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7 Management of Abdominopelvic Sarcoma Paul H. Sugarbaker OVERVIEW The principles of management of all sarcomas that involve the abdominal and pelvic cavity are presented. The anatomic sites for the primary malignancy includes retroperitoneal sarcomas, pelvic side wall sarcomas, sarcomas arising from the abdominal viscera and sarcomas arising from the pelvic organs. All histologic types of sarcomas may be considered together when therapeutic options are being discussed. This presentation stresses surgical removal with an adequate margin of resection as the principal goal of management. The curative treatment of these cancers places great emphasis on the surgeon’s knowledge of anatomy, technical skills, innovation and surgical courage. Systemic chemotherapy and radiotherapy have not shown reproducible efficacy. Complete clearance at the margins of resection and complete containment of tumor spillage remains the only reliable treatment option. Possible benefits of induction chemotherapy to reduce the size of advanced primary tumors prior to attempts at resection and intraperitoneal chemotherapy using heated cisplatin and doxorubicin for eradication of microscopic residual disease in the perioperative period are presented. Malawer Chapter 07 22/02/2001 14:37 Page 147

Transcript of 7 Management of Abdominopelvic Sarcoma

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7

Management ofAbdominopelvic Sarcoma

Paul H. Sugarbaker

OVERVIEW

The principles of management of all sarcomas that involve the abdominal and pelvic cavity are presented. Theanatomic sites for the primary malignancy includes retroperitoneal sarcomas, pelvic side wall sarcomas, sarcomasarising from the abdominal viscera and sarcomas arising from the pelvic organs. All histologic types of sarcomasmay be considered together when therapeutic options are being discussed. This presentation stresses surgicalremoval with an adequate margin of resection as the principal goal of management. The curative treatment ofthese cancers places great emphasis on the surgeon’s knowledge of anatomy, technical skills, innovation andsurgical courage. Systemic chemotherapy and radiotherapy have not shown reproducible efficacy. Completeclearance at the margins of resection and complete containment of tumor spillage remains the only reliabletreatment option. Possible benefits of induction chemotherapy to reduce the size of advanced primary tumorsprior to attempts at resection and intraperitoneal chemotherapy using heated cisplatin and doxorubicin foreradication of microscopic residual disease in the perioperative period are presented.

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INTRODUCTION

Sarcomas are unusual but not rare malignancies. Theyaccount for only 1% of adult solid tumors. Thesesarcomas appear most frequently between the fourthand sixth decades of life with a 2:1 male/female ratio.They can arise anywhere in the body with the lowerextremity being the most common site. Incidence are asfollows: lower extremities (46%), upper extremities(13%), retroperitoneum, pelvis and visceral (12%),truncal sarcomas (19%), and head and neck sarcomas(9%)1 (Table 7.1). The presenting symptoms and signs ofall sarcomas are nonspecific. With sarcomas involvingthe abdominal and pelvic cavity diagnosis is even moresubtle because these tumors may progress for long timeperiods without causing overt symptoms.1 Furtherconfusion may arise when abdominal and pelvicsarcomas mimic the more common types of gastroin-testinal malignancy. However, complete cancer resectionof even large abdominal and pelvic sarcomas can beassociated with long-term survival and even cure.

In the last decade treatment results with extremitysoft-tissue sarcomas have improved dramatically. Bothsurvival and quality-of-life benefits have occurred as aresult of new treatment approaches based on multi-modality treatment. Recently, patients with sarcomasthat involve the abdominal or pelvic cavity haveexperienced improvements in therapy. Moderntreatments require an aggressive pursuit of amultimodality approach involving meticulous surgeryand regional chemotherapy. Further studies withinnovative treatment options are required to achieve abetter outcome with these malignancies.

The purpose of this chapter is to critically review theresults of management of sarcomas that involve theabdominal and pelvic cavity and to make recommen-dations regarding current strategies for management.

NATURAL HISTORY

Retroperitoneal and Pelvic Sidewall Sarcomas versusVisceral Sarcomas

The natural history of retroperitoneal and pelvicsidewall sarcomas differs significantly from the morecommon abdominal and pelvic adenocarcinomas andfrom visceral sarcoma. These variations are importantwhen planning treatment. A unique feature of manyretroperitoneal and pelvic sidewall sarcomas concernstheir large size at the time of diagnosis.1–4 These fleshytumors often push rather than invade into thesurrounding structures. Their location deep within thebody precludes palpation of the tumor mass early inthe course of the disease. Consequently, these tumorsoften reach a large size prior to diagnosis (Table 7.2).

On the other hand, visceral sarcomas or adeno-carcinomas are less likely to achieve this large size priorto diagnosis because they cause intestinal dysfunction.5The most common symptom is gastrointestinal bleeding(Table 7.3). Even though symptoms may arise earlier inthe course of the disease, the anatomic location of thesecancers is contiguous with the abdominal space. Theyfrequently present with a regional disease processreferred to as peritoneal sarcomatosis. For this reason,visceral (gastric, small bowel and colonic) sarcomas alsocarry a poor prognosis. A majority of gastrointestinalsarcomas (previously called leiomuyosacromas) arestromal sarcomas. The distribution of gastrointestinalstromal tumors is presented in Table 7.4.5

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Table 7.1 Soft-tissue sarcomas by site (percentages)

Head and neck 9Trunk 19Retroperitoneum, pelvic sidewall, visceral 12Upper extremity 13Lower extremity 46

Table 7.2 Clinical presentation of retroperitoneal sarcomas(percentages)

Abdominal mass 80Abdominal pain 60Weight loss 35Nausea, vomiting 20Lower extremity edema 17Urinary symptoms 3Hypoglycemia 1

From ref. 4

Table 7.3 Clinical presentation of gastrointestinal sarcomas(percentages)

Symptom Gastric Small bowel Large bowel

Bleeding 45 54 28Mass 42 23 65Pain 36 57 43Nausea/vomiting 33 – –Weight loss 6 15 –Change bowel habit – 15 48Asymptomatic 11 – –

From ref. 5.

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Tumor Biology of Hematogenous versus LymphaticDissemination

The tendency to disseminate to lymph nodes is markedlydifferent for sarcomas than for adenocarcinomas.Epithelial cancers (squamous cell carcinomas and adeno-carcinoma) metastasize through both the lymphaticroute and the hematogenous route. In contrast,mesenchymal cancers frequently enter the bloodstream, causing lung or liver metastases, but rarelyresult in lymph node metastases. Overall metastaticinvolvement of regional nodes is observed in only 13%of patients with soft-tissue sarcomas and in 7% of bonesarcomas at initial presentation.6 Lymph node involve-ment by a sarcoma is unusual; when it occurs itindicates a dismal prognosis.

Direct evidence for the preferential hematogenous orlymphogenous dissemination of the two classes oftumors is based on numerous observations thatregional lymph node metastases are more common incarcinomas than in sarcomas.7 Although nodal metas-tasis do occur with sarcomas, they generate lymph nodemetastasis in a much smaller proportion of patientsthan do carcinomas. The explanation for this phenome-non from a tumor biology perspective has not yet beenformulated. Are the observed differences in pattern ofmetastases due entirely to the properties of the cancercells themselves? Could there be a greater destruction(metastatic inefficiency) of sarcomatous tumor emboliin lymphatics? Are the differences the consequence of amore intimate association of sarcomas than carcinomaswith their vasculature? A new hypothesis is that theanatomic microenvironment of the primary tumormass controls the proportion of tumors disseminatingby hematogenous or by lymphatic routes.

Our knowledge of the intrinsic capabilities of sarcomacells versus carcinoma cells to invade and then tometastasize is limited. We must accept that invasionmust occur before metastases can occur. For bothsarcomas and for carcinomas there must be sufficientinvasion and sufficient progression for metastases to

result. From a histopathologic study of sarcomas andadenocarcinoma, both cancers have an intimate relation-ship with their blood supply. Breakdown of bloodvessel walls and hemorrhage into tumor tissue may bea more impressive aspect of the histopathologic studyof the sarcomas. Yet invasion of veins and venules isalso a common pathologic finding with adenocarcinoma.The fact that both sarcomas and carcinomas dissem-inate via veins (hematogenous metastases) to distantcapillary networks is not the issue. The discrepancy inpatterns of dissemination concerns the relativelyinfrequent sarcomatous dissemination to lymph nodes.

Currently, no differences in the invasive capabilitiesof the primary tumor to penetrate capillary venules asopposed to lymphatic channels have been described.There is no reason to suspect that sarcomas selectivelyinvade capillary venules versus lymphatic channels.Basic differences in the tumor biology of malignantmesenchymal versus malignant epithelial tumors donot explain the low rate of lymph node metastasesobserved for sarcomas.

Mesenchymal structures such as bone, striated muscleand smooth muscle have a very rich blood supply. It isnot surprising that this blood supply is readily violatedby tumor invasion, and venules are seeded byexfoliation of the cancerous process. However, mes-enchymal structures have a severely limited lymphaticdrainage system. From an evolutionary perspective thelymphatic system has evolved as a host defense againstpathogens. Antigens gathered from epithelial (endo-dermal or ectodermal) structures are secured withinthe lymph nodes. Then through antigen processing,immunocyte selection and proliferation, a specificimmune response is generated. There is a limitedlymphatic supply for mesodermal structures becausethese soft tissues are rarely involved in host defenseagainst invasion by pathogens. Lymphatic systemswithin the mesoderm are poorly developed, and whatoccurs may communicate less directly with the regionalnode groups that accompany the vasculature of thebowel or that drain to axilla or groin. The reducedlymphatic supply of bone, cartilage, muscle, fat andother mesenchymal tissues leads to a decreasedexposure of lymphatic channels and lymph nodes tosarcoma metastases.

In summary, the hypothesis is that fewer lymph nodemetastases occur in patients with sarcomas becausefewer lymphatic channels are at risk for invasion andembolization by the primary malignancy. Table 7.5relates the lymphatic supply of the tissue of origin ofcarcinomas and sarcomas to the incidence of lymphnode metastases. Bone does not have lymphatic chan-nels and therefore osteosarcoma rarely shows lymphnode metastases. Rhabdomyosarcomas occur within

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Table 7.4 Distribution of gastrointestinal stromal sarcoma(percentages)

Esophageal 5Stomach 47Small bowel 35Colon 4Rectum 17Total 99

Modified from ref. 5.

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muscle. Muscle has an intermediate number of lym-phatic channels and consequently there are moderatenumbers of lymph nodes involved by this cancer.Epithelioid sarcomas involve lymph nodes relativelyfrequently. As predicted, these tumors are verycommon on the hands, involve the subcuticular dermisand have access to the rich lymphatic plexus at thesesites. The higher incidence of metastases in epithelioidsarcomas is to be expected because of the richlymphatic supply of the skin.

Tumor Biology of Local–Regional Recurrence ofSarcoma

Another feature characteristic of the natural history ofsarcomas involving the abdomen or pelvis is thealarmingly high local recurrence rate. The major site forsurgical treatment failure is the same anatomic areafrom which the sarcoma was removed. Local recur-rence is a component of treatment failure in nearly100% of patients and is the only site of treatment failurein nearly 50% of patients.8,9 One factor to be consideredas a cause of local recurrence is a multifocal primarytumor (Figure 7.1). This phenomenon may be especiallyprominent with retroperitoneal liposarcoma. A secondfactor that will cause local recurrence is small foci oftumor (satellite nodules) present at a distance from theprimary sarcoma. Narrow margins of resection maycause cancer persistence of these satellite sarcomadeposits within the resection site. With time these smallfoci of cancer will progress; also, their growth may alsobe promoted by the wound-healing process. However,in a majority of patients the high rate of local andregional recurrence comes about as a result of sarcomaseeding at the resection site and on peritoneal surfaces.Intraperitoneal sarcoma emboli may occur as a resultof: (1) sarcoma penetration of the peritoneal layer withrelease of tumor emboli into the peritoneal space

preoperatively; (2) sarcoma emboli in venous bloodthat is lost into the abdomen at the time of surgery; (3)surgical trauma that causes a sarcoma spill into theabdominal cavity. These free intra-abdominal tumoremboli become entrapped in fibrinous exudate thatfloods the traumatized surfaces involved in the surgicaldissection. This outpouring of serosanguinous fluid isthe first phase of the wound-healing process. After thefibrin becomes organized into a coagulum, tumor cellsare trapped at the wounded site. Platelets and mono-nuclear cells infiltrate the fibrinous matrix and releasecopious amounts of growth factors. These solublemediators result in the proliferation of normal cells andmodulate the healing process.

Recurrence at the resection site of a visceral sarcomaor retroperitoneal and pelvic sidewall sarcoma usuallyhas a fusiform gross appearance. This characteristicprogression along the narrow margins of resection ismost frequently caused by high-density sarcomaseeding of intraperitoneal cancer cells. Sarcoma emboliare also likely to adhere at a lower density totraumatized peritoneal surfaces where they becomecovered by a fibrinous exudate. These peritonealsurface implants progress as individual sarcomanodules that may be widely distributed throughout theabdomen and pelvis. In summary, high-densityseeding of sarcoma emboli at the resection site resultsin local recurrence that has a fusiform grossappearance. Low-density seeding of sarcoma emboli onperitoneal surfaces causes sarcomatosis. These noduleswill usually occur within adhesions because thesarcoma emboli were entrapped at that site by fibrin.

The growth factor stimulation as a result of woundhealing results in accelerated local progression of thesarcoma emboli; also, further sarcoma dedifferentiationmay result from the exposure of sarcoma cells togrowth factors.10 It is well established that the invasivepotential of sarcomas may dramatically increase overtime as a result of multiple reoperations.

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Table 7.5 Relationship of lymphatic supply of the tissue of origin to the incidence of lymph node metastases

Tumor type Tissue of origin Lymph supply tissue Lymph node metastasesof origin (0–4+) (%)

Osteosarcoma Bone ± 5Liposarcoma Fat ± 5Gastrointestinal stromal tumor Purkinje plexus ± 5Rhabdomyosarcoma Striated muscle 2+ 20Epithelioid sarcoma Skin appendages 2+ 20Gastric carcinoma Gastric epithelium 4+ 50Melanoma Skin 4+ 50

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Figure 7.1 Factors contributing to the high rate of local recurrence of sarcomas involving the abdominal and pelvic cavity.

Mechanisms of Local Recurrence and Peritoneal Sarcomatosis

Tumor emboli in venous blood loss Pseudocapsule penetration

Tumor spill

Intraperitoneal Tumor Emboli

Fibrin Entrapment MultifocalPrimary Tumor

UnresectedPrimary Tumor

PERITONEALNODULE

RECURRENCE

Infiltration of Plateletand Mononuclear cells

Growth Factors

TUMORDEDIFFERENTIATION

SARCOMAPROGRESSION

LOCAL SARCOMA RECURRENCE

High DensitySeeding

Low DensitySeeding

t

t

tt t t

t

t

t

t

t

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Tumor Biology of Peritoneal Sarcomatosis

After resection site recurrence the second most commonsite for abdominal or pelvic sarcoma recurrence are theperitoneal surfaces.8,9 In some patients sarcoma seedingof the peritoneum will have occurred prior to resectionof the primary tumor and is documented uponexploration of the abdomen. In the reoperative setting,peritoneal sarcomatosis results from tumor emboli invenous hemorrhage or from tumor spill that occurredwith a prior sarcoma resection.11 As implied fromFigure 7.1, the distribution of sarcomatosis favors sitesof prior peritoneal trauma. Sarcoma deposits areexpected to grow out from single cancer cells trappedwithin abdominal adhesions. Of course, theseadhesions develop with the resolution of fibrinousdeposits that result from previous surgical trauma. Thepathobiology of peritoneal implantation suggests thatmultiple factors control the distribution of cancerseeding within the abdomen and pelvis and that this isnot a random event.12

Hematogenous Seeding to Lungs versus Liver

A difference in the intravascular dissemination ofextremity sarcoma, retroperitoneal and pelvic sidewallsarcoma on the one hand and visceral sarcoma on theother needs to be noted. The first capillary bed drainingthe primary tumor is at highest risk for sarcomametastasis.7 For extremity sarcoma this is the lungs. Forretroperitoneal and pelvic sidewall sarcoma thecapillary bed at increased risk is also the lungs. Forvisceral sarcoma the venous blood draining the canceris the portal system. With these malignancies the liver isby far the most common site for hematogenousmetastases.

Figure 7.2 summarizes the patterns of treatmentfailure of sarcomas involving the abdomen and pelvis.The diagram emphasizes the high local recurrence rateand indicates that peritoneal seeding of sarcoma is acomponent of local recurrence. The first capillary beddraining retroperitoneal and pelvic sidewall sarcomasare the lungs; for visceral sarcomas this capillary bed isthe liver. Neither group of sarcomas metastasizes tolymph nodes in a significant proportion of patients.

TREATMENT

Enneking and colleagues have emphasized that thereare two basic principles by which the treatments forsarcoma are directed.13 First, one must determine asprecisely as possible the anatomic location of the tumor.The second determinant for treatment of sarcomaconcerns the biologic aggressiveness of the malignantprocess. With knowledge of these two determinants,cancer treatments can be selected that have the greatestlikelihood of destroying the lesion with minimalcompromise of normal function and quality of life.Low-grade lesions can be treated with a high expec-tation for cure even with minimal surgical margins.Also, one does not need to consider any therapies inaddition to surgery for low-grade lesions excised withnegative surgical margins. On the other hand,aggressive sarcomas must be expected to invade moredeeply into the adjacent tissues, can produce satellitelesions in the surrounding soft tissue, and are capableof metastasizing via hematogenous routes to distantsites. Knowledge of the low biologic aggressiveness of adisease process in an advanced stage may encourageultraradical regional treatments. At other times thefutility of highly morbid therapies will become evident,

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Figure 7.2 Surgical treatment failures of abdominal and pelvic sarcomas.

Lungs

SystemicSites

PeritonealSeeding

LOCAL

SystemicSites

LOCAL

Liver

PeritonealSeeding

Retroperitonealand Pelvic side-wall

SarcomaVisceralSarcoma

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and an aggressive lesion of large volume will be treatedwith conservatism because the clinician’s judgementhas determined that it is an incurable process.

In dealing with abdominal and pelvic sarcomas oneshould realize that the routes for cancer disseminationare considerably different from those of adenocar-cinomas. The adenocarcinomas require wide excision ofthe draining lymphatic tissues because lymph nodemetastases are common and the excision of involvednodes can result in cure. In contrast, lymph nodeinvolvement with abdominal and pelvic sarcoma isunusual, and if it does occur excision of the involvednodes will rarely result in long-term survival. Lymphnode positivity in patients with sarcoma is almostalways regarded as a signal of an unusually aggressivecancer, and it is highly probable that there has beensystemic dissemination of disease. Consequently, indealing with these sarcomas one attempts to removethe tumor with a generous margin of normal tissue, butwide lymph node dissections are unnecessary.14

Our comments will focus on the treatment optionthat have demonstrated efficacy in the management ofabdominal and pelvic sarcomas. The first priority fortreatment is surgery with negative margins of excision.15

The results of surgical treatment alone are shown inFigure 7.3. The more recent addition to abdominopelvictreatment options is intraperitoneal chemotherapy.16–18

Radiotherapy has not shown survival benefits whenused as an adjuvant with surgery19,20; also, aggressivesystemic chemotherapy combined with surgery has nodemonstrated survival benefits.21

Surgical removal with a clear margin is the treatmentoption indicated for all abdominal and pelvic sarcomas.This approach will test the surgeon's ability to exerciseall those principles of surgery which allow large oper-ations to be performed with minimal morbidity andmortality. Successful surgical treatments demand optimalexposure, skill in dealing with intestinal adhesions,meticulous hemostasis that is maintained throughoutthe procedure, a thorough knowledge of anatomy, aplan of attack on sarcomas at difficult anatomic sitesand experience in reconstruction. The surgeon must beknowledgeable regarding those structures that can besacrificed because their involvement by tumor, andthose structures that must be preserved event if there isresidual sarcoma.

SURGICAL APPROACH

At this point in time the first priority for treatment forabdominal and pelvic sarcoma that is associated withlong-term survival is complete surgical removal of thecancer with adequate margins. The cardinal principleof surgeryis en-bloc excision of the primary tumor plusinvolved adjacent organs and tissues with dissection

well clear of the sarcoma pseudocapsule. The majorfactor determining resectability is the extent of invasionto vital structures rather than the size of the tumor.Although preoperative radiological evaluation isessential, operability can be evaluated definitively onlyby laparotomy. Even with adherence of tumor to vitalstructures, with meticulous dissection most sarcomasare resectable. The surgeon must always remember thatinadequate clearance resulting in local recurrence andinadequate containment resulting in sarcoma seedingare the major causes of treatment failure. Tumordebulking may occasionally be beneficial in a palliativeway in cases where complete resection is impossible.However, palliative surgery for abdominal and pelvicsarcoma carries a high morbidity and limitedprogression-free survival and should be undertakenwith great caution.

Patient Position and Exposure

One must be prepared for a major surgical event withwide abdominal and pelvic exposure in order to achievethe greatest incidence of success. In many patients bothabdominal and pelvic dissections must be performed.Positioning of the patients so that surgery through theperineum is possible is often indicated (Figure 7.4).Long abdominal incisions from xiphoid to pubis areusually not required. Self-retraining retractors that canexpose the entire abdomen and pelvis are necessary

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Figure 7.3 Actuarial survival for retroperitoneal sarcomas.Only complete resection achieves any hope for long-termsurvival. The expected survival for complete resectionshows approximately 50% survival at 5 years. Unresectedpatients have a uniformly poor prognosis. Some patientswith positive margins of resection who have grade I or lesssarcomas will survive long term; often these patients livewith gradually progressive cancer and require multipleresections over a long time period. From Jaques DP, Coit DG,Brennan MF. Soft tissue of the retroperitoneum. In: ShiuMH, Brennan MF, editors. Surgical Management of SoftTissue Sarcomas. Philadelphia: Lea & Febiger; 1989:166.

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(Figure 7.5). Skin preparation so that a thoraco-abdominal or an abdomino-inguinal incision isfrequently required (Figure 7.6).

One must always be cognizant of the surgeon’sneeds to think three-dimensionally in approachingthese deep-seated malignancies. This helps to avoidinadvertent damage to vital structures. In order to buildwithin the surgeon’s mind a three-dimensional appre-ciation of the vital structures in the abdomen, oneshould always strive to open the abdomen and set up

the self-retaining retractor system in the same way. Thismeans that vital structures such as the left common iliacvein, the ureters, the left gastric artery, and thecommon bile duct have a particular spatial orientationwithin the surgeon’s mind. A standard exposure of theabdominal cavity through a midline incision withuniform placement of the self-retaining retractor canassist the surgeon in his goal of avoiding hemorrhageand inadvertent damage to vital structures.

Reoperative Surgery

Frequently, in a tertiary referral center, one sees patientswith abdominal and pelvic sarcomas after one or moreprior attempts at the surgical removal of the cancer. Inthese patients, removal of the recurrent sarcoma maybe delayed many hours because exposure of the tumormass may be difficult and time-consuming. Extensiveabdominal adhesions, tumor that has regrown withinscar tissue, fibrosis that accompanies the local recur-rence of cancer, and alterations of normal anatomy byprior reconstructions may require patience andadvanced technical skills to bring about the completeexposure of the malignant process.

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Figure 7.4 Patient position for surgical treatment ofabdominal and pelvic sarcoma.

Figure 7.5 Exposure for abdominal and pelvic surgeryusing a self-retaining retractor.

Figure 7.6 Abdomino-inguinal incision used for resectionof sarcomas on the pelvic side wall.

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Always Open Old Incisions

Even though opening an old incision is difficult, andmay result in seromuscular tears of small or largebowel, rarely should a new incision be made into theabdomen in performing reoperative surgery. Newincisions will cause additional adhesions and mayseverely jeopardize primary wound healing of theabdominal wall. It is usually necessary to excise oldincisions because they often contain recurrent sarcomaembedded within the scar tissue. The surgeonroutinely plans to completely excise the old scar tissuein the skin, subcutaneous tissue and in fascia as theabdominal wall is opened.

Safe Entry into the Abdominal Cavity

Opening the abdomen without damage to bowels in apatient who has had several prior surgical proceduresis difficult and time-consuming. One should realizethat entering an abdomen with multiple adhesionsrequires an elevation of the abdominal wall in order toavoid inadvertent small bowel or large bowel entero-tomy. Clamps should be used to apply strong upwardtraction on the skin or abdominal fascia as the abdomenis entered (Figure 7.7). Pushing down in order to spreadthe scar that makes up the old abdominal incision is tobe avoided.

Surgical Approach to Intra-abdominal Adhesions

Small bowel adhesions present a special problem inmanagement. Small bowel enterotomy resulting infistula formation after reoperative procedures is a majorproblem that will be encountered. The experiencedsurgeon will adhere to several principles in lysing smallbowel adhesions:

1. Tactile sense should be added to visual perceptionsin the dissection of the adhesions (Figure 7.8). Thisrequires the use of ball-tipped electrosurgery.Fibrous adhesions and fat are morseled between thethumb and index finger of the nondominant hand.Considerable pressure may need to be applied. Ball-tip electrosurgery electroevaporates (carbonizes)residual tissue on the small bowel surface as thistissue is splayed out on the middle finger.

2. Absolute hemostasis must be maintained at all timesin dissecting small bowel adhesions. One mustrealize that any bleeding that occurs while dissectinga small bowel adhesion means the surgeon is in animproper plane. Fat with blood vessels within shouldbe divided in the abdomen and pelvis only when thesurgeon is knowingly transecting omentum, tran-secting retroperitoneal structures, or transectingperirectal fat. Bleeding that is encountered whiletaking down intestinal adhesions indicates that thesurgeon is dissecting within the wrong plane,

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Figure 7.7 Opening the old abdominal incision by pulling upward on skin (left) or fascial edges (right) using Adair clamps.

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usually the small or large bowel mesentery, and thisshould be avoided.

3. Large-volume saline irrigation should be usedfrequently. Even small amounts of blood can inter-fere with adequate visualization of subtle tissueplanes for further dissection. If absolute hemostasisis combined with frequent irrigation the translucentnature of the tissues will be preserved throughoutthe dissection and inadvertent damage to vitalstructures or to blood vessels should not occur.

4. Fat or scar tissue should never be left behind onsmall bowel surfaces. This scar tissue may frequentlycontain entrapped tumor cells. Also, if miscellaneoustissues remain on bowel surfaces, confusion mayarise in subsequent dissection. There is only onesmall bowel surface that contains fat on its anti-mesenteric border, and this is in the terminal ileum.

5. Strong traction should be maintained at the dissec-tion point of the adhesion. The small bowel shouldbe splayed out (broad traction) so that the plane ofdissection for the ball-tipped electrosurgical hand-piece is clearly visualized.

6. Complete removal is the rule when dealing withintra-abdominal adhesions. Generally, all adhesionsmust be lysed and then resected. The completeanatomy of the large and small bowel is visualized

prior to a decision regarding curative versus pal-liative sarcoma resection.

In summary, in the reoperative setting opening oldabdominal incisions and the dissection of abdominaladhesions without damage to the bowel must be mas-tered by the sarcoma surgeon. Use of electrosurgerywith the ball-tip is indicated because it allows tactilesensations to be added to visual perceptions in thedissection. This makes the process safer and certainlyexpedites the opening of the abdomen, lysis of intra-abdominal adhesions and clarification of the dissectionrequired for definitive excision of the recurrent sarcoma.

Exploring for Sarcomatosis

In performing surgery on patients with retroperitonealor visceral sarcoma, the complete (both visceral andparietal) abdominal and pelvic surfaces must be visuallyinspected to look for tumor deposits. This means thatall abdominal adhesions must be lysed as part of thecomplete exploration. The omentum, likewise, must bedissected free and inspected to determine whether itcontains sarcoma nodules. The problem of sarcomatosisis of course more important in patients undergoingreoperative surgery for intra-abdominal sarcoma. If

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Figure 7.8 Dividing abdominal adhesions. Pressure between thumb and index finger is used to thin out the adhesion betweentwo loops of small bowel. Ball-tip electrosurgery is used to divide and evaporate the adhesion (right). Division of adherent tissueon small bowel surfaces on the middle finger of the nondominant hand adds tactile to visual perceptions (left).

Smokeevacuator

Ball tipelectrosurgicalhandpiece

Digital compression forthinning intestinal adhesions

Intestinaladhesions

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there was tumor spillage at the time of earlier surgery,then sarcomatosis is expected to be discovered with theabdominal exploration.

If the patient can be made disease-free in the presenceof sarcoma nodules, then the benefits of intraperitonealchemotherapy should be considered. The adhesionsare completely separated and resected as part of theoncologic procedure to allow uniform distribution ofchemotherapy. From a purely surgical point of view,complete lysis and resection of all abdominal adhesionsis not an absolute requirement for safe resection ofabdominal and pelvic sarcoma. From an oncologic per-spective, complete lysis and resection of all adhesionsfollowed by peri-operative intraperitoneal chemother-apy may be an absolute requirement for the preventionof subsequent sarcomatosis.

Centripetal Dissection

Centripetal dissection requires wide continuedexposure of the abdomen and pelvis as provided by along midline abdominal incision and self-retainingretractors. Repeated dissection in a circular fashionaround the principal tumor mass at multiple sites is thegoal. Dissection continues at a particular site only ifthere is clear visualization of the operative field. Thesurgeon should repeatedly circle the sarcoma as thelaborer would repeatedly circle a tree stump that isbeing removed with shovel and axe. The “stumpanalogy” suggests that the surgeon never attempts adefinitive dissection in one area. He always completesthe superficial dissections before the more difficultdeep ones are attempted. The axiom is always “Dowhat is easy first.” He moves around and around thecancer, working only where he has good exposure.Criteria for continued dissection at a particular anatomicsite include: (1) no loss of blood; (2) small chance fordamage to vital structures; (3) dissection proceedingswith a clear margin. If any of these criteria for safeprogress are not met, the surgeon should move hisdissection to a different area. The tumor mass is gener-ally circled many times prior to delivering the intactspecimen. In summary, centripetal dissection avoids atall times major hemorrhage or damage to vital struc-tures by limiting dissection to areas that allow clearvisualization of the operative field. A circular pattern ofprogressively deeper dissection results from thisapproach.

Avoid Trauma to the Vasculature of the SarcomaCapsule

In the removal of abdominal and pelvic sarcomas onemust always be aware of possible major hemorrhage

from surface vasculature of the sarcoma. Blood vesselsin the sarcoma pseudocapsule are large, thin-walled,easily traumatized and difficult to control oncebleeding has occurred. Once one disrupts the tumorvasculature, bleeding is likely to be brisk and difficult.One should dissect away from the tumor in normaltissues as much as possible. If dissection of the tumoritself is required, this should be done only after all otherdissection is completed.

Maintain Hemostasis throughout the Procedure

One must always pay continuous attention to hemo-stasis, because inadequate hemostasis interferes withsubsequent exposure. Moreover, blood in the operativefield obscures the identification of additional bleedingpoints. Hemostasis must be achieved with electroco-agulation, ligatures, or clips as the dissection proceeds.The translucent nature of the tissues within the surgicalfield can be maintained by frequent irrigation andmeticulous hemostasis.

Use of Peritonectomy Procedures

Often in the reoperative setting or work with aretroperitoneal sarcoma the surgeon must be willing todissect in a preperitoneal or retroperitoneal planerather than moving through the peritoneal cavity itself.Peritonectomy procedures go beneath scar tissue toachieve a negative margin of resection.22 Sarcomarecurrent at a resection site will almost always bebeneath the peritoneal surface. An effective way tosafely approach these recurrent tumor masses is bygoing beneath the peritoneal layer into a deeper planeaway from the tumor mass (Figure 7.9). The concept ofperitonectomy should be pursued in the reoperativesetting, in dealing with sarcomatosis, with recurrenceat the resection site, and for retroperitoneal sarcomabeing resected for the first time.

Utilize “Piecemeal” Excision

Often freeing-up of a tumor mass will progressivelyobscure the plane of dissection. This will compromisethe safety of subsequent dissection because of inade-quate visualization, inadequate hemostasis, or anunnecessarily narrow margin of excision. Large tumormasses, especially those in the pelvis, will become moreand more difficult to extirpate as the dissection proceeds.As the anatomic site for further dissection is more deeplyobscured by a large mass of tumor, the procedurebecomes more dangerous. If the tumor mass remainsintact, dangerous blunt dissection may be required tocontinue its removal.

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In this situation, piecemeal excision of the sarcoma isan important part of the operative procedure. Superficialcomponents of the tumor may be removed prior tocontinuing the dissection of a deeper aspect of thetumor. Piecemeal excision using an electrosurgical loopon pure cut is usually the best way to remove portionsof the tumor prior to its complete resection (Figure 7.10).

Piecemeal excision of a large tumor mass is muchsafer for the patient than is dissection with inadequatevisualization. However, one must do everything possibleto guard against the intra-abdominal dissemination ofsarcoma cells. The surrounding structures must beprotected with laparotomy pads and towels. Theelecrosurgical loop at high voltage on pure cut removesfillets of tumor with minimal spillage of viablemalignant cells. After each level of tumor is resected,thorough irrigation of the operative field is required.Before the procedure is completetd intraperitonealchemotherapy is indicated.

Guard against Frustration Toward the End of aDifficult Resection

The surgeon should realize that the greatest number ofsurgical misadventures occur just a few minutes priorto final removal of the tumor mass. Special care shouldbe taken when the tumor mass is almost out. The finaldissection is often performed over a large mass ofsarcoma that results in reduced visualization. One mustavoid damage to a vital structure such as a ureter ordamage to a major blood vessel which results in

profuse hemorrhage. Many serious intraoperativeerrors in cancer resection occur just prior to the removalof a large specimen.

Transplants of Primary Vascularized Tissue

Within the abdomen there are two prominent sourcesof primarily vascularized tissue. These are the omen-tum and the rectus abdominus muscles. The rectusabdominus muscles based on the deep inferiorepigastric vessels can be harvested either bilaterally orunilaterally (Figure 7.11). The omentum can be har-vested so that its gastroepiploic pedicle is based on theleft gastroepiploic vessels and the short gastric vesselson the left side of the stomach. More frequently theomental pedicle is based on the right side from the rightgastroepiploic vessels (Figure 7.12). In both instancesthe numerous branches of the gastroepiploic vessels tothe greater curvature are ligated and the gastroepiploicarcade is preserved. These large masses of freshlyvascularized tissue can be used in four ways.

The primarily vascularized tissue is frequently usedto fill empty space in the abdomen or pelvis. This tissueis often placed into an abdominal gutter from which akidney was removed or into the pelvis. This greatlyfacilitates healing and serves to decrease the incidenceof fluid accumulation and possible pelvic sepsis. Thesetissue transplants greatly improve the healing at a siteof prior radiotherapy.

A second use of pedicle flaps is to create a newabdominopelvic partition. This tissue barrier does not

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Figure 7.9 Pelvic peritonectomy is useful to completelyexcise a pelvic sarcoma, especially if there is sarcomatosis orrecurrent tumor at the resection site.

Figure 7.10 Piecemeal excision of abdominal or pelvicsarcoma. (A) Electroevaporative surgery with a ball tip is usedto define the margin of excision. (B) Loop electrosurgery isused to resect the sarcoma mass piecemeal . (C) Even in thedepths of the pelvis with a large sarcoma the visualizationcan be excellent.

Pelvic sarcoma

Ureter

Sigmoid colon

Pelvicperitonectomyincision

Left ureter(obstructed by sarcoma)

Piecemeal excisionof large pelvic tumor

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allow small bowel to become entrapped in the pelvis,resulting in subsequent intestinal obstruction orfistulization. Other sources of tissue can also be used inconstruction of an abdominopelvic partition. Bladder,uterus, leaf of sigmoid mesentery and prosthetic mate-rials have been used successfully (Figure 7.13).

A third common need for these primarily vascular-ized tissue transplants is coverage of cancerous tissuesthat have been incompletely excised. Positive marginsof sarcoma resection are walled off from the remainderof the abdominal or pelvic cavity by the primarily vascu-larized tissue transplant. This will greatly improve long-term function by preventing cancerous invasion of thesmall bowel and the resultant intestinal obstruction.

A fourth use of these primarily vascularized tissuetransplants is to cover vascular grafts, reconstructedvessels, urinary tract reconstruction, or repair thebladder.. Omentum or muscle draped over an exposedvascular graft, vascular anastomosis or repaired ureterand protect against false aneurysm, graft infection, andsuture line disruption with late blow out (Figure 7.14).

Abdominal and Pelvic Sarcoma 159

Figure 7.11 Primarily vascularized tissue transplants maybe harvested from three sources for abdominal and pelvicsurgery. They are the greater omentum, right rectus muscleand left rectus muscle.

Figure 7.12 Primarily vascularized tissue transplant ofrectus abdominis muscles. These are especially needed if thepatient has had prior radiation therapy to the pelvis. Figure 7.13 Methods to construct abdominopelvic partitions.

Uterus

Mesentery

Omentum

Bladder

Prosthetic mesh

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Induction Chemotherapy

External beam radiation therapy and adjuvant chemo-therapy have failed to show worthy survival benefitsfor intra-abdominal sarcoma when added onto surgery.However, induction chemotherapy treatments designedto shrink large retroperitoneal or visceral tumors priorto their surgical removal is a treatment optionapplicable to selected patients (Table 7.6). Wheneverthere is a major single artery supplying the sarcoma,induction chemotherapy is used intra-arterially tomaximize responses in the primary tumor itself. Thegoal of these treatment strategies is to shrink the tumorand reduce its aggressive behavior for a defined timeperiod. After completion of induction chemotherapyexcision of the malignant process may be possible

whereas surgery alone would have been unsuccessful.The current treatment plan utilizes three preoperativecycles of ifosfamide and systemic doxorubicin prior tosurgical resection of the sarcoma.

Peritonectomy and Intraperitoneal Chemotherapy

Another strategy of great value in selected patientsconcerns the treatment and prevention of resection siterecurrence and peritoneal sarcomatosis. Heated intra-peritoneal chemotherapy employed intraoperatively iseffective in reducing the high incidence of resection siterecurrence and sarcomatosis that often occurs after pri-mary sarcoma resection. Elimination of sarcoma seedingby peritonectomy and the resulting improvement inlocal–regional control may have an effect on the sur-vival of patients with sarcomatosis or with localrecurrence. Standardized orders for heated intraop-erative intraperitoneal chemotherapy are shown inTable 7.7. Figure 7.15 shows the tubes and drainsrequired to deliver early postoperative intraperitonealchemotherapy. Figure 7.16 shows the methodology forsafe intraoperative delivery of heated cisplatin anddoxorubicin via the intraperitoneal route.

The indications for perioperative intraperitonealchemotherapy are shown in Table 7.8. Tumor spillageshould in all instances be accompanied by heated intra-operative intraperitoneal chemotherapy. Sugarbakerand colleagues, and Eroglu and colleagues, have usedintraperitoneal cisplatin and doxorubicin.16,17 Othergroups have explored the use of mitoxantrone.18 Itshould be emphasized that the prevention of peritonealsarcomatosis is a surgeon’s responsibility. Treatment ofthis component of sarcoma cannot be delayed untillater systemic chemotherapy treatment by the medicaloncologist. Once sarcoma cells are embedded in scartissue they are not treatable by any technique. Otherindications for intraoperative intraperitoneal chemo-therapy include small-volume peritoneal sarcomatosis;small-volume residual disease on peritoneal surfaces orat the margins of resection; and use in a randomizedcontrol trial in patients who have a complete excision of

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Figure 7.14 Omental pedicle flap used to cover commoniliac artery reconstruction.

Arterialgraft

Omentalpedicle flap

Gastroepiploicarcade

Table 7.6 Standardized orders for induction chemotherapy of abdominal and pelvic sarcoma

Induction ifosfamide and doxorubicin1. Ifosfamide __ mg (2.25 gm/m2) intravenous for 4 consecutive days in 250 cc 5% dextrose solution via intravenous catheter as

2-hour infusion. Repeat every 3 weeks.2. Doxorubicin __ mg (75 mg/m2 per day) in 500 cc 5% dextrose in water to run by continuous intravenous catheter infusion

through a central vein over 72 hours.3. 25% dose reduction for both ifosfamide and doxorubicin for age greater than 65 or prior radiation therapy.4. All cycles of chemotherapy are supplemented with G-CSF support at 5 mg/kg subcutaneous, starting 24 hours after

chemotherapy is finished.

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sarcoma in order to identify a surgical adjuvanttreatment.

The results of treatment of patients with recurrentsarcoma have been tested in phase II studies usingreoperative surgery plus intraperitoneal chemtherapy(Table 7.9). In all four of these studies the surgery forrecurrent sarcoma was designed to completely resectcancer. The treatments with intraperitoneal chemother-apy varied greatly. Berthet and colleagues, and Erogluand colleagues, used heated intraoperative chemother-apy.16,17 Karakousis and colleagues, and Eilber andcolleagues, used intraperitoneal chemotherapy in adelayed manner after wound healing had occurred.18,23

The results of the perioperative intraoperitonealchemotherapy suggested superior results when com-pared to the delayed intraperitoneal chemotherapy.Figure 7.17 shows the statistically significant difference

Abdominal and Pelvic Sarcoma 161

Figure 7.16 Heated intraoperative intraperitonealchemotherapy for sarcomatosis following cytoreduction andfor patients with a high risk for microscopic residual disease.

Table 7.7 Cisplating and doxorubicin orders for heated intraoperative intraperitoneal chemotherapy

1. For gastric and ovarian cancer, mesothelioma and sarcoma; add cisplatin __ mg to 2 liters of 1.5% dextrose peritoneal dialysissolution. Dose of cisplatin 50 mg/m2.

2. Add doxotrubicin __ mg to same 2 liters of 1.5% dextrose peritoneal dialysis solution. Dose of doxorubicin 15 mg/m2.3. Use 33% dose reduction for heavy prior chemotherapy, marginal renal function, age greater than 60, extensive intraoperative

trauma to small bowel surfaces, or prior radiotheray.4. Send 1 liter of 1.5% dextrose peritoneal dialysis solution to test the perfusion circuit.5. Send the above to the operating room at __ o’clock.

Figure 7.15 Tubes and drains used for perioperativeintraperitoneal chemotherapy.

Tikhoffcatheter

Pursestringsuture

Closed suctiondrain

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which complete resection plus perioperative intraperi-toneal chemotherapy shows when compared toincomplete resection.16 Additional aggressive treatmentmodalities are indicated in recurrent abdominal andpelvic sarcoma along with phase III adjuvant studies inpatients with primary sarcoma.

Surgical Use of Radiotherapy

Intraoperative radiotherapy has been suggested for usein patients who have positive margins of excision onbone or on other vital structures such as aorta or venacava. Interstitial radiation therapy (brachytherapy) maybe considered in some instances. However, the use ofbrachytherapy and intraoperative radiation therapyremains controversial, and they have not been shownto be of benefit. Unfortunately, these radiotherapy tech-nologies have been limited to only a few centers, andno phase III data are available by which to criticallyevaluate these treatment options.

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Table 7.8 Indications for heated intraoperative intraperitoneal chemotherapy

1. Rupture or perforated sarcoma.2. Tumor spillage.3. Small-volume peritoneal sarcomatosis after resection of primary sarcoma and peritonectomy of sarcomatosis.4. Small-volume local residual disease.5. After complete cytoredction of sarcomatosis or sarcoma recurrence.6. Clinical trials to test adjuvant treatments.

Table 7.9 Adjuvant regional chemotherapy for abdominopelvic sarcoma: four nonrandomized series16,17,18,23

Series Tumor type at Chemotherapy Mean follow-up 5 year overall Outcomes Recurrencepresentation regimen time (range) survival (%)

(median)

Karakousis et al., Recurrent abdominal Postoperative cisplatin 17 months 7% 2 NED, 26 DOD, 9328 patients sarcoma 1 DOC

Sugarbaker et al., Recurrent abdomino- Perioperative 20 months 39% 9 NED, 23 DOD, 7443 patients pelvic sarcoma hyperthermic cisplatin (4–84) 10 AWD, 1DOC

and/or doxorubicinEilber et al., Recurrent abdomino- Postoperative 26 months 31% 9 NED, 35 DOD, 83

54 patients pelvic sarcoma mitoxantrone (2–98) 10 AWDEroglu et al., Primary or recurrent Intraoperative 57 months 49% 15 NED, 15 DOD, 73

33 patients retroperitoneal sarcoma hyperthermic abdominal (28–95) (58 months) 3 AWDperfusion, cisplatin

and doxorubicin

Figure 7.17 Complete versus incomplete resection ofrecurrent sarcoma in patients receiving perioperativeintraperitoneal chemotherapy. From Berthet B, SugarbakerTA, Chang D, Sugarbaker PH. Quantitative methodologioesfor selection of patients with recurrent abdominopelvicsarcoma for treatment. Eur J Cancer. 1999;35:413–19.

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1. Sondak VK, Economou JS, Eilber FR. Soft tissue sarcomasof the extremity and retroperitoneum: advances inmanagement. Adv Surg. 1991;24P:333–59.

2. Van Dam PA, Lowe PG, McKenzie-Gray B, Shepherd JH.Retroperitoneal soft tissue sarcomas. Obstet Gynecol Surv.1990;45:670–82.

3. Lawrence W Jr, Neifeld JP. Soft tissue sarcomas. Curr ProblSurg. 1989;26:753–827.

4. Storm FK, Sondak VK, Economou JS. Sarcomas of theretroperitoneum. In: Eilber FC et al., editors. Soft Tissue Sarcomas. New York: Grune & Stratton, 1987:239–48.

5. Licht JD, Weissmann LB, Antman K. Gastrointestinalsarcomas. Semin Oncol. 1988;15:181–8.

6. Tsu Y, Lee M. Leiomyosarcoma of the gastrointestinaltract: general pattern of metastases and recurrence.Cancer Treat Rev. 1983;10:91–101.

7. Weiss L. Principles of Metastasis. New York: AcademicPress, Harcourt Brace Jovanovich; 1985:187–9.

8. Glenn J, Sindelar WF, Kinsella T et al. Results of multi-modality therapy of resectable soft-tissue sarcomas of theretroperitoneum. Surgery. 1985;97:316–25.

9. Potter DA, Glenn J, Kinsella T et al. Patterns of recurrencein patients with high-grade soft-tissue sarcomas. J ClinOncol. 1985;3:353–66.

10. Sporn MD, Roberts AB. Peptide growth factors andinflammation, tissue repair and cancer. J Clin Invest. 1986;78:329–32.

11. Sugarbaker TA, Chang D, Koslowe P, Sugarbaker PH.Patterns of spread of recurrent intra-abdominal sarcoma.In: Sugarbaker PH, editor. Peritoneal Carcinomatosis:Principles of Management. Boston: Kluwer; 1996:65–78.

12. Sugarbaker PH. Observations concerning cancer spreadwithin the peritoneal cavity and concepts supporting anordered pathophysiology. In: Sugarbaker PH, editor.Peritoneal Carcinomatosis: Principles of Management.Boston: Kluwer; 1996:79–100.

13. Enneking WF, Spanier SS, Malawer MM. The effects of theanatomic setting on the results of surgical procedures forsoft part sarcoma of the thigh. Cancer. 1981;47:1005–22.

14. Mazeron JJ, Suit HD. Lymph nodes as sites of metastasesfrom sarcomas of soft tissue. Cancer. 1987;60:1800–8.

15. McGrath PC, Neifeld JP, Lawrence W et al. Improvedsurvival following complete excision of retroperitonealsarcomas. Ann Surg. 1984;200:200–4.

16. Berthet B, Sugarbaker TA, Chang D, Sugarbaker PH.Quantitative methodologies for selection of patients withrecurrent abdominopelvic sarcoma for treatment. Eur JCancer. 1999;35:413–19.

17. Eroglu A, Kocaoglu H, Demirci S, Akgul H. Retroperitonealsoft tissue sarcoma: effect of hyperthermic totalabdominal perfusion. Tumori. 1999;85:259–64.

18. Eilber FC, Rosen G, Forscher C, Nelson SD, Dorey FJ,Eilber FR. Surgical resection and intraperitoneal chemo-therapy for recurrent abdominal sarcomas. Ann SurgOncol. 1999;6:645–50.

19. Kinsella TJ, Sindelar WF, Lack E, Glatstein E, RosenbergSA. Preliminary results of a randomized study of adju-vant radiation therapy in resectable adult retroperitonealsoft tissue sarcomas. J Clin Oncol. 1988;6:18–25.

20. Tepper JE, Suit HD, Wood WC, Proppe KH, Harmon D,McNulty P. Radiation therapy of retroperitoneal softtissue sarcomas. Int J Radiat Oncol Biol Phys. 1984;10:825–30.

21. Elias AD, Antman KH. Adjuvant chemotherapy for softtissue sarcoma: a critical appraisal. Semin Surg Oncol.1988;4:59–65.

22. Sugarbaker PH. Peritonectomy procedures. Ann Surg.1995;221:29–42.

23. Karakousis CP, Kontzoglou K, Driscoll DL. Intraperitonealchemotherapy in disseminated abdominal sarcoma. AnnSurg Oncol. 1997;4:496–8.

References

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