Research Article| Volume 49, ISSUE 6, P1102-1110, June 2023

Download started.


Pelvic soft tissue sarcomas


      • -
        Adequate imaging and biopsy are crucial for diagnosis and planning surgical approach
      • -
        Histologic subtypes are different in pelvic sarcomas compared to retroperitoneal
      • -
        Multimodal treatment is frequently adopted at referral centers
      • -
        Pelvic anatomy impacts functional outcome and decision for preoperative therapy
      • -
        Benefit from referral to high volume centers and histology driven tailored approach


      Pelvic soft tissue sarcomas (PSTS) are a rare, heterogeneous group of tumors. They have been usually analyzed with retroperitoneal sarcomas (RPS), but actually have key differences. Due to their unique anatomic location, symptomatic presentation of PSTS may be more common than RPS. Adequate imaging approach is paramount for guiding differential diagnosis, while preoperative biopsy is mandatory, especially when preoperative treatment may be considered as initial approach. The most frequent histologic subtype is leiomyosarcoma, which is different as expected in the retroperitoneum where liposarcoma is the commonest histology. Also solitary fibrous tumor is commonly diagnosed in the pelvis. Surgical approach for PSTS differs from that for RPS mainly due to anatomic relations. Similarly, in the lack of definite evidence from specific trials about neoadjuvant and adjuvant treatments, the anatomic constraints to obtain wide margins in the pelvis as well as the expected functional outcome in case of organ resections should be factored into decision for individualized treatment offer. Vascular and genitourinary involvement are frequent, as well as herniation through pelvic foramina. For these reasons a multidisciplinary surgical team should always be considered. Early referral of these patients to high-volume centers is critical and may impact on survival, given that optimal initial resection is a major predictor of curative treatment. International consensus on PSTS treatment is advocated, similarly to the recent efforts realized for RPS.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gronchi A.
        • Lo Vullo S.
        • Fiore M.
        • et al.
        Aggressive surgical policies in a retrospectively reviewed single-institution case series of retroperitoneal soft tissue sarcoma patients.
        J Clin Oncol. 2009; 27: 24-30
        • Monteiro De Barros J.
        • Hodson J.
        • et al.
        • Transatlantic Australasian Retroperitoneal Sarcoma Working Group
        Intercontinental collaborative experience with abdominal, retroperitoneal and pelvic schwannomas.
        Br J Surg. 2020; 107: 452-463
        • Stiller C.A.
        • Trama A.
        • Serraino D.
        • et al.
        Descriptive epidemiology of sarcomas in Europe: report from the RARECARE project.
        Eur J Cancer. 2013; 49: 684-695
        • Lewis S.J.
        • Wunder J.S.
        • Couture J.
        • et al.
        Soft tissue sarcomas involving the pelvis.
        J Surg Oncol. 2001; 77: 8-14
        • Keyzer-Dekker C.M.G.
        • Houtkamp R.G.
        • Peterse J.L.
        • Van Coevorden F.
        Adult pelvic sarcomas: a heterogeneous collection of sarcomas?.
        Sarcoma. 2004; 8: 19-24
        • Hui J.Y.C.
        Epidemiology and etiology of sarcomas.
        Surg Clin. 2016; 96: 901-914
        • Clark M.A.
        • Thomas J.M.
        Soft-tissue sarcomas in adults.
        N Engl J Med. Published online. 2005; : 11
        • Gladdy R.A.
        • Qin L.X.
        • Moraco N.
        • et al.
        Do radiation-associated soft tissue sarcomas have the same prognosis as sporadic soft tissue sarcomas?.
        J Clin Oncol. 2010; 28: 2064-2069
        • Gamboa A.C.
        • Gronchi A.
        • Cardona K.
        Soft-tissue sarcoma in adults: an update on the current state of histiotype-specific management in an era of personalized medicine.
        CA Cancer J Clin. 2020; 70: 200-229
        • Mullen J.T.
        • van Houdt W.
        Soft tissue tumors of the pelvis: technical and histological considerations.
        J Surg Oncol. 2018; 117: 48-55
        • Koh W.J.
        • Greer B.E.
        • Abu-Rustum N.R.
        • et al.
        Uterine sarcoma, version 1.2016.
        J Natl Compr Cancer Netw. 2015; 13: 1321-1331
        • Ferrandina G.
        • Aristei C.
        • Biondetti P.R.
        • et al.
        Italian consensus conference on management of uterine sarcomas on behalf of S.I.G.O. (Societa’ italiana di Ginecologia E Ostetricia).
        Eur J Cancer. 2020; 139: 149-168
        • Gronchi A.
        • Miah A.B.
        • Dei Tos A.P.
        • et al.
        Soft tissue and visceral sarcomas: ESMO–EURACAN–GENTURIS Clinical Practice Guidelines for diagnosis, treatment and follow-up.
        Ann Oncol. 2021; 32: 1348-1365
        • Swallow C.J.
        • Strauss D.C.
        • Bonvalot S.
        • et al.
        Management of primary retroperitoneal sarcoma (RPS) in the adult: an updated consensus approach from the transatlantic australasian RPS working group.
        Ann Surg Oncol. 2021; 28: 7873-7888
        • Coppola S.
        • Desai A.
        • Tzanis D.
        • et al.
        Conservative en bloc surgery for aggressive angiomyxoma achieves good local control: analysis of 14 patients from a single institution.
        Int J Gynecol Cancer. 2013; 23: 540-545
        • Lee J.J.
        • Dickson B.C.
        • Sreeharsha B.
        • Gladdy R.A.
        • Thipphavong S.
        Presacral myelolipoma: diagnosis on imaging with pathologic and clinical correlation.
        Am J Roentgenol. 2016; 207: 470-481
        • Sangkhathat S.
        Current management of pediatric soft tissue sarcomas.
        World J Clin Pediatr. 2015; 4: 94
        • Kadhim M.
        • Oyoun N.A.
        • Womer R.B.
        • Dormans J.P.
        Clinical and radiographic presentation of pelvic sarcoma in children.
        SICOT-J. 2018; 4: 44
        • Tan M.C.B.
        • Yoon S.S.
        Surgical management of retroperitoneal and pelvic sarcomas: surgical management of retroperitoneal sarcomas.
        J Surg Oncol. 2015; 111: 553-561
        • Messiou C.
        • Moskovic E.
        • Vanel D.
        • et al.
        Primary retroperitoneal soft tissue sarcoma: imaging appearances, pitfalls and diagnostic algorithm.
        Eur J Surg Oncol EJSO. 2017; 43: 1191-1198
        • Fiore M.
        • Sarre-Lazcano C.
        • Dumitra S.
        • Honoré C.
        • Sargos P.
        • Grignani G.
        • et al.
        Pelvic soft tissue sarcomas: an international retrospective study from the trans-atlantic australasian retroperitoneal sarcoma working group (TARPSWG).
        in: 25th CTOS virtual annual meeting. 2020
        • Taylor A.T.
        Radionuclides in nephrourology, Part 2: pitfalls and diagnostic applications.
        J Nucl Med. 2014; 55: 786-798
        • Messiou C.
        • Morosi C.
        Imaging in retroperitoneal soft tissue sarcoma.
        J Surg Oncol. 2018; 117: 25-32
        • Rajiah P.
        • Sinha R.
        • Cuevas C.
        • Dubinsky T.J.
        • Bush W.H.
        • Kolokythas O.
        Imaging of uncommon retroperitoneal masses.
        Radiographics. 2011; 31: 949-976
        • Treglia G.
        • Taralli S.
        • Bertagna F.
        • et al.
        Usefulness of whole-body fluorine-18-fluorodeoxyglucose positron emission tomography in patients with neurofibromatosis type 1: a systematic review.
        Radiol Res Pract. 2012; (2012): 1-9
        • Levy A.D.
        • Manning M.A.
        • Al-Refaie W.B.
        • Miettinen M.M.
        Soft-tissue sarcomas of the abdomen and pelvis: radiologic-pathologic features, Part 1—common sarcomas: From the radiologic pathology archives.
        Radiographics. 2017; 37: 462-483
        • Mahnert N.
        • Morgan D.
        • Campbell D.
        • Johnston C.
        • As-Sanie S.
        Unexpected gynecologic malignancy diagnosed after hysterectomy performed for benign indications.
        Obstet Gynecol. 2015; 125: 397-405
        • Kho K.A.
        • Nezhat C.H.
        Evaluating the risks of electric uterine morcellation.
        JAMA. 2014; 311: 905
        • Nougaret S.
        • Nikolovski I.
        • Paroder V.
        • et al.
        MRI of tumors and tumor mimics in the female pelvis: anatomic pelvic space–based approach.
        Radiographics. 2019; 39: 1205-1229
        • Jagannathan J.P.
        • Tirumani S.H.
        • Ramaiya N.H.
        Imaging in soft tissue sarcomas.
        Surg Oncol Clin. 2016; 25: 645-675
        • Janvier A.
        • Rousset P.
        • Cazejust J.
        • Bouché O.
        • Soyer P.
        • Hoeffel C.
        MR imaging of pelvic extraperitoneal masses: a diagnostic approach.
        Diagn Interv Imaging. 2016; 97: 159-170
        • Nishino M.
        • Hayakawa K.
        • Minami M.
        • Yamamoto A.
        • Ueda H.
        • Takasu K.
        Primary retroperitoneal neoplasms: CT and MR imaging findings with anatomic and pathologic diagnostic clues.
        Radiographics. 2003; 23: 45-57
        • Strauss D.C.
        • Qureshi Y.A.
        • Hayes A.J.
        • Thway K.
        • Fisher C.
        • Thomas J.M.
        The role of core needle biopsy in the diagnosis of suspected soft tissue tumours: core Needle Biopsy.
        J Surg Oncol. 2010; 102: 523-529
        • Callegaro D.
        • Fiore M.
        • Gronchi A.
        Personalizing surgical margins in retroperitoneal sarcomas.
        Expert Rev Anticancer Ther. 2015; 15: 553-567
        • Fairweather M.
        • Raut C.P.
        To biopsy, or not to biopsy: is there really a question?.
        Ann Surg Oncol. 2019; 26: 4182-4184
        • Won S.Y.
        • Kim H.S.
        • Park S.Y.
        Transrectal or transvaginal ultrasoundguided biopsy for pelvic masses: external validation and usefulness in oncologic patients.
        Ultrasonography. 2019; 38: 149-155
        • Volanis D.
        • Neal D.E.
        • Warren A.Y.
        • Gnanapragasam V.J.
        Incidence of needle-tract seeding following prostate biopsy for suspected cancer: a review of the literature: incidence of needle-tract seeding after prostate biopsy.
        BJU Int. 2015; 115: 698-704
        • Raut C.P.
        • George S.
        • Hornick J.L.
        • Butrynski J.E.
        • Morgan J.A.
        • Ready J.
        • et al.
        High rates of histopathologic discordance in sarcoma with implications for clinical care.
        J Clin Oncol. 2011; 2910065
        • Brennan M.F.
        • Antonescu C.R.
        • Moraco N.
        • Singer S.
        Lessons learned from the study of 10,000 patients with soft tissue sarcoma.
        Ann Surg. 2014; 260: 416-422
        • Gronchi A.
        • Strauss D.C.
        • Miceli R.
        • et al.
        Variability in patterns of recurrence after resection of primary retroperitoneal sarcoma (RPS): a report on 1007 patients from the multi-institutional collaborative RPS working group.
        Ann Surg. 2016; 263: 1002-1009
        • Bonvalot S.
        • Gronchi A.
        • Le Péchoux C.
        • et al.
        Preoperative radiotherapy plus surgery versus surgery alone for patients with primary retroperitoneal sarcoma (EORTC-62092: STRASS): a multicentre, open-label, randomised, phase 3 trial.
        Lancet Oncol. 2020; 21: 1366-1377
        • Yuen N.K.
        • Li C.S.
        • Monjazeb A.M.
        • Borys D.
        • Bold R.J.
        • Canter R.J.
        Older age impacts radiotherapy-related outcomes in soft tissue sarcoma.
        J Surg Res. 2015; 199: 494-504
        • Wong P.
        • Han K.
        • Sykes J.
        • et al.
        Postoperative radiotherapy improves local control and survival in patients with uterine leiomyosarcoma.
        Radiat Oncol. 2013; 8: 128
        • Dalsania R.M.
        • Shah K.P.
        • Stotsky-Himelfarb E.
        • Hoffe S.
        • Willingham F.F.
        Management of long-term toxicity from pelvic radiation therapy.
        Am Soc Clin Oncol Educ Book. 2021; : 147-157
        • Viswanathan A.N.
        • Lee L.J.
        • Eswara J.R.
        • et al.
        Complications of pelvic radiation in patients treated for gynecologic malignancies: morbidity from Pelvic Radiation.
        Cancer. 2014; 120: 3870-3883
        • Frebourg T.
        • Bajalica Lagercrantz S.
        • Oliveira C.
        • Magenheim R.
        • Evans D.G.
        • The European Reference Network GENTURIS
        Guidelines for the Li–Fraumeni and heritable TP53-related cancer syndromes.
        Eur J Hum Genet. 2020; 28: 1379-1386
        • Almond L.M.
        • Gronchi A.
        • Strauss D.
        • Jafri M.
        • Ford S.
        • Desai A.
        Neoadjuvant and adjuvant strategies in retroperitoneal sarcoma.
        Eur J Surg Oncol. 2018; 44: 571-579
        • Sugawara S.
        • Ehara S.
        • Hitachi S.
        • Okada K.
        Patterns of soft-tissue tumor extension in and out of the pelvis.
        Am J Roentgenol. 2010; 194: 746-753
        • Karakousis C.P.
        Refinements of surgical technique in soft tissue sarcomas.
        J Surg Oncol. 2010; 101: 730-738
        • Fairweather M.
        • Gonzalez R.J.
        • Strauss D.
        • Raut C.P.
        Current principles of surgery for retroperitoneal sarcomas.
        J Surg Oncol. 2018; 117: 33-41
        • Asencio Pascual J.M.
        • Fernandez Hernandez J.A.
        • Blanco Fernandez G.
        • et al.
        Update in pelvic and retroperitoneal sarcoma management: the role of compartment surgery.
        Cir Esp Engl Ed. 2019; 97: 480-488
        • Nakamura T.
        • Abudu A.
        • Murata H.
        • et al.
        Oncological outcome of patients with deeply located soft tissue sarcoma of the pelvis: a follow up study at minimum 5 years after diagnosis.
        Eur J Surg Oncol EJSO. 2013; 39: 1030-1035
        • Trans-Atlantic RPS Working Group
        Management of recurrent retroperitoneal sarcoma (RPS) in the adult: a consensus approach from the trans-atlantic RPS working group.
        Ann Surg Oncol. 2016; 23: 3531-3540
        • Gronchi A.
        Surgery in soft tissue sarcoma: the thin line between a surgical or more conservative approach.
        Future Oncol. 2021; 17: 3-6
      1. Management of metastatic retroperitoneal sarcoma: a consensus approach from the trans-atlantic retroperitoneal sarcoma working group (TARPSWG).
        Ann Oncol. 2018; 29: 857-871
        • Smolle M.A.
        • Szkandera J.
        • Andreou D.
        • Palmerini E.
        • Bergovec M.
        • Leithner A.
        Treatment options in unresectable soft tissue and bone sarcoma of the extremities and pelvis – a systematic literature review.
        EFORT Open Rev. 2020; 5: 799-814
        • Garcia-Ortega D.Y.
        • Villa-Zepeda O.
        • Martinez-Said H.
        • Cuellar-Hübbe M.
        • Luna-Ortiz K.
        Oncology outcomes in retroperitoneal sarcomas: prognostic factors in a retrospective cohort study.
        Int J Surg. 2016; 32: 45-49
        • Villano A.M.
        • Zeymo A.
        • Chan K.S.
        • Shara N.
        • Al-Refaie W.B.
        Identifying the minimum volume threshold for retroperitoneal soft tissue sarcoma resection: merging national data with consensus expert opinion.
        J Am Coll Surg. 2020; 230 (e2): 151-160
        • Rutkowski P.
        • Ługowska I.
        Follow-up in soft tissue sarcomas.
        Memo - Mag Eur Med Oncol. 2014; 7: 92-96