Tseng et al.1 have made an interesting analogy comparing sarcomas and wine. Although wine has far more varieties than sarcomas, sarcomas, despite their rarity (perhaps like good wine), come in about 75 flavors, and each is unique. Studies investigating each type of sarcoma will never be sufficient for the development of meaningful guidelines other than concentration of care in the hands of experts who understand the complexities of this unique disease process.

Tseng et al.1 state that in the retroperitoneum are two common varieties, red and white, corresponding to liposarcomas and leiomyosarcomas. Making guidelines that mix the two groups corresponds to mixing the two wines into a pseudo-rosé. We do not disagree with many of the statements made in the papers from the TARPS Working Group,2,3 but take issue rather with the concept of using guidelines for multidisciplinary management of individual clinical scenarios.

We believe it might be possible to design the studies needed to obtain consensus on the management of patients with resectable, primary, well-differentiated liposarcoma. For this to be a possibility, a better consensus on the pathologic description of well-differentiated liposarcoma is needed because with all too increased frequency, we are seeing qualifying descriptors of unknown clinical significance (e.g., myxoid, inflammatory, colloid, fibrous) added to the well-differentiated liposarcoma diagnosis. It is unclear how the TARPS Working Group has handled this potential inconsistency. A true well-differentiated liposarcoma is a tumor that does not metastasize, so local recurrence determines prognosis. Data from members of the TARPS Working Group suggest that more extensive surgery may be beneficial,4 – 6 but much more follow-up evaluation on existing studies is needed, and concern exists that these tumors may be multifocal by nature and that no resection could ever be complete.

Perhaps the TARPS Working Group could perform a randomized study to determine whether more extensive surgery early would improve overall survival compared with a more conservative approach with organ-sparing surgery and more repeated procedures. In 20 years or so, we may have an answer. However, before embarking on any trial, the TARPSWG members will have to come to a consensus on what constitutes an “extended” resection.7

Dedifferentiated liposarcoma is more complex and should not really be mixed with well-differentiated liposarcoma, although it is a member of the same family. It is as different from well-differentiated liposarcoma as a Bordeaux is from a Burgundy. It can metastasize. It recurs more rapidly. Clearly, if one knew a priori that the tumor would metastasize outside the abdomen, the extent of surgery would become a secondary priority. We and others believe that neoadjuvant chemotherapy has a role in the management of these tumors, both to delay intraabdominal recurrence and to treat distant metastases. For individual patients who respond well to chemotherapy, prolonged disease control can be achieved.

The TARPS Working Group excluded from their recommendations the majority of intraabdominal leiomyosarcomas, those arising from the uterus, male genitourinary organs, intestines, or mesentery, leaving those of major vessels (e.g., inferior vena cava, renal vein) and other retroperitoneal leiomyosarcomas, presumably of vascular origin, as well. This can also potentially be problematic because the tissue or organ of origin is not always readily discernable. Leiomyosarcomas kill by metastatic disease, so finding effective chemotherapy is the key to prolonged control. Adequate tumor resection usually is determined by the local extent of the tumor, and resection of major adjacent organs is rarely needed, so this may be an area in which surgical consensus might be achieved.

The major concern raised in our initial editorial8 was not focused on the individual statements made in the TARPS Working Group paper on guidelines for the management of recurrent retroperitoneal sarcomas.3 Rather, the focus was on a cautious “alert” as to the potential for inappropriate application of the guidelines in these rare clinical situations. Each case is unique, and therapy should be tailored to the case at hand. The guidelines put forward by the TARPS Working Group for primary retroperitoneal sarcomas made the point clearly as follows:

“12f. In cases of loco-regional recurrences, surgery still may reproduce what is done for primary RPS if the first operation consisted of a simple excision. Otherwise, it should be aimed simply at achieving macroscopic complete resection including surrounding organs only when overtly infiltrated.”2

We must recognize that we do not have sufficient evidence for definitive answers to every histologic subtype of sarcoma and need to do the best we can for each individual patient given the nature of the problem at hand. Let us appreciate the diversity we face, and rather than settle for white or red, choose when to favor Chambolle-Musigny over Charmes-Chambertin, and vice versa.