J Vasc Surg. 2006 Jul;44(1):46-55.

Clinical results of surgery for retroperitoneal sarcoma with major blood vessel involvement.

Schwarzbach MH, Hormann Y, Hinz U, Leowardi C, Böckler D, Mechtersheimer G, Friess H, Büchler MW, Allenberg JR.

Department of Surgery, University of Heidelberg, Heidelberg, Germany.


PURPOSE: The study was conducted to evaluate the clinical results of resection for retroperitoneal soft tissue sarcoma (STS) with vascular involvement. METHODS: The study group consisted of consecutive patients (mean age, 52 years) who underwent surgery for retroperitoneal STS with vascular involvement. The procedures were performed between 1988 and 2004. Vessel involvement by STS was classified as type I, artery and vein; type II, only artery; type III, only vein; and type IV, neither artery nor vein (excluded from the analysis). Patient data were prospectively gathered in a computerized database and retrospectively analyzed. RESULTS: Of 141 patients with retroperitoneal STS, 25 (17.7%) underwent surgery for tumors with vascular involvement. The most common vascular involvement pattern was vein only (type III) at 64%. Arterial and vein (type I) and arterial only (type II) involvement were observed in 16% and 20% of the cases, respectively. STS originating from the vessel wall (primary vessel involvement) was seen in eight patients, and 17 patients had secondary vascular involvement. Resection and vascular repair were done in 22 patients (no vascular repair in three patients due to ligation of the external iliac vein in one patient, and debulking procedures in two). All patients with arterial involvement (type I and II) had arterial reconstruction consisting of aortic replacement (Dacron, n = 3; and expanded polytetrafluoroethylene [ePTFE], n = 2), iliac repair (Dacron, n = 3), and truncal reimplantation (n = 1). The inferior vena cava (6 ePTFE tube grafts, 3 ePTFE patches, 2 venoplasties), iliac vein (1 ePTFE bypass, 1 Dacron bypass, 1 venous patch), and superior mesenteric vein (1 anastomosis, 1 Dacron bypass) were restored in 80% of the patients (n = 16) with either arterial and venous or only venous involvement (type I and type III setting). Morbidity was 36% (hemorrhage, others), and mortality was 4%. At a median follow-up of 19.3 months (interquartile range, 12.8 to 49.9 months) the arterial patency rate was 88.9%, and the venous patency rate was 93.8% (primary and secondary). Thrombosis developed in one arterial and venous (type I) iliac reconstruction due to a perforated sigmoid diverticulitis 12 months after surgery. The local control rate was 82.4%. The 2-year and 5-year survival rates were 90% and 66.7% after complete resection with tumor-free resection margins (n = 10 patients, median survival not reached at latest follow-up). The median survival was 21 months in patients with complete resection but positive resection margins (n = 7) and 8 months in patients with incomplete tumor clearance (n = 8, persistent local disease or metastasis). CONCLUSIONS: Patency rates and an acceptable surgical risk underline the value of en bloc resection of retroperitoneal STS together with involvement of blood vessels. The oncologic outcome is positive, especially after complete resection with tumor-free resection margins. A classification of vascular involvement can be used to plan resection and vascular replacement as well as to compare results among reports in a standardized fashion.

PMID: 16828425 [PubMed – indexed for MEDLINE]

J Vasc Surg. 2005 Jul;42(1):88-97.

Results of limb-sparing surgery with vascular replacement for soft tissue sarcoma in the lower extremity.

Schwarzbach MH, Hormann Y, Hinz U, Bernd L, Willeke F, Mechtersheimer G, Böckler D, Schumacher H, Herfarth C, Büchler MW, Allenberg JR.

Department of Vascular and Endovascular Surgery, University of Heidelberg, Mannheim, Germany.


OBJECTIVE: To evaluate limb-salvage surgery with vascular resection for lower extremity soft tissue sarcomas (STS) in adult patients and to classify blood vessel involvement. METHODS: Subjects were consecutive patients (median age, 56 years) who underwent vascular replacement during surgery of STS in the lower limb between January 1988 and December 2003. Blood vessel involvement by STS was classified as follows: type I, artery and vein; type II, artery only; type III, vein only; and type IV, neither artery nor vein (excluded from the analysis). Patient data were prospectively gathered in a computerized database. RESULTS: Twenty-one (9.9%) of 213 patients underwent vascular resections for lower limb STS. Besides 17 type I tumors (81.0%), 3 (14.3%) type II and 1 (4.7%) type III STS were diagnosed. Arterial reconstruction was performed for all type I and II tumors. Venous replacement in type I and III tumors was performed in 66.7% of patients. Autologous vein (n = 8) and synthetic (Dacron and expanded polytetrafluoroethylene; n = 12) bypasses were used with comparable frequency for arterial repair, whereas expanded polytetrafluoroethylene prostheses were implanted in veins. Morbidity was 57.2% (hematoma, thrombosis, and infection), and mortality was 5% (embolism). At a median follow-up of 34 months, the primary and secondary patency rates of arterial (venous) reconstructions were 58.3% (54.9%) and 78.3% (54.9%). Limb salvage was achieved in 94.1% of all cases. The 5-year local control rate and survival rate were 80.4% and 52%, respectively. We observed a 5-year metastasis-free survival rate of 37.7% and found vessel infiltration and higher tumor grade (low-grade vs intermediate grade and high grade tumors) to be negative prognostic factors at univariate and multivariate analysis. CONCLUSIONS: Long-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of STS involving major vessels in the lower limb. Disease-specific morbidity must be anticipated. The classification of vascular involvement (type I to IV) is useful for surgical management.

PMID: 16012457

Recent Results Cancer Res. 2009;179:301-19.

Current concepts in the management of retroperitoneal soft tissue sarcoma.

Schwarzbach MH, Hohenberger P.

Department of Surgery, University Clinic of Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1-3, 68167 Mannheim, Germany.


Soft tissue sarcomas (STS) in the retroperitoneum are usually diagnosed at the late stages. Surgery is the mainstay of treatment. The technique of resection is standardized. After dissection of the retroperitoneal blood vessel, a retroperitoneal plane of dissection adjacent to the spinal foramina is established in between the layers of the abdominal wall. Complete resection with tumor-free resection margins is the primary goal in retroperitoneal sarcoma surgery. Preoperative assessment of pathoanatomical growth patterns with respect to retroperitoneal vascular structures–as well as to visceral and retroperitoneal organs–influences surgical strategies and thus the surgical outcome. Blood vessel replacement and a multivisceral en bloc approach improve the quality of resection. Blood vessel involvement is stratified in type I (arterial and venous involvement), type II (arterial involvement), type III(venous involvement), and type IV (no vascular involvement). Adjuvant and neoadjuvant treatment options (chemotherapy, targeted therapy, and radiation therapy) are currently being investigated. A prospective randomized phase III trial has shown a positive effect of neoadjuvant chemotherapy combined with regional hyperthermia in disease-free survival, response rate, and local control. Subsets of liposarcomas (myxoid and round cell type) are selectively responsive to novel drugs, such as trabectedin, a DNA-binding agent. Radiotherapy is applied in higher-grade locally advanced retroperitoneal STS. The optimal technique of delivering radiotherapy remains to be determined. The restricted number of patients with retroperitoneal STS and unsatisfying results in local tumor control and long-term survival indicate the need for multi-institutional cooperative studies. An international effort is required to improve the evidence level on multimodal treatment algorithms.

PMID: 19230548