to mutilating surgery. The surgical procedures were often very extensive and in more than 80% of cases were connected with the removal of other organs. Naturally, IOBRT should be used by experienced multidisciplinary teams of radiation oncologists and surgeons to ensure the best results for patients. According to the systematic review of radiotherapy effects in soft tissue sarcomas, the available data concerning the effect of IOBRT for RSTS3 are still inconclusive, although some studies showed a tendency for increased local control when intraoperative radiotherapy was added.8,27 The point is the effect of combining IOBRT with EBRT. It has been suggested that in certain clinical situations (especially in extra-compartmental presentation of the tumor, as is seen in retroperitoneal sarcomas and in recurrent tumors), more comprehensive irradiation (e.g., a combination of EBRT and IOBRT) is required.26 EBRT may be delivered as adjuvant treatment in two sequences: before or after surgery and combined or not with IO-BRT.7,8,9,11,12,27,32–36 In our study, we used postoperative EBRT, and the results allow prediction that the application of adjuvant EBRT is the fundamental part of combined treatment in retroperitoneal sarcomas. It allows for the delivery of an appropriate dose of radiotherapy (not IOBRT alone) to provide favorable local control. Other adjuvant treatment options (such as systemic or intraperitoneal chemotherapy) remain disappointing.2

The OS and LRFS rates in our group of patients are comparable to the range of survival rate results observed in other patient series. As we have already mentioned, the treatment outcomes reported in the literature are based predominantly on small cohorts of patients and vary (the 5-year OS ranges from 12% to 70%).1,15,16,23–25,33,37–41 It is also difficult to find a current database that would present patients treated only surgically. However, when the results of a contemporary group of patients presented by Jenkins et al.1 from the Royal Marsden Hospital (London, UK), which has shown a 5-year survival rate of 20%, are analyzed, the survival analysis of our entire cohort of patients (the IOBRT patients comprise a self-selected subset with a more favorable outcome) demonstrated a beneficial result of 44%. Similarly, Storm and Mahvi,42 in a series of 204 patients who had undergone macroscopically complete resection, reported a local recurrence rate of 72% at 5 years, as compared with approximately 50% in our study. Also the outcomes of treatment of primary tumors are far better than those for locally recurrent cases.23,43 Therefore, considering the prevalence of recurrent and high-grade tumors in our group of patients after IOBRT, the 5-year OS and LRFS rates imply the positive effect of radiotherapy. An important positive factor that influenced both OS and LRFS was performing surgery of primary tumors. We may conclude that surgical treatment in recurrent disease is less effective, because most patients after surgical removal of locally recurrent lesions again demonstrate recurrent disease. Tumor grade is the most important prognostic factor for OS in soft tissue sarcomas, and this was also shown in our group of retroperitoneal sarcomas.44 It is interesting to note that the diagnosis of the most frequent subtype of RSTS—liposarcoma—showed favorable OS, but not LRFS. This may be explained by the fact that most of these tumors are characterized by low aggressive behavior, although they have a high recurrence potential.

In conclusion, scheduled combined treatment (surgery plus IOBRT) was possible to perform in 66% of RSTS patients who received surgical treatment. In cases of retroperitoneal sarcomas, adjuvant EBRT after surgery combined with IOBRT seems to be the necessary element of such combined treatment to ensure a high local control rate. The complication rate was high, but acceptable, because of the necessity of aggressive extensive surgical treatment in regionally advanced RSTS. The estimated OS of 55% warrants further studies to achieve improvement of the treatment methods for RSTS.


   ACKNOWLEDGMENTS
 
The authors thank M. Symonides, MD, PhD, for linguistic assistance.

Received for publication March 4, 2005. Accepted for publication August 17, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Jenkins MP, Alvaranga JC, Thomas JM. The management of retroperitoneal soft tissue sarcomas. Eur J Cancer 1996;32A: 622–6.[CrossRef]
  2. McGrath PC. Retroperitoneal sarcomas. Semin Surg Oncol 1994;10:364–8.[Medline]
  3. Strander H, Turesson I, Cavallin-Stahl E. A systematic overview of radiation therapy effects in soft tissue sarcomas. Acta Oncol 2003;42:516–31.[CrossRef][Medline]
  4. O’Sullivan B, Ward I, Catton C. Recent advances in radiotherapy for soft-tissue sarcoma. Curr Oncol Rep 2003;5:274–81.[Medline]
  5. Gilbeau L, Kantor G, Stoeckle E, et al. Surgical resection and radiotherapy for primary retroperitoneal soft tissue sarcoma. Radiother Oncol 2002;65:137–43.[CrossRef][Medline]
  6. Bobin JY, Al-Lawati T, Granero LE, et al. Surgical management of retroperitoneal sarcomas associated with external and intraoperative electron beam radiotherapy. Eur J Surg Oncol 2003;29:676–81.[Medline]
  7. Petersen IA, Haddock MG, Donohue JH, et al. Use of intraoperative electron beam radiation therapy in the management of retroperitoneal soft tissue sarcoma. Int J Radiat Oncol Biol Phys 2002;52:469–75.[CrossRef][Medline]
  8. Sindelar WF, Kinsella TJ, Chen PW, et al. Intraoperative radiotherapy in retroperitoneal sarcomas. Final results of a prospective, randomized, clinical trial. Arch Surg 1993;128:402–10.[Abstract]
  9. Gieshen HL, Spiro IJ, Suit H, et al. Long-term results of intraoperative electron beam radiation therapy for primary and recurrent retroperitoneal soft tissue sarcoma. Int J Radiat Oncol Biol Phys 2001;50:127–31.[CrossRef][Medline]
  10. Bussieres E, Stockle EP, Richaud PM, et al. Retroperitoneal soft tissue sarcomas: a pilot study of intraoperative radiation therapy. J Surg Oncol 1996;62:49–56.[Medline]
  11. Alektiar KM, Hu K, Anderson L, et al. High dosed rate intraoperative radiation therapy (HDR-IORT) for retroperitoneal sarcomas. Int J Radiat Oncol Biol Phys 2000;47:157–63.[CrossRef][Medline]
  12. Willet CG, Suit HD, Tepper JE, et al. Intraoperative electron beam radiation of retroperitoneal soft tissue sarcoma. Cancer 1991;68:278–83.[Medline]
  13. Classen J, Hehr T, Lamprecht U, Zumbragel A, Bamberg M, Budach W. Hyperfractionated 192Ir brachytherapy for recurrent retroperitoneal sarcoma: a technique for delivery of local tumor boost dose. Strahlenther Onkol 2003;179:118–22.[Medline]
  14. Ellis RJ, Kim E, Kinsella TJ, Eisenberg BL. Intraoperative radiotherapy in the multimodality approach to bone and soft tissue cancers. Surg Oncol Clin North Am 2003;12:1015–29.[Medline]
  15. Ferrario T, Karakousis CP. Retroperitoneal sarcomas: grade and survival. Arch Surg 2003;138:248–51.[Abstract/Free Full Text]
  16. Lewis JJ, Leung D, Woodruff JM, et al. Retroperitoneal soft tissue sarcoma. Analysis of 500 patients treated and followed at a single institution. Ann Surg 1998;228:355–65.[CrossRef][Medline]
  17. Pisters PW, Harrison LB, Leung DH, et al. Long-term results of a prospective randomized trial of adjuvant brachytherapy in soft tissue sarcoma. J Clin Oncol 1996;14:859–68.[Abstract/Free Full Text]
  18. Heslin MJ, Lewis JJ, Nadler E, et al. Prognostic factors associated with long-term survival for retroperitoneal sarcoma: implications for management. J Clin Oncol 1997;15: 2832–39.[Abstract]
  19. Jones JJ, Catton CN, O’Sullivan B, et al. Initial results of a trial of preoperative external-beam radiation therapy and postoperative brachytherapy for retroperitoneal sarcoma. Ann Surg Oncol 2002;9:346–54.[Abstract/Free Full Text]
  20. Wang YN, Zhu WQ, Shen ZZ, Li S, Liu SY. Treatment of locally recurrent soft tissue sarcomas of the retroperitoneum: report of 30 cases. J Surg Oncol 1994;56:213–6.[Medline]
  21. Hassan I, Park SZ, Donohue JH, et al. Operative management of primary retroperitoneal sarcomas: a reappraisal of an institutional experience. Ann Surg 2004;239:244–50.[CrossRef][Medline]
  22. Chiappa A, Zbar AP, Biffi R, et al. Primary and recurrent retroperitoneal sarcoma: factors affecting survival and long-term outcome. Hepatogastroenterology 2004;51:1304–9.[Medline]
  23. Gronchi A, Casali PG, Fiore M, et al. Retroperitoneal soft tissue sarcomas: patterns of recurrence in 167 patients treated at a single institution. Cancer 2004;100:2448–55.[CrossRef][Medline]
  24. Cody HS, Turnbull AD, Fortner JG, Hajdu SI. The continuing challenge of retroperitoneal sarcomas. Cancer 1981;47:2147–52.[CrossRef][Medline]
  25. Jaques DP, Coit DG, Hajdu SI, Brennan MF. Management of primary and recurrent soft-tissue sarcoma of the retroperitoneum. Ann Surg 1990;212:51–9.[Medline]
  26. Ballo MT, Lee AK. Current results of brachytherapy for soft tissue sarcoma. Curr Opin Oncol 2003;15:313–8.[Medline]
  27. Van Doorn RC, Gallee MPW, Hart AAM, et al. Resectable retroperitoneal soft tissue sarcoma. The effect of extent of resection and postoperative radiation therapy on local tumor control. Cancer 1994;73:637–42.[CrossRef][Medline]
  28. Fein D, Corn BW, Lanciano RM, Herbert SH, Hoffman JP, Coia LR. Management of retroperitoneal sarcomas: does dose escalation impact on locoregional control? Int J Radiat Oncol Biol Phys 1995;31:129–34.[CrossRef][Medline]
  29. Zagars GK, Ballo MT. Significance of dose in postoperative radiotherapy for soft tissue sarcoma. Int J Radiat Oncol Biol Phys 2003;56:473–81.[Medline]
  30. Tepper JE, Suit HD, Wood WC, et al. Radiation therapy of retroperitoneal soft tissue sarcomas. Int J Radiat Oncol Biol Phys 1984;10:825–30.[Medline]
  31. Nag S, Hu KS. Intraoperative high-dose-rate brachytherapy. Surg Oncol Clin North Am 2003;12:1079–97.[Medline]
  32. Azinovic I, Martinez Monge R, Javier Aristu J, Salgado E. Intraoperative radiotherapy electron boost followed by moderate doses of external beam radiotherapy in resected soft-tissue sarcoma of the extremities. Radiother Oncol 2003; 67:331–7.[Medline]
  33. Catton CN, O’Sullivan B, Kotwall C, et al. Outcome and prognosis in retroperitoneal soft tissue sarcoma. Int J Radiat Oncol Biol Phys 1994;29:1005–10.[Medline]
  34. Youssef E, Fontanesi J, Mott M, et al. Long-term outcome of combined modality therapy in retroperitoneal and deep-trunk soft-tissue sarcoma: analysis of prognostic factors. Int J Radiat Oncol Biol Phys 2002;54:514–9.[CrossRef][Medline]
  35. Mikula LA, Ko MA, Catton CN, et al. Long-term results of a prospective trial of preoperative radiation and postoperative brachytherapy for retroperitoneal sarcoma (abstract 9007). J Clin Oncol 2005;Suppl:823s.
  36. Gilbeau L, Kantor G, Stoeckle E, et al. Surgical resection and radiotherapy for primary retroperitoneal soft tissue sarcoma. Radiother Oncol 2002;65:137–43.[CrossRef][Medline]
  37. McGrath PC, Neifeld JP, Lawrence W, et al. Improved survival following complete excision of retroperitoneal sarcomas. Ann Surg 1984;200:200–4.[Medline]
  38. Karakousis CP, Velez AF, Emrich LJ. Management of retroperitoneal sarcomas and patient survival. Am J Surg 1985;150:376–80.[CrossRef][Medline]
  39. Salvadori B, Cusumano F, Delledonne V, De Lellis R, Conti R. Surgical treatment of 43 retroperitoneal sarcomas. Eur J Surg Oncol 1986;12:29–33.[Medline]
  40. Dalton RR, Donohue JH, Mucha P, van Heerden JA, Reiman HM, Chen SP. Management of retroperitoneal sarcomas. Surgery 1989;106:725–32.[Medline]
  41. Stoeckle E, Coindre JM, Bonvalot S, et al. Prognostic factors in retroperitoneal sarcoma: a multivariate analysis of a series of 165 patients of the French Cancer Center Federation Sarcoma Group. Cancer 2001;92:359–68.[CrossRef][Medline]
  42. Storm FK, Mahvi DM. Diagnosis and management of retroperitoneal soft-tissue sarcoma. Ann Surg 1991;214:2–10.[Medline]
  43. Karakousis CP, Velez AF, Gerstenbluth R, Driscoll DL. Resectability and survival in retroperitoneal sarcomas. Ann Surg Oncol 1996;3:150–8.[Abstract]
  44. van Dalen T, Hennipman A, Van Coevorden F, et al. Evaluation of a clinically applicable post-surgical classification system for primary retroperitoneal soft-tissue sarcoma. Ann Surg Oncol 2004;11:483–90.[Abstract/Free Full Text]




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