The value of pre-operative split renal function radionuclide imaging in multi-visceral resection for retroperitoneal sarcoma: A retrospective cohort study from a high-volume tertiary sarcoma referral centre.

BACKGROUND: Radionuclide dimercaptosuccinic acid (DMSA) renal imaging is considered a standard pre-operative assessment for renal function before multi-visceral resection (MVR) with en bloc nephrectomy in retroperitoneal sarcoma (RPS), according to Transatlantic Retroperitoneal Sarcoma Working Group guidelines. DMSA scans assess split renal function (SRF) to evaluate both the ipsilateral kidney's contribution and the remaining kidney's function post-surgery. However, limited evidence supports routine DMSA use. This study aimed to evaluate the impact of DMSA on surgical planning. METHODS: This retrospective cohort study, performed in a UK high volume specialist sarcoma centre, included 312 patients considered for MVR of RPS between 2010 and 2023. Phase 1 represented pre 2019 surgical practice with phase 2 representing the period which included more selective DMSA guideline implementation. DMSA SRF was correlated with other imaging, comorbidities, renal tests, and clinical decisions. A significant SRF difference (≥10 %) was the threshold for this study, with p < 0.05 deemed significant for eGFR and ipsilateral versus contralateral SRF. RESULTS: 217 patients were referred for DMSA imaging, of which 165 patients (76 %) underwent surgery. 18 patients (8 %) were excluded due to insufficient data and 34 patients (16 %) did not undergo surgery. Of the 165 patients who underwent surgery, 19 (12 %) had a contralateral SRF ≤45 %, with the lowest at 28 %. Post-operatively, eGFR insignificantly declined from 77.1 to 63.9 and slightly improved to 65.5 after 2-5 years. Unfavourable DMSA SRF did not correlate to additional poorer long term renal function or factor in those failing to progress to surgery; pre-operative death (10/34 patients; 29 %) and inoperable RPS (10/34 patients; 29 %) being the primary reasons for failing to progress to surgery. In only two cases were unfavourable DMSA results cited in pre-operative planning clinic letters and did not prevent resection. From 2010 to 2019, 87.2 % (164/188) of patients underwent pre-operative DMSA scans. Given paucity of departmental evidence related to the utility of DMSA in surgical planning the department of sarcoma moved away from routine DMSA requests unless perceived risk factors for poor renal function were apparent. Thus after 2019, DMSA usage significantly reduced to 28.6 % (8/28) in 2020, further decreasing significantly (p < 0.001) to 4.5 % (1/22), 8.5 % (3/35), and 2.5 % (1/39) from 2021 to 2023. Only 13 DMSA scans were performed out of 124 resections between 2020 and 2023, saving £63,270, reducing patient disruption and preserving resources. CONCLUSION: Pre-operative DMSA had minimal impact on MVR decision-making for RPS. Reflective guideline adaptations streamlined the patient assessment pathway for consideration of MVR for RPS surgery.

Citation

Basit RH, Malik R, Tattersall H, Price L, Badger N, Khan A, Basit RM, Almond M, Tirotta F, Desai A, Ford SJ. The value of pre-operative split renal function radionuclide imaging in multi-visceral resection for retroperitoneal sarcoma: A retrospective cohort study from a high-volume tertiary sarcoma referral centre. Eur J Surg Oncol. 2025 Dec 9;52(2):111334. doi: 10.1016/j.ejso.2025.111334. Epub ahead of print.

Type

Article