A 60-year-old male patient had previously undergone a radical resection of a T2bN0M0G3 Stage III retroperitoneal sarcoma, including right nephrectomy and cholecystectomy, in 2002.
Pathologic evaluation demonstrated a 25 cm high-grade liposarcoma with different histologic components, including myxoid, round cell, well-differentiated, sclerosing and pleomorphic patterns.
Surgical margins were negative as the tumor did not invade the kidney, and since the renal vein and ureter were free of tumor as well.
The patient did not undergo any additional therapy.
Surveillance magnetic resonance imaging in 2007 revealed an isolated tumor recurrence in the retroperitoneum.
An exploratory celiotomy revealed tumor involvement of the duodenum, head of the pancreas, superior mesenteric vein, vena cava and left renal vein with severe adhesive changes, leading to the intraoperative assessment of unresectable disease.
Subsequently, the patient underwent stereotactic body radiation to the retroperitoneal tumor in five fractions for a total dose of 30 Gy, without complication.
Postradiation imaging revealed near complete resolution of the retroperitoneal mass.
One year later, the patient presented with weight loss, postprandial abdominal pain, nausea and vomiting.
Cross-sectional imaging revealed a 7 cm mass with involvement of the third portion of the duodenum (Figure ​1).
However, there was no obvious involvement of the pancreatic head or the other structures that were noted to be involved during the previous laparotomy.
We elected to perform another resection attempt, including a possible pancreatoduodenectomy or retroperitoneal vascular resection if necessary.
At exploration, the residual tumor was an entirely intraduodenal, pedunculated mass at the posterior duodenal wall distal to the ampulla that filled the entire duodenal lumen.
The patient underwent a duodenotomy and stalk transection of the polypoid mass, followed by partial duodenal resection with hand-sewn duodenojejunal anastomosis (Figure 2).
Surgical pathology examination revealed a 9.5 cm recurrent high-grade liposarcoma with polypoid intraluminal growth containing myxoid, round cell, well-differentiated, sclerosing and focally pleomorphic areas.
Surgical margins were negative as the tumor came within 0.1 cm of the stalk margin and there was no evidence of additional neoplastic components within the remaining resected duodenum.
The postoperative course was uncomplicated, and the patient has demonstrated no recurrence up to 30 months from this resection.