Case report of retroperitoneal sarcoma excision

1. Retroperitoneal
Sarcoma
SHAY DAJI
10/10/20

2. HPI
 CC: “Fever and chills”
 40 y/o M w/ PMH of RLE Myxoid Liposarcoma (T2N0) s/p neoadjuvant RT presented with
imaging findings concerning for oligometastatic recurrence in RLL juxtapleural and L suprarenal
space
PMH: Asthma, R-popliteal fossa Myxoid Liposarcoma, GERD
FH: Unremarkable; Neg for malignancy
SH: Denies tobacco, alcohol abuse, and recreational drug use. Divorced w/ 2 young children.
Systems engineer at CMU. Strong support system.
Meds: Ondansetron, Loratadine, Miralax

3. Oncological History
Initially dx after palpated a mass at the back of his right knee. MRI in 09/2017 showed possible
sarcoma, measuring 7.7 x 4.6 x 11.4 cm heterogeneous mass.
Ultrasound-guided bx on 11/14/17 noted myxoid liposarcoma, no round cells identified. FISH
+CHOP.
Neoadjuvant RT completed 1/30/18, 50 Gy in 25 fractions
Surgical resection of the mass on 3/12/18. Pathology noted Myxoid Liposarcoma, measuring 9.5-
cm, necrosis 30%, treatment effect present, viable tumor % was <10%, Mitotic rate 0/10 hpf,
margins were negative for tumor. Stage T2N0. Grade could not be assessed (s/p neoadj tx).
No adjuvant chemotherapy recommended.
June 2018 showed a fluid collection in the surgical bed. Sent for cytology which was negative for
malignancy.

4. Physical Exam / ROS / Labs
General: No acute distress, lying comfortably in bed. Calm, answers questions appropriately,
Respiratory: Lungs CTBA, Respirations are non-labored, Breath sounds are equal, Symmetrical
chest wall expansion, No chest wall tenderness.
Cardiovascular: Normal rate, Regular rhythm. No m/r/g.
Gastrointestinal: Soft, Non-tender to palpation, Non-distended. Normoactive BS. No rebound
tenderness.
Eye, HENT, GU, MSK, Neuro, Psych exam all unremarkable.
 14 point ROS neg except for fevers/chills
Vitals: Afebrile. HDS.
Labs:

5. April 2020 CT showed new posteromedial RLL pleural-based mass as well as left suprarenal
lesion (in hindsight had grown since March 2019 CT from 1.2-cm).

6. CT-guided bx of the juxtapleural mass and left suprarenal mass on 4/27/20. Pathology noted
metastatic myxoid liposarcoma at both locations

7. Radical Resection of 8cm L Retroperitoneal Mass

9. Post-op
Transferred to the PACU in stable condition and then transferred to floor.
Able to ambulate and void. Denied CP, SoB, and n/v
Pain well controlled with Lidocaine paravertebral catheter, Dilaudid.
Tachycardic to 110s on 10/4, did not respond to fluid bolus, obtained CT AP on 10/5 CT AP showing
partially loculated fluid collection containing gas locules, measuring 9 x 5.6 x 11 cm (AP x transverse x
craniocaudal) in the surgical bed, c/f pancreatic leak s/p IR drain placement on 10/5.
Fluid cx showed no growth. Fluid Amylase 488 (10/5) -> 22 (10/7).
Continued to improve, vital signs remained stable, patient remained afebrile, tolerating PO,
ambulating without assistance, surgical wounds healed without signs of infection or complications ->
discharged to home on 10/7/20.
Scheduled for resection of juxtapleural metastasis in November
Sent specimen to Pathology for margins  consider RT if not completely resected

11. Post-op
Transferred to the PACU in stable condition and then transferred to floor.
Able to ambulate and void. Denied CP, SoB, and n/v
Pain well controlled with Lidocaine paravertebral catheter, Dilaudid.
Tachycardic to 110s on 10/4, did not respond to fluid bolus, obtained CT AP on 10/5 CT AP showing
partially loculated fluid collection containing gas locules, measuring 9 x 5.6 x 11 cm (AP x transverse x
craniocaudal) in the surgical bed, c/f pancreatic leak s/p IR drain placement on 10/5.
Fluid cx showed no growth. Fluid Amylase 488 (10/5) -> 22 (10/7).
Continued to improve, vital signs remained stable, patient remained afebrile, tolerating PO,
ambulating without assistance, surgical wounds healed without signs of infection or complications ->
discharged to home on 10/7/20.
Scheduled for resection of juxtapleural metastasis in November
Sent specimen to Pathology for margins

12. Pathology
Histologic sections demonstrated a conventional myxoid liposarcoma. There are focal areas with
modestly increased cellularity “transitional areas”; however, high-grade transformation (round cell
change) is not identified.
Morphology supports the diagnosis of Myxoid Liposarcoma.

13. Retroperitoneal Sarcomas
• Sarcomas = malignant tumors arising from connective tissue
• Most commonly osteosarcoma
• Retroperitoneal sarcomas constitute 10-15% all sarcomas
• 80% malignant
• Majority of patients presenting with retroperitoneal, extravisceral, solitary
soft tissue mass found to have a sarcoma
• Typically asymptomatic until mass effect
• Median 15 cm at time of presentation
• Distant mets at presentation in 10% pts; spread hematogenously most
commonly to the lungs

14. Retroperitoneal Sarcomas
Preferred diagnostic workup -> A/P CT scan
Chest CT to rule out metastatic disease to the lungs
Low threshold for percutaneous core needle biopsy -> low risk of complications
Surgical resection has traditionally been the only potentially curative approach.
Resection with microscopically negative margins is often not achieved, and locoregional
recurrence is common (especially low-grade tumors)
Role of adjunctive therapy is unclear -> no consensus as to the best approach for all
patients
The main prognostic factors for long-term outcome are resectability, histologic grade of
differentiation, and histologic subtype.