What preoperative optimisation strategies improve outcomes in BSTTs?

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What pre-operative optimisation strategies improve outcomes in BSTTs?

Introduction

A number of pre-operative optimisation strategies have been proposed to improve outcomes in patients undergoing complex cancer resection. Most of these studies involve multi-modality interventions, such as ‘fast track protocols’ to optimise nutritional, analgesia and mobility outcomes and reduce surgical morbidity and/or transfusion requirements.

Other preoperative strategies, such as preoperative embolisation are aimed at reduction of intraoperative blood loss.

There is limited evidence to support the use of targeted pre-operative therapies.

Pre-operative embolisation of bone neoplasms

A limited number of publications describe the use of gelatin microspheres or polyvinyl alcohol particles as pre-operative embolisation strategy for bone neoplasms.[1][2] Whilst well described for palliation of unresectable bone tumours or giant cell tumours of the sacrum, there is limited data to support the use of embolisation pre-operatively for sarcoma. No randomised controlled trials (RCTs) have been conducted comparing the use of embolisation with either no-preoperative intervention or with an alternate modality.

Pre-operative embolisation in retroperitoneal sarcoma

Pre-operative embolisation is sometimes considered prior to resection of large intra-abdominal tumours. The rationale of this approach is to reduce operative blood loss, and facilitate surgical resection. Whilst some data suggests that this approach is safe,[1][2] no RCTs have been conducted to compare the use of embolisation with either no preoperative intervention or with an alternate modality.

Pre-operative imatinib mesylate in dermatofibrosarcoma

Kerob et al conducted a Phase II multicentre study of 25 patients and report a benefit for patients with dermatofibrosarcoma treated with imatinib mesylate.[3] This data, whilst limited, support the consideration of imatinib in the pre-operative setting in non-resectable DFSP or when surgery is difficult or mutilating.

Evidence summary and recommendations

Evidence summary Level References
Use of pre-operative embolisation in selected cases may decrease operative blood loss and facilitate surgical resectability. IV [1], [2]
Evidence-based recommendationQuestion mark transparent.png Grade
Pre-operative embolisation may be considered in selected cases.
D


Evidence summary Level References
Pre-operative Imatinib mesylate may benefit selected patients with DFSP. IV [3]
Evidence-based recommendationQuestion mark transparent.png Grade
Pre-operative imatinib mesylate may be considered in selected patients with DFSP when surgery is difficult or potentially mutilating.
D


Practice pointQuestion mark transparent.png

It is advisable to consider the suitability and applicability of pre-operative optimisation strategies, such as embolisation, prior to surgery for large or complex BSSTs.

Issues requiring more clinical research study

A number of gaps in the evidence have been identified. These include:

  • What is the role of preoperative embolisation?
  • What is the role for ‘fast track’ protocols in management of BSSTs?

References

  1. 1.0 1.1 1.2 Nagata Y, Mitsumori M, Okajima K, Mizowaki T, Fujiwara K, Sasai K, et al. Transcatheter arterial embolization for malignant osseous and soft tissue sarcomas. II. Clinical results. Cardiovasc Intervent Radiol 2017 Nov 23;21(3):208-13 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/9626436.
  2. 2.0 2.1 2.2 Rossi C, Ricci S, Boriani S, Biagini R, Ruggieri P, De Cristofaro R, et al. Percutaneous transcatheter arterial embolization of bone and soft tissue tumors. Skeletal Radiol 1990;19(8):555-60 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/1703665.
  3. 3.0 3.1 Kérob D, Porcher R, Vérola O, Dalle S, Maubec E, Aubin F, et al. Imatinib mesylate as a preoperative therapy in dermatofibrosarcoma: results of a multicenter phase II study on 25 patients. Clin Cancer Res 2010 Jun 15;16(12):3288-95 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20439456.

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Appendices

Further resources