Quantitative methodologies for selection of patients with recurrent abdominopelvic sarcoma for treatment

Peritoneal sarcomatosis is a major cause of surgical treatment failure in patients with abdominal or pelvic sarcoma. In the past, patients with this condition have had a lethal outcome. In this study, 43 consecutive patients with recurrent sarcomatosis were studied in order to evaluate an aggressive reoperative approach. In all patients, the goal of surgery was to resect all recurrent sarcoma in the abdomen and pelvis. In 30 patients in whom sarcomatosis was demonstrated and in whom a complete cytoreduction could be performed, resection was associated with peri-operative intraperitoneal chemotherapy with doxorubicin or cisplatin plus doxorubicin. Using a standardised and quantitative methodology to assess local-regional recurrence and dissemination on peritoneal surfaces, the clinical features that may affect prognosis were tabulated and analysed statistically. The median survival of these 43 patients was 20 months. Clinical features that had a significant impact on survival were involvement of less than six abdominopelvic regions (P = 0.0009), an increase in the involvement of abdominopelvic regions of less than four regions (P = 0.0007), involvement of less than 10 anatomic sites (P = 0.0002), complete cytoreduction with tumour reduced to nodules < 2.5 mm (P = 0.005) and a Peritoneal Cancer Index less than 13 (P = 0.01). Histological type and grade of recurrent sarcoma were not correlated with prognosis. In the multivariate analysis, an increase in abdominopelvic regions by four or more showed a risk ratio of 18.5. The involvement of 10 or more anatomic sites showed a risk ratio of 5.9. These data suggest that selected patients with recurrent sarcoma should be considered for further treatment and that the results of aggressive reoperative surgery and peri-operative intraperitoneal chemotherapy are greatly dependent on the volume and distribution of disease, determined at the initiation of therapy. Because of the great likelihood of local-regional treatment failure, the use of peri-operative intraperitoneal chemotherapy in a randomised study in patients with primary abdominopelvic sarcoma should be considered.