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Sedaghat S, Ravesh MS, Sedaghat M, Meschede J, Jansen O, Both M. Does the primary soft-tissue sarcoma configuration predict configuration of recurrent tumors on magnetic resonance imaging? Acta Radiol 2022; 63:642-651. [PMID: 33853376 DOI: 10.1177/02841851211008381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Soft-tissue sarcomas (STS) are rare malignancies of the soft tissue. PURPOSE To assess whether the magnetic resonance imaging (MRI) configuration of primary STS can predict the configuration of a recurring tumor and whether the MRI configuration of multiple recurrences differs in one and the same patient. MATERIAL AND METHODS Thirty-nine patients with histologically proven recurrent STS were included in this retrospective study and underwent pre- and post-treatment MRI. Three main configurations of primary and recurrent tumors were identified: polycyclic/multilobulated; ovoid/nodular; and streaky. RESULTS Sixty recurrent lesions were detected: 34 ovoid/nodular; 15 polycyclic/multilobulated; and 11 streaky. Five recurrences were multifocal and eight were bifocal. Of 39 patients, 28 (71.8%) presented one recurrence within the MRI follow-up period (P = 0.006); in 10 patients (25.6%), up to three different configurations of recurring STS were identified in one patient. Recurrences of polycyclic/multilobulated primaries were mostly ovoid/nodular (48%; P = 0.003) or polycyclic/multilobulated (37%; P = 0.014), and recurring ovoid/nodular STS significantly most often showed the same configuration as the primary tumor (85%; P < 0.001). Primary STS with a streaky configuration recurred in all three configurations in roughly equal proportions. Homogeneity/heterogeneity and tumor borders are significantly associated with the configuration of recurrences. CONCLUSION Primary STS configuration may help predict recurrent tumor configuration when the primary STS had a polycyclic/multilobulated or ovoid/nodular configuration. However, recurrent STS configuration can also differ from primary STS configuration, especially when the primary STS had a streaky configuration, rendering recurrent STS difficult to predict. Different configurations of recurrent STS in one and the same patient are common.
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Affiliation(s)
- Sam Sedaghat
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
- Institute of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Bergmannsheil, Bochum, Germany
| | - Mona Salehi Ravesh
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Maya Sedaghat
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
- Institute of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Bergmannsheil, Bochum, Germany
| | - Jens Meschede
- Institute of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Bergmannsheil, Bochum, Germany
- Department for Radiology and Neuroradiology, Klinikum Dortmund, Germany
| | - Olav Jansen
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Marcus Both
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
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Weiss S, Korthaus A, Baumann N, Yamamura J, Spiro AS, Lübke AM, Frosch KH, Schlickewei C, Priemel M. Musculoskeletal Soft-Tissue Sarcoma: Quality Assessment of Initial MRI Reports Shows Frequent Deviation from ESSR Guidelines. Diagnostics (Basel) 2021; 11:695. [PMID: 33919690 PMCID: PMC8069769 DOI: 10.3390/diagnostics11040695] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 01/27/2023] Open
Abstract
Soft-tissue sarcomas (STS) are a rare subtype of soft-tissue mass and are frequently misinterpreted as benign lesions. Magnetic resonance imaging (MRI) is the primary recommended type of diagnostics. To assess the quality of primary radiology reports, we investigated whether recommended MRI report elements were included in compliance with European Society of Musculoskeletal Radiology (ESSR) guidelines. A total of 1107 patients were evaluated retrospectively, and 126 radiological reports on patients with malignant STS were assessed for ESSR quality criteria. One or more required sequences or planes were missing in 67% of the reports. In all 126 cases, the report recognized the mass as anomalous (100%). Sixty-eight percent of the reports mentioned signs of malignancy. The majority of reports (n = 109, 87%) articulated a suspected diagnosis, 32 of which showed a mismatch with the final diagnosis (25%). Thirty-two percent of the reports had a misinterpretation of the masses as benign. Benign misinterpretations were more common in masses smaller than 5 cm (65% vs. 27%). Thirty percent of the reports suggested tissue biopsy and 6% recommended referral to a sarcoma center. MRI reports showed frequent deviations from ESSR guidelines, and protocol guidelines were not routinely met. Deviations from standard protocol and reporting guidelines could put patients at risk for inadequate therapy.
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Affiliation(s)
- Sebastian Weiss
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (A.K.); (N.B.); (A.S.S.); (K.-H.F.); (C.S.); (M.P.)
| | - Alexander Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (A.K.); (N.B.); (A.S.S.); (K.-H.F.); (C.S.); (M.P.)
| | - Nora Baumann
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (A.K.); (N.B.); (A.S.S.); (K.-H.F.); (C.S.); (M.P.)
| | - Jin Yamamura
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Alexander S. Spiro
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (A.K.); (N.B.); (A.S.S.); (K.-H.F.); (C.S.); (M.P.)
- Department of Pediatric Orthopedics, Children’s Hospital Hamburg Altona, 22763 Hamburg, Germany
| | - Andreas M. Lübke
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (A.K.); (N.B.); (A.S.S.); (K.-H.F.); (C.S.); (M.P.)
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, 21033 Hamburg, Germany
| | - Carsten Schlickewei
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (A.K.); (N.B.); (A.S.S.); (K.-H.F.); (C.S.); (M.P.)
| | - Matthias Priemel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (A.K.); (N.B.); (A.S.S.); (K.-H.F.); (C.S.); (M.P.)
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3
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Tokumoto H, Akita S, Kubota Y, Mitsukawa N. Effect of unplanned excision of soft tissue sarcomas on skin defects and reconstructive procedures. J Plast Surg Hand Surg 2020; 54:372-376. [PMID: 32734802 DOI: 10.1080/2000656x.2020.1799817] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Unplanned excision (UE) is defined as a procedure wherein a surgeon operates a tumor resection without appropriate preoperative diagnostic modalities and without the intent to achieve tumor-free margins. Generally, the reconstruction rate after UE is higher than that after planned excision (PE). The present study aimed to investigate how the reconstructive procedure and size of skin defect could be influenced. We reviewed the cases of 442 patients who underwent the resection of soft tissue sarcoma. Patients were stratified into two groups (UE vs. PE). We compared the histologic grade, skin defect, reconstructive procedures, depth of the reconstruction layer. For superficial reconstructions, we also compared procedures involving skin graft-only or flap. 105 cases (23.8%) were UE. Histologic grade in PE was significantly higher (p = .024). The reconstruction rate and size of skin defect in UE was significantly higher (76.2% vs. 27.3%, p < .001) and larger (124.5 cm2 vs. 65.7 cm2, p < .001). The rate of deep layer reconstruction was significantly higher in PE (7.5% vs. 26.1%, p = .001). In superficial reconstructions, 18 (24.3%) skin graft-only procedures were performed in UE and 15 (22.1%) in PE, all other superficial reconstructive procedures involved flap, and there was no significant difference (p = .45). Skin defects were 1.9 times larger after UE than PE. UE did not affect the superficial reconstructive procedure.
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Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
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Gómez J, Tsagozis P. Multidisciplinary treatment of soft tissue sarcomas: An update. World J Clin Oncol 2020; 11:180-189. [PMID: 32355640 PMCID: PMC7186235 DOI: 10.5306/wjco.v11.i4.180] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 03/13/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
Standard treatment for soft tissue sarcoma, based on complete surgical resection with or without adjuvant radiotherapy and chemotherapy, has not substantially changed during the last several decades. Nevertheless, recent advances have contributed to considerable improvement in the management of these patients; for example, new magnetic resonance imaging sequences such as diffusion-weighted imaging and magnetic resonance imaging radiomics can better assess tumor extension and even estimate its grade. Detection of circulating genetic material (liquid biopsy) and next-generation sequencing are powerful techniques for genetic analysis, which will increase our understanding of the underlying molecular mechanisms and may reveal potential therapeutic targets. The role of chemotherapy in non-metastatic disease is still controversial, and there is a need to identify patients who really benefit from this treatment. Novel chemotherapeutic regimens have entered clinical praxis and can change the outcome of patients with metastatic disease. Advances in radiotherapy have helped decrease local adverse effects and sustain good local control of the disease. The following report provides an updated view of the diagnosis, treatment, and future perspectives on the management of patients with soft tissue sarcomas.
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Affiliation(s)
- Jorge Gómez
- Department of Orthopedic Surgery, Clínica Universidad de Navarra, University of Navarra, Pamplona 31008, Spain
| | - Panagiotis Tsagozis
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm 17176, Sweden
- Muskuloskeletal Tumour Service, Karolinska University Hospital, Stockholm 17176, Sweden
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5
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Trends in practice patterns and outcomes: A decade of sarcoma care in the United States. Surg Oncol 2019; 29:168-177. [PMID: 31196484 DOI: 10.1016/j.suronc.2019.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/16/2019] [Accepted: 05/18/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Soft tissue sarcomas (STS) represent a rare and heterogeneous group of tumors. We sought to characterize national trends in referral patterns, treatment strategies, and overall survival (OS) over the course of a decade. METHODS Adult patients with extra-abdominal STS were identified using the National Cancer Database and categorized by diagnosis year (2005-2009 and 2010-2014). High-volume hospitals (HVH) were defined as those >90th percentile in volume of STS patients treated, and others were defined as low-volume hospitals (LVH). Standard statistical methods were used to compare treatment strategies and OS by diagnosis period. RESULTS Of 55,212 patients, 25,469 (46.1%) were diagnosed in 2005-2009 and 29,743 (53.9%) in 2010-2014. Despite increased utilization of neoadjuvant radiation therapy (26.6% vs. 34.8%, P < 0.001), the rate of R0 resections did not change (75.0% vs. 74.8%, P = 0.067). Furthermore, at a national level, OS did not improve over time (HR 0.99, 95% CI 0.96-1.01). When outcomes were stratified by volume, treatment at HVH compared to LVH was associated with improved rates of R0 resection (OR 1.27, 95% CI 1.20-1.35) and OS (HR 0.92, 95% CI 0.89-0.95). Moreover, there was a modest improvement in OS at HVH (HR 0.95, 95% CI 0.91-1.00), but not at LVH (HR 1.01, 95% CI 0.97-1.04). However, referral to HVH did not change over time (40.7% vs. 40.7%, P = 0.91). CONCLUSION OS for STS did not change at a national level over the course of a decade, although it improved at HVH. Further outcome improvements will likely require more effective systemic therapies.
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Pollock RE, Payne JE, Rogers AD, Smith SM, Iwenofu OH, Valerio IL, Zomerlei TA, Howard JH, Dornbos D, Galgano MA, Goulart C, Mendel E, Miller ED, Xu-Welliver M, Martin DD, Haglund KE, Bupathi M, Chen JL, Yeager ND. Multidisciplinary sarcoma care. Curr Probl Surg 2018; 55:517-580. [PMID: 30526918 DOI: 10.1067/j.cpsurg.2018.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Raphael E Pollock
- The Ohio State University Comprehensive Cancer Center, Columbus, OH.
| | - Jason E Payne
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - Alan D Rogers
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - Stephen M Smith
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - O Hans Iwenofu
- Department of Pathology & Laboratory Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ian L Valerio
- The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | - David Dornbos
- The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | - Ehud Mendel
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - Eric D Miller
- The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | - Karl E Haglund
- The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - James L Chen
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - Nicholas D Yeager
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
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Toepfer A, Harrasser N, Dreyer F, Mogler C, Walther M, von Eisenhart-Rothe R. Epithelioid sarcoma of the plantar fascia mimicking Morbus Ledderhose - A severe pitfall for clinical and histopathological misinterpretation. Foot Ankle Surg 2017; 23:e25-e30. [PMID: 29202999 DOI: 10.1016/j.fas.2017.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/22/2016] [Accepted: 03/21/2017] [Indexed: 02/04/2023]
Abstract
Plantar fibromatosis, also known as Morbus Ledderhose, is a well known and frequently encountered disorder of the planta pedis. When conservative treatment fails, surgical therapy with complete resection is the therapeutical procedure of choice. Soft tissue sarcoma is a heterogeneous and rare malignant disease of the musculoskeletal system with over 50 histopathological subtypes which can potentially arise in any localization but is most commonly found at the extremities. Here, we report the case of an epithelioid sarcoma of the sole of the foot which was initially and repeatedly clinically and histopathologically misinterpreted as plantar fibromatosis, receiving insufficient resection and subsequently ending in amputation of the lower leg.
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Affiliation(s)
- Andreas Toepfer
- Schön Klinik München Harlaching, Zentrum für Fuß- und Sprunggelenkschirurgie, Harlachinger Str. 51, 81547 München, Germany; Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675 München, Germany; Wilhelm Sander-Therapieeinheitfür Knochen- und Weichteilsarkome am Klinikum rechts der Isar, Ismaninger Str. 22, 81675 München, Germany.
| | - Norbert Harrasser
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675 München, Germany; Wilhelm Sander-Therapieeinheitfür Knochen- und Weichteilsarkome am Klinikum rechts der Isar, Ismaninger Str. 22, 81675 München, Germany
| | - Florian Dreyer
- Schön Klinik München Harlaching, Zentrum für Fuß- und Sprunggelenkschirurgie, Harlachinger Str. 51, 81547 München, Germany
| | - Carolin Mogler
- Institut für Pathologie, Klinikum rechts der Isar der Technischen Universität München, Trogerstraße 18, 81675 München, Germany
| | - Markus Walther
- Schön Klinik München Harlaching, Zentrum für Fuß- und Sprunggelenkschirurgie, Harlachinger Str. 51, 81547 München, Germany
| | - Rüdiger von Eisenhart-Rothe
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675 München, Germany; Wilhelm Sander-Therapieeinheitfür Knochen- und Weichteilsarkome am Klinikum rechts der Isar, Ismaninger Str. 22, 81675 München, Germany
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Hoekstra HJ, Haas RLM, Verhoef C, Suurmeijer AJH, van Rijswijk CSP, Bongers BGH, van der Graaf WT, Ho VKY. Adherence to Guidelines for Adult (Non-GIST) Soft Tissue Sarcoma in the Netherlands: A Plea for Dedicated Sarcoma Centers. Ann Surg Oncol 2017; 24:3279-3288. [PMID: 28748443 PMCID: PMC5596052 DOI: 10.1245/s10434-017-6003-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Optimal management of soft tissue sarcoma (STS) remains a challenge. A nationwide survey assessed the quality of STS care in the Netherlands, thereby aiming to identify potentialities for improvement through more centralized disease management. METHODS From the Netherlands Cancer Registry (NCR), data were obtained on 3317 adult STS patients (excluding gastrointestinal stromal tumor, GIST) diagnosed in 2006-2011. Logistic regression models were employed to compare outcomes on selected clinical indicators reflecting prevailing STS guidelines between high-volume (≥10 resections annually) and low-volume (<10 resections) hospitals, between academic and general hospitals, and between sarcoma research centers and other hospitals, adjusted for case mix. Analyses were performed on imputed datasets (m = 50), generated through multiple imputations by chained equations. RESULTS Overall, 89% of patients underwent surgical resection. Resection status remained unknown in 24% (excluding those with metastasized disease), and grade was not documented for one-third of tumors. Microscopic residual disease was detected in 20% with an increased risk for older patients, larger and deeply located tumors, and those located in the (retro)peritoneum or upper extremity. Almost half of patients with an R1 resection received adjuvant radiotherapy. Following adjustment for case mix factors, patients treated in high-volume hospitals less often had macroscopic residual disease (R2 resection; adjusted odds ratio: 0.54). A strongly skewed distribution of surgical volumes was observed. CONCLUSIONS These survey results indicate a potential for improving Dutch STS care. More centralized sarcoma management should improve definitive pathology reporting on tumor characteristics, adherence to treatment guidelines and overall disease outcome.
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Affiliation(s)
- Harald J Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Rick L M Haas
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Albert J H Suurmeijer
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carla S P van Rijswijk
- Department of Radiology, University of Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Ben G H Bongers
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Vincent K Y Ho
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
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Dyrop HB, Vedsted P, Rædkjær M, Safwat A, Keller J. Imaging investigations before referral to a sarcoma center delay the final diagnosis of musculoskeletal sarcoma. Acta Orthop 2017; 88:211-216. [PMID: 28077058 PMCID: PMC5385118 DOI: 10.1080/17453674.2016.1278113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The use of point-of-care or local investigations before referral to specialist sarcoma centers as part of a fast-track diagnostic pathway varies, and may affect the time to diagnosis. We wanted to investigate differences in time intervals and proportion of malignancy in patients who were referred after initial diagnostic investigations were performed locally and in patients who were referred without these investigations. Patients and methods - We included 545 consecutive patients who were referred to Aarhus Sarcoma Center for suspected musculoskeletal sarcoma. Data on time intervals and investigations performed were collected from questionnaires and patient records. Patients who were referred from outside Aarhus uptake area after initial MRI/CT or histology performed locally were compared with patients who were referred from Aarhus uptake area without these investigations. Results - The median total interval from first symptom to diagnosis was 166 days for outside patients referred with MRI/CT or histology, which was 91 (95% CI: 76-106) days longer than for local patients who were referred without MRI/CT or histology. Comparing the same groups, the median diagnostic interval was 41 (95% CI: 30-51) days longer for outside patients including both primary care and hospital intervals. Both the proportion of malignancies (38% vs. 14%) and the proportion of sarcomas (24% vs. 7%) were higher in the outside group referred with MRI/CT or histology than in the local group without MRI/CT or histology. Interpretation - Pre-referral investigations at a local hospital increased the diagnostic interval by at least 1 month for 50% of the patients, and the proportion of malignancy was more than doubled-to almost 40%. If investigations are to be performed before referral to a sarcoma center, they should be part of the fast-track pathway in order to ensure timely diagnosis.
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Affiliation(s)
- Heidi Buvarp Dyrop
- Sarcoma Center of Aarhus University Hospital;,Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark.,Correspondence:
| | - Peter Vedsted
- The Research Unit for General Practice, Research Center for Cancer Diagnosis, Aarhus University
| | - Mathias Rædkjær
- Sarcoma Center of Aarhus University Hospital;,Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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Haddad J, Kalbacher E, Piccard M, Aubry S, Chaigneau L, Pauchot J. [Evaluation of the management of soft tissue sarcomas in Franche-Comté since the establishment of a multidisciplinary meeting at University Hospital. About 47 cases]. ANN CHIR PLAST ESTH 2016; 62:15-22. [PMID: 27777135 DOI: 10.1016/j.anplas.2016.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/19/2016] [Indexed: 01/22/2023]
Abstract
GOALS OF STUDY A multidisciplinary meeting (RCP) dedicated to the treatment of sarcoma was established in Franche-Comte in 2010. The goals of the study are: (a) To evaluate the treatment of sarcomas by confrontation with the existing literature; (b) To evaluate the influence of the multidisciplinary meeting on the management of sarcomas by hospitals at the regional level. MATERIALS AND METHODS This is a retrospective single center study from 2010 to 2015 on patients with sarcoma and peripheral soft tissue drawn from a Netsarc database (National Network of sarcomas) and communicating cancer record. A database Cleanweb especially dedicated is created. RESULTS Forty-seven patients were included: ten sarcomas at the upper member 26 to the lower limbs, 11 on the trunk. Forty patients were operated on: ten out of the university hospital, 28 at the university hospital and two in a coordinating center. Ninety percent of patients treated at the university hospital were in accordance with the recommandations. None of the patients operated out of the university hospital benefited from medical care in accordance to the recommendations. There is an increase in the number of files sent by the hospitals out of the university hospital discussed in multidisciplinary meeting, before treatment. CONCLUSION The creation of a dedicated multidisciplinary meeting sarcoma improves the medical management of these tumors and decreases inappropriate medical managements thanks to a better education of the regional physicians.
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Affiliation(s)
- J Haddad
- Service de chirurgie orthopédique, traumatologique et plastique, chirurgie de la main, CHU Jean-Minjoz, 1, boulevard Flemming, 25030 Besançon, France
| | - E Kalbacher
- Service d'oncologie médicale, CHU Jean-Minjoz, 1, boulevard Flemming, 25030 Besançon, France
| | - M Piccard
- Service d'épidémiologie et d'hygiène hospitalière, CHU de Dijon, 21079 Dijon cedex, France
| | - S Aubry
- Service de radiologie A, CHU Jean-Minjoz, 1, boulevard Flemming, 25030 Besançon, France
| | - L Chaigneau
- Service d'oncologie médicale, CHU Jean-Minjoz, 1, boulevard Flemming, 25030 Besançon, France
| | - J Pauchot
- Service de chirurgie orthopédique, traumatologique et plastique, chirurgie de la main, CHU Jean-Minjoz, 1, boulevard Flemming, 25030 Besançon, France.
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11
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Kim JI, Lee IS, Song YS, Park SK, Choi KU, Song JW. Short-term follow-up MRI after unplanned resection of malignant soft-tissue tumours; quantitative measurements on dynamic contrast enhanced and diffusion-weighted MR images. Br J Radiol 2016; 89:20160302. [PMID: 27459249 DOI: 10.1259/bjr.20160302] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the diagnostic availability of dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) MR images for evaluating residual tumours at short-term follow-up after unplanned excision of malignant soft-tissue tumours. METHODS From January 2013 to September 2014, 38 patients underwent first follow-up MRI, including DCE and DW imaging (DWI), within 3 months of unplanned malignant soft-tissue tumour excision. The presence or absence of definite nodule formation, focal fluid/haematoma collection, oedema and fascial thickening around or at tumour beds were evaluated using conventional MR images. The volume transfer constant between blood plasma and extracellular/extravascular space (EES) (Ktrans), rate constant between EES and blood plasma (Kep), volume of EES space per unit volume of tissue and initial area under the concentration curve (iAUC) values with time-concentration curve (TCC) plots were obtained on DCE images, and apparent diffusion coefficient (ADC) values were measured on ADC maps. All data were statistically analyzed. RESULTS Of the 21 patients who underwent re-excision, 12 patients had a residual tumor and 9 did not. All conventional MRI variables, except definite nodule formation, were insignificantly related to the presence of residual tumour. However, ADC values were found to be significantly associated with the presence of residual tumour, as were the DCE MRI variables, Ktrans, Kep and iAUC. In particular, TCC pattern and Kep were most significantly associated with residual tumour. CONCLUSION Additional DCE images may be useful for determining the presence of residual tumours in tumour beds during short-term follow-up after inadequate malignant soft-tissue tumour excision. ADVANCES IN KNOWLEDGE The addition of DCE MRI and quantitative analysis of the images obtained might be useful for determining the presence of residual tumour in a tumour bed during short-term follow-up after inadequate excision of a malignant soft-tissue tumour, although DWI was also found to be helpful.
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Affiliation(s)
- Jeung Il Kim
- 1 Department of Orthopaedic Surgery, Pusan National University Hospital, Biomedical Research Institute, Busan, Korea
| | - In Sook Lee
- 2 Department of Radiology, Pusan National University School of Medicine & Pusan National University Hospital, Biomedical Research Institute, Busan, Korea
| | - You Seon Song
- 2 Department of Radiology, Pusan National University School of Medicine & Pusan National University Hospital, Biomedical Research Institute, Busan, Korea
| | - Se Kyoung Park
- 3 Department of Radiology, Kosin University Gospel Hospital, Busan, Korea
| | - Kyung-Un Choi
- 4 Department of Pathology, Pusan National University Hospital, Biomedical Research Institute, Busan, Korea
| | - Jong Woon Song
- 5 Department of Radiology, Inje University Haeundae Paik Hospital, Busan, Korea
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12
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Pass B, Jafari M, Rowbotham E, Hensor EMA, Gupta H, Robinson P. Do quantitative and qualitative shear wave elastography have a role in evaluating musculoskeletal soft tissue masses? Eur Radiol 2016; 27:723-731. [PMID: 27277260 PMCID: PMC5209430 DOI: 10.1007/s00330-016-4427-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 01/25/2016] [Accepted: 05/20/2016] [Indexed: 02/04/2023]
Abstract
Objectives To determine if quantitative and qualitative shear wave elastography have roles in evaluating musculoskeletal masses. Methods 105 consecutive patients, prospectively referred for biopsy within a specialist sarcoma centre, underwent B-mode, quantitative (m/s) and qualitative (colour map) shear wave elastography. Reference was histology from subsequent biopsy or excision where possible. Statistical modelling was performed to test elastography data and/or B-mode imaging in predicting malignancy. Results Of 105 masses, 39 were malignant and 6 had no histology but benign characteristics at 12 months. Radiologist agreement for B-mode and elastography was moderate to excellent Kw 0.52-0.64; PABAKw 0.85-0.90). B-Mode imaging had 78.8% specificity, 76.9% sensitivity for malignancy. Quantitatively, adjusting for age, B-mode and lesion volume there was no statistically significant association between longitudinal velocity and malignancy (OR [95% CI] 0.40[0.10, 1.60], p=0.193), but some evidence that higher transverse velocity was associated with decreased odds of malignancy (0.28[0.06, 1.28], p=0.101). Qualitatively malignant masses tended to be towards the blue spectrum (lower velocities); 39.5% (17/43) of predominantly blue masses were malignant, compared to 14.3% (1/7) of red lesions. Conclusions Quantitatively and qualitatively there is no statistically significant association between shear wave velocity and malignancy. There is no clear additional role to B-mode imaging currently. Key Points • Correlation between shear wave velocity and soft tissue malignancy was statistically insignificant • B-mode ultrasound is 76.9 % sensitive and 78.8 % specific • Statistical models show elastography does not significantly add to lesion assessment
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Affiliation(s)
- B Pass
- Musculoskeletal Centre X-Ray Department, Leeds Teaching Hospitals Trust, Chapel Allerton Hospital, Leeds, UK
| | - M Jafari
- Musculoskeletal Centre X-Ray Department, Leeds Teaching Hospitals Trust, Chapel Allerton Hospital, Leeds, UK
| | - E Rowbotham
- Musculoskeletal Centre X-Ray Department, Leeds Teaching Hospitals Trust, Chapel Allerton Hospital, Leeds, UK
| | - E M A Hensor
- Chapel Allerton Hospital, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - H Gupta
- Musculoskeletal Centre X-Ray Department, Leeds Teaching Hospitals Trust, Chapel Allerton Hospital, Leeds, UK
| | - P Robinson
- Musculoskeletal Centre X-Ray Department, Leeds Teaching Hospitals Trust, Chapel Allerton Hospital, Leeds, UK. .,Chapel Allerton Hospital, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK.
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13
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Abstract
PET can be used to guide percutaneous needle biopsy to the most metabolic lesion, improving diagnostic yield. PET biopsy guidance can be performed using visual or software coregistration, electromagnetic needle tracking, cone-beam computed tomography (CT), and intraprocedural PET/CT guidance. PET/CT-guided biopsies allow the sampling of lesions that may not be clearly visible on anatomic imaging, or of lesions that are morphologically normal. PET can identify suspicious locations within complex tumors that are most likely to contain important diagnostic and prognostic information.
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Affiliation(s)
- Ghassan El-Haddad
- Division of Interventional Radiology, Department of Radiology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612-9416, USA.
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14
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Kainhofer V, Smolle MA, Szkandera J, Liegl-Atzwanger B, Maurer-Ertl W, Gerger A, Riedl J, Leithner A. The width of resection margins influences local recurrence in soft tissue sarcoma patients. Eur J Surg Oncol 2016; 42:899-906. [PMID: 27107792 DOI: 10.1016/j.ejso.2016.03.026] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/04/2016] [Accepted: 03/21/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patients with soft tissue sarcoma (STS) being treated following the standardized guidelines can still not be guaranteed to remain free from local recurrence (LR). A complete tumour resection has been accepted as a major prognostic factor for LR. This retrospective study was designed to analyse the influence of two different classifications of resection margins (R-classification and UICC-classification) on LR in STS patients. MATERIALS AND METHODS Of 411 patients treated at our institution for STS, 265 were eligible for statistical analysis. Kaplan-Meier curves and Cox regression models were used to assess the impact of an R0 resection according to the R-classification (resection margin clear but allowing <1 mm) and according to the UICC-classification (minimal resection margin ≥1 mm) on LR. RESULTS Survival curves showed a lower LR rate for R0 resections in the UICC-classification, namely 1.3%, 12% and 12% as compared to 2.1%, 9.5% and 16.5% for the R-classification. In multivariate analysis calculated separately for each classification, R1 resection as defined by the R-classification (HR: 11.214; 95%CI: 2.394-52.517; p = 0.002) as well as by UICC-classification (HR: 15.634; 95%CI: 2.493-98.029; p = 0.003) remained significant. CONCLUSION In our study, margin status according to both classifications represents an independent prognostic factor for LR in patients with STS following curative surgery. Local control rates were superior after a minimal resection margin of 1 mm (R0 by UICC-classification) compared to R0 resections after the R-classification.
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Affiliation(s)
- V Kainhofer
- Department of Orthopaedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - M A Smolle
- Department of Orthopaedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - J Szkandera
- Division of Clinical Oncology, Department of Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria.
| | - B Liegl-Atzwanger
- Institute of Pathology, Medical University of Graz, Auenbruggerplatz 25, 8036 Graz, Austria.
| | - W Maurer-Ertl
- Department of Orthopaedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
| | - A Gerger
- Division of Clinical Oncology, Department of Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria; Center for Biomarker Research in Medicine, Stiftingtalstraβe 5, 8010 Graz, Austria.
| | - J Riedl
- Division of Clinical Oncology, Department of Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria.
| | - A Leithner
- Department of Orthopaedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria.
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15
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Management of desmoid tumours: A nationwide survey of labelled reference centre networks in France. Eur J Cancer 2016; 58:90-6. [PMID: 26974708 DOI: 10.1016/j.ejca.2016.02.008] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 02/09/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The optimal management of rare tumours (i.e. from accurate diagnosis to management in reference centres) is a public health challenge. In 2009, the French National Cancer Institute (INCa) identified and financially supported the two expert networks for pathological and clinical diagnosis and management of soft tissue tumours. METHODS The activities of both networks were prospectively collected using a nationwide database (rreps.org). Data describing the diagnosis management of 863 successive cases of desmoids tumours (DT) were prospectively collected from 2010 to 2013 and analysed. RESULTS The number of confirmed DT constantly improved from January 2010 to December 2013 (from 173 to 273 cases per year); the expected incidence ranged from 132 to 330 cases/year. The rate of cases diagnosed with core-needle biopsies and CTNNB1 mutational status analysis increased from 30.6 to 40.7% and from 87.8 to 94.1%, respectively. The mean delay for pathological diagnosis confirmation constantly decreased from 107 to 47 d. Among the 846 adult patients, 414 (48.9%) patients were treated by reference centres. The rate of patients managed by reference centres constantly increased with time from 36.9 to 49.5% since 2010. The median management time of the referral centres constantly decreased from 440 to 67 d. CONCLUSION The two expert networks worked synergistically and improved diagnosis modalities of rare desmoid tumours at a national level. The impact of management by expert networks on the outcome will be prospectively analysed in the future.
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16
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Brunello A, Rizzato MD, Rastrelli M, Roma A, Maruzzo M, Basso U, Fiduccia P, Buzzaccarini MS, Scarzello G, Rossi CR, Zagonel V. Adjuvant chemotherapy for soft tissue sarcomas: a 10-year mono-institutional experience. J Cancer Res Clin Oncol 2015; 142:679-85. [PMID: 26547435 PMCID: PMC4751155 DOI: 10.1007/s00432-015-2065-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/23/2015] [Indexed: 01/03/2023]
Abstract
Purpose The role of adjuvant chemotherapy (ACT) for soft tissue sarcomas (STS) is not standard practice. We investigated effectiveness and tolerability of ACT in patients (pts) with operated high-risk STS in clinical practice. Methods Medical records of pts with localized STS referred to Istituto Oncologico Veneto, Padova, from January 1, 2003 to July 07, 2012 were reviewed. Data were collected for pts with high-risk STS (size ≥5 cm, high grade and stage III). For those who received ACT, regimens used, drug doses, number of cycles, toxicity, and reasons for dose reduction or treatment interruption were recorded. Disease-free survival (DFS) and overall survival (OS) were calculated with the Kaplan–Meier method. Results Out of 96 eligible pts, median age 62 years, 36 received ACT after loco-regional treatment. Median DFS was 29.6 months (95 % CI 13.2–46.0) in pts receiving ACT and 7.8 months (95 % CI 3.9–11.7) in untreated pts (p < 0.0001); median OS was 67.0 months (95 % CI 25.4–108.6) in treated and 33.7 months (95 % CI 23.3–44.2) in untreated pts (p = 0.005). Among pts receiving ACT, a significant difference in DFS was observed between pts with limb/girdle disease (median DFS 82.4 months; 95 % CI 0.0–184.7) and pts with other primary sites (median DFS 18.3 months; 95 % CI 8.0–28.5) (p = 0.052). Grade ≥3 toxicities occurred in 20 pts (20.8 %), leading to dose reductions, delays, and treatment discontinuation in five cases. There was no treatment-related death. Conclusion Our data confirm benefit of ACT with regard to DFS and OS in pts with high-risk STS, greatest for limb/girdle STS.
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Affiliation(s)
- Antonella Brunello
- Medical Oncology 1 Unit, Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata 64, 35128, Padua, Italy.
| | | | - Marco Rastrelli
- Melanoma and Sarcoma Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - Anna Roma
- Medical Oncology 1 Unit, Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata 64, 35128, Padua, Italy
| | - Marco Maruzzo
- Medical Oncology 1 Unit, Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata 64, 35128, Padua, Italy
| | - Umberto Basso
- Medical Oncology 1 Unit, Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata 64, 35128, Padua, Italy
| | - Pasquale Fiduccia
- Clinical Trials and Biostatics Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | | | - Giovanni Scarzello
- Radiation Therapy Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | | | - Vittorina Zagonel
- Medical Oncology 1 Unit, Istituto Oncologico Veneto IOV - IRCCS, Via Gattamelata 64, 35128, Padua, Italy
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17
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Trieu J, Sinnathamby M, Di Bella C, Pianta M, Perera W, Slavin JL, Schlicht SM, Choong PFM. Biopsy and the diagnostic evaluation of musculoskeletal tumours: critical but often missed in the 21st century. ANZ J Surg 2015; 86:133-8. [PMID: 26235443 DOI: 10.1111/ans.13251] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2015] [Indexed: 11/29/2022]
Abstract
Bone and soft-tissue sarcomas are rare and heterogeneous malignancies arising from tissues of mesenchymal origin. Treatment planning is informed by accurate diagnosis for which biopsy is the diagnostic standard. Biopsy in the setting of suspected malignancy is a technically challenging procedure that should only be performed at specialist institutions. Without the requisite expertise, they can compromise the viability of reconstructive procedures and may make necessary amputation to achieve adequate surgical margins. The risk of complications arising from the procedure must be minimized and therefore biopsy should always be preceded by imaging. There must be no attempt at biopsy or excision prior to referral if there is any suspicion of malignancy. Patients with suspected bone and soft-tissue tumours are best evaluated and treated at specialist sarcoma centres under the care of expert multidisciplinary teams. Prompt referral to a specialist sarcoma centre should always be made prior to biopsy for any suspicious mass that is painful, progressively increasing in size, greater than 5 cm in diameter, deep to deep fascia or recurs following inadvertent excision.
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Affiliation(s)
- Jason Trieu
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Claudia Di Bella
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Orthopaedics, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Marcus Pianta
- Department of Radiology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Warren Perera
- Department of Radiology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - John L Slavin
- Department of Pathology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Stephen M Schlicht
- Department of Radiology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Peter F M Choong
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Orthopaedics, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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18
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Treatment Guidelines for Preoperative Radiation Therapy for Retroperitoneal Sarcoma: Preliminary Consensus of an International Expert Panel. Int J Radiat Oncol Biol Phys 2015; 92:602-12. [DOI: 10.1016/j.ijrobp.2015.02.013] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/12/2015] [Accepted: 02/06/2015] [Indexed: 12/25/2022]
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19
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Ligier K, Maynou C, Leroy X, Robin YM, Martin P, Clisant S, Richard F, Penel N. Improvement of the initial management of sarcomas after the dissemination of evidence-based guidelines depends on the primary sarcoma location: a population-based study. BMC Cancer 2015; 15:218. [PMID: 25886606 PMCID: PMC4424525 DOI: 10.1186/s12885-015-1225-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 03/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improvement of the initial management of sarcomas after the dissemination of evidence-based guidelines depends on the primary sarcoma location: a population-based study. To improve the initial management of adult sarcomas, a regional expert team in Northern France performed two actions: dissemination of evidence-based guidelines (EBG) for the management of soft tissue/visceral sarcoma and yearly educational symposia. The aim of this study was to measure the impact of the dissemination of EBG on the key-indicators of adult sarcoma management. METHODS We conducted a before-after population-based study (before: 2005 with 63 cases, after: 2008-2009 with 86 cases) in the Lille area (Northern France urban/sub-urban area with 800,000 inhabitants). The following were the key-indicators of adult sarcoma management: pre-therapeutic biopsy, appropriate tumour and chest imaging, expert interdisciplinary discussion, expert interdisciplinary discussion before the first treatment and in operated cases, the rate of R0 resection. RESULTS There was no statistically significant difference in patient and tumour characteristics for the two time periods in terms of gender, prior cancer, primary location, histological subtype, grade, size, metastasis and lymph node involvement. There was no statistically significant improvement in primary tumour imaging (83 versus 87%), chest imaging (67 vs 71%), pre-therapeutic biopsy (57 vs 58%). There was an improvement in expert multidisciplinary discussion (37 vs 45%) or discussion before the first treatment (26 vs 44%) but no statistically significant. However, when soft tissue and bone sarcomas were analysed separately, we observed statistically significant improvements in expert multidisciplinary discussion (50 vs 74%, p = 0.02) and R0 resection rate (58 vs 91%, p = 0.002). In contrast, in cases of visceral sarcoma, there was no improvement in expert multidisciplinary discussion (10 vs 16%, p = 0.7) or in R0 resection (88 vs 81%, p = 0.7). CONCLUSIONS The dissemination of EBG was associated with a limited improvement in sarcoma management when measured in this before-after population-based study, and this improvement was dependent on the primary location of the tumour. Efforts to implement these guidelines by all surgical teams that could treat sarcoma, including visceral sarcoma, need to be made.
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Affiliation(s)
- Karine Ligier
- Registre général des cancers de Lille et de sa région, GCS C2RC, CHRU de Lille, Hôpital Calmette - Pavillon Breton, Boulevard du Professeur Jules Leclercq, 59037, Lille, Cedex, France. .,SIRIC ONcoLille, Plateforme 4 (Méthodologie et Recherche Clinique), Lille, France.
| | - Carlos Maynou
- Département d'Orthopédie A, Hopital Roger Salengro, CHRU de Lille, Lille, France.
| | - Xavier Leroy
- Département de Pathologie, CHRU de Lille, Lille, France.
| | | | | | - Stéphanie Clisant
- SIRIC ONcoLille, Plateforme 4 (Méthodologie et Recherche Clinique), Lille, France. .,Unité de Recherche Clinique, Centre Oscar Lambret, Lille, France.
| | - Florence Richard
- SIRIC ONcoLille, Plateforme 4 (Méthodologie et Recherche Clinique), Lille, France. .,Institut Pasteur Lille, INSERM U744, Lille, France.
| | - Nicolas Penel
- SIRIC ONcoLille, Plateforme 4 (Méthodologie et Recherche Clinique), Lille, France. .,Département de Cancérologie Générale, Centre Oscar Lambret, 3, rue F Combemale, 59020, Lille, Cedex, France.
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20
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Comparative effectiveness research for sarcoma. Cancer Treat Res 2015; 164:51-65. [PMID: 25677018 DOI: 10.1007/978-3-319-12553-4_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Modern multidisciplinary management of sarcoma represents several opportunities for comparative effectiveness research. Focusing on the outcomes of survival, quality of life and cost-effectiveness of care, the current state of the art is summarized. Specialized/regional care for sarcoma and the utility of tumor boards or multispecialty discussion is discussed. Issues related to treatment efficacy and sequencing in relation to chemotherapy, radiation, and surgery as well as margin reporting and surveillance are also discussed. Finally, future avenues of comparative effectiveness research for sarcoma are highlighted throughout the chapter.
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21
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Dyrop HB, Vedsted P, Safwat A, Maretty-Nielsen K, Hansen BH, Jørgensen PH, Baad-Hansen T, Keller J. Alarm symptoms of soft-tissue and bone sarcoma in patients referred to a specialist center. Acta Orthop 2014; 85:657-62. [PMID: 25175662 PMCID: PMC4259033 DOI: 10.3109/17453674.2014.957086] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The Danish Cancer Patient Pathway for sarcoma defines a set of alarm symptoms as criteria for referral to a sarcoma center. This may exclude cancer patients without alarm symptoms, so we investigated the presence of alarm symptoms (defined as being indicative of a sarcoma) in patients who had been referred to the Aarhus Sarcoma Center. PATIENTS AND METHODS We reviewed the medical records of all 1,126 patients who had been referred, with suspected sarcoma, from other hospitals in the period 2007-2010 for information on symptoms, clinical findings, and diagnosis. Alarm symptoms were analyzed for predictive values in diagnosing sarcoma. RESULTS 179 (69%) of 258 sarcoma patients were referred with alarm symptoms (soft-tissue tumor>5 cm or deep-seated, fast-growing soft-tissue tumor, palpable bone tumor, or deep persisting bone pain). The remaining 79 sarcomas were found accidentally. "Size over 5 cm" for soft-tissue tumors, and "deep persisting bone pain" for bone tumors had the highest sensitivity and positive predictive value. Of the 79 sarcoma patients who were referred without alarm symptoms, 7 were found accidentally on imaging, 5 were referred with suspected recurrence of a sarcoma, 64 were referred with a confirmed histological diagnosis, and 3 were referred for other reasons. INTERPRETATION Defined alarm symptoms are predictive of sarcoma, but one-third of the patients were found accidentally. Further studies on presenting symptoms in primary care are needed to assess the true value of alarm symptoms.
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Affiliation(s)
- Heidi B Dyrop
- Department of Experimental Clinical Oncology, Aarhus University Hospital,Aarhus Sarcoma Center, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Vedsted
- The Research Unit for General Practice, Aarhus University
| | - Akmal Safwat
- Department of Oncology, Aarhus University Hospital,Aarhus Sarcoma Center, Aarhus University Hospital, Aarhus, Denmark
| | - Katja Maretty-Nielsen
- Department of Experimental Clinical Oncology, Aarhus University Hospital,Aarhus Sarcoma Center, Aarhus University Hospital, Aarhus, Denmark
| | - Bjarne H Hansen
- Aarhus Sarcoma Center, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Johnny Keller
- Aarhus Sarcoma Center, Aarhus University Hospital, Aarhus, Denmark
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22
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Thibault C, Fizazi K, Barrios D, Massard C, Albiges L, Baumert H, Patard JJ, Escudier B, Loriot Y. Compliance with guidelines and correlation with outcome in patients with advanced germ-cell tumours. Eur J Cancer 2014; 50:1284-90. [DOI: 10.1016/j.ejca.2014.01.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 01/26/2014] [Accepted: 01/28/2014] [Indexed: 11/24/2022]
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23
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Salipas A, Dowsey MM, May D, Choong PFM. 'Beware the lump in the foot!': predictors of recurrence and survival in bone and soft-tissue sarcomas of the foot and ankle. ANZ J Surg 2014; 84:533-8. [PMID: 24712375 DOI: 10.1111/ans.12593] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although benign lumps around the foot and ankle are common, sarcomas in this area are frequently missed, and the consequences can be disastrous. Patients are often referred to tumour centres after suboptimal prior surgical excision. The predictors of local recurrence, metastasis and survival in this cohort have yet to be elucidated. METHODS We performed a retrospective review of 61 consecutive patients that were surgically treated for a bone (BS) or soft-tissue sarcoma (STS) of the foot and ankle between 1996 and 2012 at a specialist tumour centre. Factors such as tumour versus non-tumour centre surgery and BS versus STS were examined. Univariate and multivariate analyses were performed to determine which factors predicted local recurrence, metastasis and survival. RESULTS The overall 5-year survival rates were 74% in the STS group and 90% in the BS group. Furthermore, 33 (54%) patients had STS. Non-tumour centre surgery was performed in 23 (38%) patients. Overall local recurrence rate was 6.6%. Intra-lesional margins predicted a local recurrence, whereas non-tumour centre surgery was a predictor for developing a metastasis post-treatment. Tumour size, STS, radical margins (i.e. entire anatomical compartment removed with tumour) and metastasis, either at the time of referral or post-treatment, were associated with higher mortality. CONCLUSION STSs of the foot and ankle appear to have a worse prognosis than BSs. Early referral to a specialist tumour centre before surgical intervention is recommended.
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Affiliation(s)
- Andrew Salipas
- Department of Surgery, St Vincent's Hospital, Melbourne, Victoria, Australia; Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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24
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Bagaria SP, Ashman JB, Daugherty LC, Gray RJ, Wasif N. Compliance with National Comprehensive Cancer Network guidelines in the use of radiation therapy for extremity and superficial trunk soft tissue sarcoma in the United States. J Surg Oncol 2014; 109:633-8. [PMID: 24464402 DOI: 10.1002/jso.23569] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 12/19/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND We sought to examine adherence to National Comprehensive Cancer Network guidelines for use of radiation therapy (RT) in patients with soft tissue sarcoma (STS) in the United States. METHODS The surveillance, epidemiology, and end results cancer registry was queried to identify patients undergoing surgery for truncal and extremity STS from 2004 to 2009. RESULTS Of 5,075 patients, 50% received RT. Although routine RT is not recommended for Stage I patients, 25% still underwent RT. Even though routine RT is recommended for Stage II and III tumors, only 60% underwent RT. On multivariate analysis predictors of RT included age <50 years (OR 1.57, 95% CI 1.28-1.91), malignant fibrous histiocytoma histology (OR 1.47, 95% CI 1.3-1.92), T2 classification (OR 1.88, 95% CI 1.60-2.20), and G3 (OR 6.27, 95% CI 5.10-7.72). Patients with Stage III STS who received RT showed improved disease specific survival at 5 years compared to those who did not, 68% versus 46%, P <0.001. CONCLUSIONS Underuse of RT is seen for a significant proportion of patients undergoing treatment for STS in the United States. More effort needs to be directed towards compliance with appropriate treatment recommendations, perhaps by regionalizing sarcoma care or remote multidisciplinary tumor boards.
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Affiliation(s)
- Sanjay P Bagaria
- Department of Surgery, Mayo Clinic Florida, Jacksonville, Florida
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25
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Todd R, Lunec J. Molecular pathology and potential therapeutic targets in soft-tissue sarcoma. Expert Rev Anticancer Ther 2014; 8:939-48. [DOI: 10.1586/14737140.8.6.939] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Dyrop HB, Safwat A, Vedsted P, Maretty-Nielsen K, Hansen BH, Jørgensen PH, Baad-Hansen T, Bünger C, Keller J. Cancer Patient Pathways shortens waiting times and accelerates the diagnostic process of suspected sarcoma patients in Denmark. Health Policy 2013; 113:110-7. [PMID: 24138955 DOI: 10.1016/j.healthpol.2013.09.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 07/16/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
Cancer Patient Pathways (CPPs) for suspected cancer were implemented in Denmark to reduce waiting times for cancer diagnosis and treatment. Our study describes developments in time intervals and tumour size in a natural experiment before and after implementation of the CPP for sarcomas (January 1st, 2009). Medical files for patients referred with suspected sarcoma from other hospitals to Aarhus Sarcoma Centre during 2007-2010 (n=1126) were reviewed for data on milestones, time intervals, performed diagnostics, and tumour size. Results showed a statistically significant reduction in median number of work days in the phase "referral to first appointment" for all patients. For bone sarcomas, median time was significantly reduced from 11 to five work days in the phase "first appointment to decision of treatment", for soft tissue sarcomas it was reduced from 28 to 18 work days in the phase "referral to start of treatment". Passive waiting time was reduced, and delays in the fast-track programme were caused mostly by supplementary diagnostics. Median tumour size for soft tissue sarcomas was reduced from 7.0 to 4.9cm, possibly a secondary effect of increased awareness. CPPs have accelerated the diagnostic process for sarcomas, and our results may aid international development of similar initiatives.
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Affiliation(s)
- Heidi Buvarp Dyrop
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Norrebrogade 44, Bldg. 5, DK-8000 Aarhus C, Denmark; Sarcoma Centre of Aarhus University Hospital, Norrebrogade 44, DK-8000 Aarhus C, Denmark.
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Heudel PE, Cousin P, Lurkin A, Cropet C, Ducimetiere F, Collard O, De Laroche G, Biron P, Meeus P, Thiesse P, Bergeron C, Vaz G, Mithieux F, Farsi F, Fayet Y, Gilly FN, Cellier D, Blay JY, Ray-Coquard I. Territorial inequalities in management and conformity to clinical guidelines for sarcoma patients: an exhaustive population-based cohort analysis in the Rhône-Alpes region. Int J Clin Oncol 2013; 19:744-52. [PMID: 23933822 DOI: 10.1007/s10147-013-0601-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 07/16/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Sarcomas are rare cancers with great variability in clinical and histopathological presentation. The main objective of clinical practice guidelines (CPGs) is to standardize diagnosis and treatment. METHODS From March 2005 to February 2007, all patients diagnosed with localized sarcoma in the Rhône-Alpes region were included in a cohort-based study, to evaluate the compliance of sarcoma management with French guidelines in routine practice and to identify predictive factors for compliance with CGPs. RESULTS 634 (71 %) patients with localized sarcoma satisfying the inclusion criteria were included out of 891 newly diagnosed sarcomas. Taking into account initial diagnosis until follow-up, overall conformity to CPGs was only 40 % [95 % confidence interval (CI) = 36-44], ranging from 54 % for gastrointestinal stromal tumor to 36 % for soft tissue sarcoma and 42 % for bone sarcoma. In multivariate analysis, primary tumor type [relative risk (RR) = 4.42, 95 % CI = 2.79-6.99, p < 0.001], dedicated multidisciplinary staff before surgery (RR = 4.19, 95 % CI = 2.39-7.35, p < 0.001) and management in specialized hospitals (RR = 3.71, 95 % CI = 2.43-5.66, p < 0.001) were identified as unique independent risk factors for conformity to CPGs for overall treatment sequence. CONCLUSIONS With only 40 % of total conformity to CPGs, the conclusions support the improvement of initial sarcoma management and its performance in specialized centres or within specialized dedicated networks.
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Duman BB, Gunaldi M, Ercolak V, Afsar CU, Sahin B, Erkisi IMK, Kara O, Paydas S, Gönlüsen G, Sertdemir Y. Retrospective analysis of 498 primary soft tissue sarcomas in a single Turkish centre. Asian Pac J Cancer Prev 2012; 13:4125-8. [PMID: 23098528 DOI: 10.7314/apjcp.2012.13.8.4125] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Soft tissue sarcomas (STS) must be managed with a team involving pathologists, radiologists, surgeons, radiation therapists and medical oncologists. Treatment modalities and demographic characteristics of Turkish STS were analysed in the current study. MATERIAL-METHODS Primary adult STS followed between 1999- 2010 in Cukurova University Medical Faculty Department of Medical Oncology were analyzed retrospectively. RESULTS Of the total of 498 patients, 238 were male and 260 female. The most seen adult sarcomas were leomyosarcoma (23%). Localization of disease was upper extremity (8.8%), lower extremity (24.7%), head-neck 8.2%, thoracic 8%, retroperitoneal 5.6%, uterine 12.4%, abdominal 10%, pelvic region 3.6 and other regions 10%. Some 13.1% were early stage, 10.2% locally advanced, 8.2% metastatic and 12.2% recurrent disease. Patients were treated with neoadjuvant/adjuvant (12%) or palliative chemotherapy (7.2%) and 11.4% patients did not receive chemotherapy. Surgery was performed as radical or conservative. The most preferred regimen was MAID combination chemotherapy in the rate of 17.6%. The most common metastatic site was lung (18.1%). The overall survival was 45 months (95%CI 30-59), 36 months in men and 55 months in women, with no statistically significant difference (p=0.5). The survival rates were not different between the group of adjuvant and palliative chemotherapy (respectively 28 versus 18 months) (p=0.06), but radical surgery at 37 months was better than 22 months for conservative surgery (p=0.0001). No differences were evident for localization (p=0.152). Locally advanced group had higher overall survival rates (72 months) than other stages (p=0.0001). CONCLUSION STS can be treated successfully with surgery, chemotherapy and radiotherapy. The survival rates of Turkish people were higher in locally advanced group; these results show the importance of multimodality treatment approach and radical surgery.
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Sampo MM, Rönty M, Tarkkanen M, Tukiainen EJ, Böhling TO, Blomqvist CP. Soft tissue sarcoma - a population-based, nationwide study with special emphasis on local control. Acta Oncol 2012; 51:706-12. [PMID: 22229745 DOI: 10.3109/0284186x.2011.643821] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND A prospective diagnostics and treatment protocol for extremity and trunk wall soft tissue sarcoma (STS) was introduced by the Scandinavian Sarcoma Group in 1986 and it was also widely adopted in Finland. We have updated the protocol and made it more detailed at the Helsinki University Central Hospital. We retrospectively compared diagnostics and treatment of STS in a nationwide population-based material to this protocol with special emphasis on local control. METHODS Data for 219 patients with an STS of extremity or trunk wall diagnosed during 1998-2001 was retrieved from the nationwide Finnish Cancer Registry. Histologic review was performed. Treatment centres were divided into high-, intermediate- and low-volume centres based on the number of patients with final surgery during the study period. RESULTS Significantly more patients were operated with a preoperative histological or cytological diagnosis at high-volume centres. No preoperative diagnosis was a strong predictor for the patient to undergo more than one operation (p < 0.0001). Wide surgical margin was achieved more often at high-volume centres, but in all centre categories a considerable percentage of patients with inadequate surgical margin did not receive adjuvant radiation therapy. Local control at five years was 82% at high-volume centres, 61% at intermediate-volume centres treating highest percentage of deep tumours and 69% at low-volume centres (p = 0.046). Local control improved as the number of patients operated (surgical volume of the centre) increased. CONCLUSION The present quality-control study is the first nationwide population-based study to assess diagnostics and treatment of STS. When referred to a specialised sarcoma centre even patients with inadequate surgery can achieve good local control. STS is a rare cancer and its treatment should be centralised in Finland, which has 5.4 million inhabitants and approximately 100 new STSs of extremities and trunk wall annually.
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Affiliation(s)
- Mika M Sampo
- Department of Pathology, HUSLAB and University of Helsinki, Finland.
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Multidisciplinarity and medical decision, impact for patients with cancer: sociological assessment of two tumour committees’ organization. Bull Cancer 2012; 99:E34-42. [DOI: 10.1684/bdc.2012.1559] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Venkatesan M, Richards CJ, McCulloch TA, Perks AGB, Raurell A, Ashford RU. Inadvertent surgical resection of soft tissue sarcomas. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2012; 38:346-51. [PMID: 22264775 DOI: 10.1016/j.ejso.2011.12.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Revised: 09/05/2011] [Accepted: 12/12/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND The National Institute of Clinical Excellence (NICE) published Improving Outcome Guidance in 2006 defining urgent referral criteria for soft tissue sarcoma (STSs) with the twin aims of improving diagnostic accuracy and overall outcome. Despite these guidelines inadvertent excisions of soft tissue sarcomas continue to occur with alarming frequency, potentially compromising patient outcomes. OBJECTIVE We reviewed the East Midlands Sarcoma Service experience of treating inadvertent excision of STSs and highlight the patient profile, referral pattern, subsequent management and oncological outcome associated with inadvertent resection. METHODS Patients were identified from our sarcoma database and a retrospective case note review performed. RESULTS Over a 3-year period, 42 patients presented to our specialist centre after unplanned excision of soft tissue sarcomas. There were 29 men and 13 women, with a mean age at presentation of 59 years (19-90). 50% of the tumours were located in lower extremity, 33% around the trunk and 17% in the upper extremity. The unplanned surgery was most commonly from general surgeons, plastic surgeons, orthopaedic surgeons, general practitioners followed by vascular surgeons. Re-resection was undertaken in 40 cases to achieve clear margins with residual tumour present in 74% of cases. Limb salvage surgery was not possible in 5 cases. CONCLUSION Unplanned excision of sarcoma by non-oncologic surgeons remains a problem. It appears that it is equally prevalent in varied surgical community and general practitioners. Excision of large or deep solid soft tissue masses without tissue diagnosis is unacceptable.
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Affiliation(s)
- M Venkatesan
- Department of Orthopaedics, University Hospitals of Leicester, Infirmary Square, Leicester, LE1 5WW, UK.
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Nishimura A, Matsumine A, Asanuma K, Matsubara T, Nakamura T, Uchida A, Kato K, Sudo A. The adverse effect of an unplanned surgical excision of foot soft tissue sarcoma. World J Surg Oncol 2011; 9:160. [PMID: 22142486 PMCID: PMC3253054 DOI: 10.1186/1477-7819-9-160] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 12/05/2011] [Indexed: 01/29/2023] Open
Abstract
Background Malignant soft tissue tumors of the foot are extremely rare and thus can be prematurely excised without appropriate preoperative evaluation. The present study compares adverse effects between unplanned and planned surgical excisions. Methods We retrospectively reviewed the clinical records, radiographs, pathology reports and pathological specimens of 14 consecutive patients with soft tissue sarcoma of the foot among 592 with sarcomas between 1973 and 2009. We then compared the incidence and clinical outcomes after unplanned (UT; n = 5) and planned (PT; n = 9) surgical excisions of foot sarcomas. Results The most frequent diagnosis was synovial sarcoma (n = 4; 28.6%). The overall 5-year survival rates of the PT and UT groups were 65.6% and 60.0%, respectively, and the event-free 5-year survival rates were 63.5% and 40.0%, respectively. Event-free and overall survival rates did not significantly differ between the two groups. However, tumors were significantly larger in the PT group than in the UT group (p < 0.05). Conclusions Unplanned resection lead to a relatively worse prognosis and a likelihood of recurrence despite additional resections. We recommend that soft tumors of the foot should only be excised after appropriate preoperative evaluation regardless of the size of the tumor.
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Affiliation(s)
- Akinobu Nishimura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan
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Qureshi YA, Huddy JR, Miller JD, Strauss DC, Thomas JM, Hayes AJ. Unplanned excision of soft tissue sarcoma results in increased rates of local recurrence despite full further oncological treatment. Ann Surg Oncol 2011; 19:871-7. [PMID: 21792512 DOI: 10.1245/s10434-011-1876-z] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Unplanned excision of soft tissue sarcoma (STS) accounts for up to 40% of all initial operations for STS and is undertaken when the mass is presumed to be benign. The effect this has on outcome has never been fully established. METHODS Patients with extremity or trunk STS between 2001 and 2005 who were treated by an initial inadvertent operation and then referred immediately to our unit were identified. Outcomes were compared with a control group of patients with STS who were stage-matched and had been treated conventionally by core biopsy and definitive surgery. Endpoints were local recurrence, distant metastases and sarcoma-specific survival. RESULTS 134 patients who had undergone unplanned excision of STS were identified. One hundred twenty-one underwent further re-excision, and 51 (48%) of these patients had residual tumour identified after surgical re-excision. Two hundred nine stage-matched controls were identified who were treated conventionally. Median follow-up was 51.6 months. Local recurrence rates were considerably higher in the study group (23.8 vs. 11%, p = 0.0016), despite the control group having more stage 3 tumours. When the tumours were matched by stage, an increase in local recurrence was seen across all stages but was most pronounced for stage 3 tumours (37.5 vs. 14.2%, p = 0.005). Metastasis-free and sarcoma-specific survival were also significantly increased for stage 3 tumours. CONCLUSION Unplanned initial excision of extremity soft tissue sarcoma may compromise long-term local control of extremity STS despite full further oncological management.
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Affiliation(s)
- Y A Qureshi
- Soft Tissue Sarcoma and Melanoma Unit, Department of Academic Surgery, The Royal Marsden Hospital, London, UK
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Wasif N, Tamurian RM, Christensen S, Do L, Martinez SR, Chen SL, Canter RJ. Influence of specialty and clinical experience on treatment sequencing in the multimodal management of soft tissue extremity sarcoma. Ann Surg Oncol 2011; 19:504-10. [PMID: 21769468 DOI: 10.1245/s10434-011-1923-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE Although multimodal management of extremity soft tissue sarcoma (STS) is the standard of care, considerable variation exists in the sequencing of radiotherapy (RT) or chemotherapy (CT). Our goal was to identify factors responsible for this variation. METHODS Members of specialty societies with an interest in STS were emailed a questionnaire about multimodal treatment of STS. Survey responses were scored on a 5-point Likert scale (1 = always preoperative and 5 = always postoperative) and analyzed by specialty, years in practice, and percentage of practice consisting of STS. RESULTS The questionnaire was completed by 320 (65%) of 490 physicians, including medical oncologists (18%), radiation oncologists (8%), orthopedic oncologists (22%), surgical oncologists (45%), and others (7%). Respondents were evenly split on the use of neoadjuvant RT (mean 3.03 ± 0.06) and showed a slight preference for neoadjuvant CT (2.89 ± 0.06). Radiation oncologists (2.52 ± 0.18), physicians with a >75% STS practice (2.58 ± 0.17), and those in practice <5 years (2.79 ± 0.12) preferred neoadjuvant RT. Neoadjuvant CT was preferred by orthopedic oncologists (2.62 ± 0.12) and physicians with >75% STS practice (2.51 ± 0.16). Factors influencing the choice for neoadjuvant RT were well-defined treatment volume, increased acute morbidity, and decreased late morbidity, while for CT, they were in-situ disease monitoring and early treatment of micrometastases. CONCLUSIONS Treatment sequencing in STS is influenced by specialty and clinical experience, with no clear consensus. These patterns may reflect the recent trend toward regionalization of STS care.
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Affiliation(s)
- Nabil Wasif
- Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA.
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Follow up after Primary Treatment of Soft Tissue Sarcoma: A Survey of Current Practice in the United Kingdom. Sarcoma 2011; 2007:34128. [PMID: 18270541 PMCID: PMC2225460 DOI: 10.1155/2007/34128] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Accepted: 06/27/2007] [Indexed: 11/23/2022] Open
Abstract
Despite the clinical and financial implications, there is little evidence about how patients who have been treated for soft tissue sarcoma should be followed up. The purpose of this study was to determine current practice in the United Kingdom. 192 clinicians treating patients with soft tissue sarcoma were surveyed with a postal questionnaire enquiring about frequency and method of follow up and how patients would be followed up in each of 3 clinical scenarios: a patient with a trunk or extremity tumour at low risk of relapse; a patient with a trunk or extremity tumour at high risk of relapse; and a patient with a retroperitoneal or abdominal tumour. 155 (81%) clinicians responded. Clinic visits and X-rays were the most frequently used methods of follow up. Chest CT scans, local site imaging, and blood tests were used infrequently. The intensity and methods of follow up varied with each of the clinical scenarios. There was a seven-to-twenty fold variation in cost between the least and the most expensive regimes. Respondents were generally
supportive of the development of the clinical trial in this area.
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Funovics PT, Vaselic S, Panotopoulos J, Kotz RI, Dominkus M. The impact of re-excision of inadequately resected soft tissue sarcomas on surgical therapy, results, and prognosis: A single institution experience with 682 patients. J Surg Oncol 2010; 102:626-33. [PMID: 20886550 DOI: 10.1002/jso.21639] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Due to their rare incidence soft tissue sarcomas (STS) are often resected without clear margins. The aim of this study was to investigate the impact of re-excision of STS on survival. METHODS Out of 752 patients with STS (406 men and 346 women, average age 51 years), 310 patients were referred after an inadequate resection, 442 patients presented for primary treatment. Six hundred eighty-two patients were compared over a mean period of 65 months (median, 36 months) according to the treatment groups regarding their survival, clinical, surgical, and pathological data. RESULTS The 5-year survival rate of 621 surgically treated patients was 53.9%. There was a continuous improvement in survival during the whole treatment period in the respective decades. The overall survival rate in both groups was not significantly different regardless of low- or high-grade malignancies. Patients with a re-resection did not have a higher rate of local recurrences; patients with a primary resection had a worse prognosis regarding metastases. A re-resection within 12 weeks indicated a better prognosis. CONCLUSIONS An inadequate excision of a STS does not cogently mean deterioration of overall survival but necessitates an ample and quick re-resection.
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Affiliation(s)
- Philipp T Funovics
- Department of Orthopaedic Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria.
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Sogaard AS, Laurberg JM, Sorensen M, Sogaard OS, Wara P, Rasmussen P, Laurberg S. Intraabdominal and retroperitoneal soft-tissue sarcomas--outcome of surgical treatment in primary and recurrent tumors. World J Surg Oncol 2010; 8:81. [PMID: 20831829 PMCID: PMC2949614 DOI: 10.1186/1477-7819-8-81] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 09/12/2010] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Surgery is the only curative treatment for intraabdominal and retroperitoneal sarcoma (IaRS). Little is known about how to treat patients with recurrence. We here report the outcome in primary and recurrent sarcoma treated at the Sarcoma Center in Aarhus, Denmark. METHODS All patients evaluated for IaRS from June 1998 to May 2008 were enrolled and data on symptoms, signs, means of diagnosis, extent of surgery, perioperative complications, mortality and long time survival were registered. Primary and first-recurrence sarcomas were analyzed separately. RESULTS Sixty-five of 73 primary and 22 of 28 first-recurrence IaRS had surgery. Fifty-three (82%) and 11 (50%) patients achieved radical R0 resection. Age and radicality of surgery were independent predictors of death, while recurrence of sarcoma was not. Perioperative mortality was 2.3%. 5-year survival was 70.2% for primary and 51.8% for first-recurrent sarcomas. However, patients with radical surgery had 5-year survival of over 70% in both the primary and recurrent group. CONCLUSIONS The radicality of surgery is the most important prognostic factor. Patients with recurrence have an equally good prognosis as those with primary sarcoma if radicality is achieved and such surgery should not be considered only as a palliative effort.
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Affiliation(s)
- Ane S Sogaard
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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de Vreeze RSA, de Jong D, Nederlof PM, Ariaens A, Tielen IHG, Frenken L, Haas RL, van Coevorden F. Added Value of Molecular Biological Analysis in Diagnosis and Clinical Management of Liposarcoma: A 30-Year Single-Institution Experience. Ann Surg Oncol 2010; 17:686-93. [PMID: 20183915 PMCID: PMC2820685 DOI: 10.1245/s10434-009-0806-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Treatment decisions and prognosis assessment for liposarcoma is based on a classification that depends on morphological and genetic features. Revisions by experienced referral pathologists are often advocated. Methods The process of histopathological classification in referring hospitals and subsequently in a referral center in relation to molecular biological information is evaluated. A total of 331 consecutive liposarcoma patients were evaluated for the added value of histological review at time of referral. Subsequently, cases were reclassified with implementation of present-day molecular information. For all patients, complete data on staging, treatment, and follow-up were available. Results Upon histological revision, 15/54 (28%) diagnoses were reclassified in the first decade, 14/65 (22%) in the second, and 14/53 (26%) in the last decade. Molecular biological analysis enabled well-differentiated liposarcoma with or without dedifferentiated component to be better recognized as such and distinguished from myxoid liposarcoma and pleomorphic liposarcoma. Inclusion of cytogenetic information resulted in reclassification after revision in 4/18 (22%) cases in the first decade, 10/38 (26%) cases in the second decade, and 19/75 (25%) cases in the last decade. Conclusions This study indicates that liposarcomas are heterogeneous tumors. Expert assessment and implementation of molecular biological analysis are valuable for adequate classification as a basis for treatment decisions.
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Affiliation(s)
- Ronald S A de Vreeze
- Departments of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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Mastrangelo G, Fadda E, Cegolon L, Montesco MC, Ray-Coquard I, Buja A, Fedeli U, Frasson A, Spolaore P, Rossi CR. A European project on incidence, treatment, and outcome of sarcoma. BMC Public Health 2010; 10:188. [PMID: 20384990 PMCID: PMC2882909 DOI: 10.1186/1471-2458-10-188] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 04/12/2010] [Indexed: 11/23/2022] Open
Abstract
Background Sarcomas are rare tumors (1-2% of all cancers) of mesenchymal origin that may develop in soft tissues and viscera. Since the International Classification of Disease (ICD) attributes visceral sarcomas (VS) to the organ of origin, the incidence of sarcoma is grossly underestimated. The rarity of the disease and the variety of histological types (more than 70) or locations account for the difficulty in acquiring sufficient personal experience. In view of the above the European Commission funded the project called Connective Tissues Cancers Network (CONTICANET), to improve the prognosis of sarcoma patients by increasing the level of standardization of diagnostic and therapeutic procedures through a multicentre collaboration. Methods/Design Two protocols of epidemiological researches are here presented. The first investigation aims to build the population-based incidence of sarcoma in a two-year period, using the new 2002 WHO classification and the "second opinion" given by an expert regional pathologist on the initial diagnosis by a local pathologist. A three to five year survival rate will also be determined. Pathology reports and clinical records will be the sources of information. The second study aims to compare the effects on survival or relapse-free period - allowing for histological subtypes, clinical stage, primary site, age and gender - when the disease was treated or not according to the clinical practice guidelines (CPGs). Discussion Within CONTICANET, each group was asked to design a particular study on a specific objective, the partners of the network being free to accept or not the proposed protocol. The first protocol was accepted by the other researchers, therefore the incidence of sarcoma will be assessed in three European regions, Rhone-Alpes and Aquitaine (France) and Veneto (Italy), where the geographic distribution of sarcoma will be compared after taking into account age and gender. The conformity of the clinical practice with the recommended guidelines will be investigated in a French (Rhone Alps) and Italian (Veneto) region since the CPGs were similar in both areas.
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Affiliation(s)
- Giuseppe Mastrangelo
- Department of Environmental Medicine and Public Health, University of Padua, Padua, Italy
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Improved diagnosis and treatment of soft tissue sarcoma patients after implementation of national guidelines: A population-based study. Eur J Surg Oncol 2009; 35:1326-32. [DOI: 10.1016/j.ejso.2009.05.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Revised: 05/04/2009] [Accepted: 05/06/2009] [Indexed: 11/21/2022] Open
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Intense accumulation of 18F-FDG, not enhancement on MRI, helps to guide the surgical biopsy accurately in soft tissue tumors. Ann Nucl Med 2009; 23:887-9. [DOI: 10.1007/s12149-009-0313-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Accepted: 09/18/2009] [Indexed: 01/05/2023]
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Engellau J. Prognostic factors in soft tissue sarcomaTissue microarray for immunostaining, the importance of whole-tumor sections and time-dependence. ACTA ACUST UNITED AC 2009. [DOI: 10.1080/03008820410001887] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Ultrasound for initial evaluation and triage of clinically suspicious soft-tissue masses. Clin Radiol 2009; 64:615-21. [PMID: 19414084 DOI: 10.1016/j.crad.2009.01.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Revised: 01/05/2009] [Accepted: 01/13/2009] [Indexed: 01/28/2023]
Abstract
AIM To evaluate the efficacy of ultrasound as a first-line investigation in patients with a clinical soft-tissue mass. METHODS Three hundred and fifty-eight consecutive patients (155 male, 203 female, mean age 48 years) referred from primary and secondary care with soft-tissue masses underwent ultrasound evaluation. Five radiologists performed ultrasound using a 10-15 MHz linear transducer and recorded the referrer diagnosis, history, lesion size, anatomical location and depth, internal echogenicity, external margins (well-defined rim or infiltrative), and vascularity on power Doppler (absent or present, if present the pattern was listed as either linear or disorganized). A provisional ultrasound diagnosis was made using one of eight categories. Benign categories (categories 1-5) were referred back to a non-sarcoma specialist or original referrer for observation. Indeterminate or possible sarcomas (categories 6-8) were referred for magnetic resonance imaging (MRI) within 14 days. Additionally category 8 lesions were referred to the regional sarcoma service. Institutional and regional database follow-up was performed. RESULTS Two hundred and eighty-four of the 358 (79%) lesions were classified as benign (categories 1-5). On follow-up 15 of the 284 patients were re-referred but none (284/284) had a malignancy on follow-up (24-30 months). Overall at ultrasound 33 lesions were larger than 5 cm, 42 lesions were deep to deep fascia with 20 showing both features. In this subgroup of 95 patients there were six malignant tumours with the rest benign. Seventy-three of the 358 patients underwent MRI; the results of which indicated that there were 60 benign or non-tumours, 10 possible sarcomas, and three indeterminate lesions. Overall six of 12 (6/358, 1.68% of total patients) lesions deemed to represent possible sarcomas on imaging were sarcomas. CONCLUSION Ultrasound is an effective diagnostic triage tool for the evaluation of soft-tissue masses referred from primary care.
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Stoeckle E, Coindre JM, Kind M, Kantor G, Bui BN. Evaluating surgery quality in soft tissue sarcoma. Recent Results Cancer Res 2009; 179:229-42. [PMID: 19230543 DOI: 10.1007/978-3-540-77960-5_14] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To identify pertinent indicators for oncologic outcomes in assessing surgery in soft tissue sarcomas, only local recurrences are considered here. Functional outcomes and treatment morbidity, equally important end-points for evaluating surgery quality, are less frequently reported and are not taken into account in this review. Herein, we review recent publications reporting indicators of surgery quality in soft tissue sarcoma treatment. Local recurrence-free interval is the major end-point in evaluating the quality of surgery. Disease-free survival should not be used because the risk factors for metastases are different from those for local recurrence. Five-year local recurrence-free estimations for limb and trunk wall sarcoma should be below 20%, and best approach 10%. The risk of local recurrence depends on tumour biology (i.e. grade) and quality of surgery as defined by the quality of margins. Better than margin width as measured on the tumour specimen, margin quality determined consensually between surgeons and pathologists is the best indicator for local outcome. Quality of margin should be expressed according the UICC residual disease definitions (R0: in sano, R1: microscopic residual disease, R2: macroscopic residual disease). Other important indicators for surgery quality are treatment in specialised centres, a planned, organised surgery, and treatment within a multidisciplinary team. Soft tissue sarcoma should also be treated in specialised centres. Surgery quality depends on obtained margins that are determined best by close collaboration between the surgeon and the pathologist.
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Affiliation(s)
- Eberhard Stoeckle
- Department of Surgery, Institut Bergonie, Regional Cancer Centre, 229 Cours de I'Argonne, 33076 Bordeaux Cedex, France.
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Shapeero L, De Visschere P, Verstraete K, Poffyn B, Forsyth R, Sys G, Uyttendaele D. Post-treatment complications of soft tissue tumours. Eur J Radiol 2009; 69:209-21. [DOI: 10.1016/j.ejrad.2008.10.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 10/02/2008] [Indexed: 11/30/2022]
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Thacker MM, Potter BK, Pitcher JD, Temple HT. Soft tissue sarcomas of the foot and ankle: impact of unplanned excision, limb salvage, and multimodality therapy. Foot Ankle Int 2008; 29:690-8. [PMID: 18785419 DOI: 10.3113/fai.2008.0690] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Foot and ankle sarcomas have historically been treated with amputation because of the difficulty in achieving local disease control and maintaining a functional foot. Potential opportunities for limb salvage may be further compromised by unplanned excisions. MATERIALS AND METHODS We reviewed 52 consecutive patients with soft tissue sarcomas of the foot and ankle and analyzed the impact of planned versus unplanned initial excision, limb salvage, and multimodality therapy on treatment and outcomes. RESULTS Unplanned excisions had been performed in 29 (55.8%) patients. Limb salvage was performed in 38 patients, with 14 requiring free soft tissue transfers. At an average followup of 99 (range, 24 to 216) months, the 5-year overall survival estimate was 76.3%. Although not statistically significant, we noted clinically relevant potential differences in local recurrence-free, disease-free, and oncologic survival between the planned and unplanned excision groups. Seven patients (13.5%) had a local recurrence, five of these following an unplanned excision. Functional scores averaged 83.2% for all patients which were similar between planned versus unplanned and amputation versus limb salvage groups. Significantly more patients with unplanned excisions required free flaps for limb salvage (p = 0.017) and received adjuvant radiotherapy (p = 0.0004). CONCLUSION Unplanned surgery for soft tissue sarcomas of the foot and ankle often results in the need for more aggressive surgery and/or adjuvant radiotherapy and may impact oncologic outcomes, but does not necessarily portend worse functional outcomes. Multimodal therapy and judicious use of soft tissue flap reconstruction allows limb salvage in most patients with favorable outcomes.
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Affiliation(s)
- Mihir M Thacker
- Department of Orthopaedic Surgery, Alfred I duPont Hospital for Children, Wilmington, DE, USA
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Pérez Romasanta LA, Montero Luis A, Verges Capdevila R, Mariño Cotelo A, Rico Pérez JM. Centralised treatment of soft tissue sarcomas in adults. Clin Transl Oncol 2008; 10:102-10. [PMID: 18258509 DOI: 10.1007/s12094-008-0162-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The clinical research developed in specialised centres and oncologic cooperative groups has permitted various scientific societies to collect recommendations used in the treatment of soft tissue sarcomas (STS) and incorporate them into clinical practice guidelines (CPG). Some studies have been conducted in diverse healthcare ambits to assess the influence of CPG. This revision of the medical literature analyses the impact that healthcare management -centralised or otherwise- and clinical practice in conformity with CPG have on the clinical outcome variables of STS. Eight CPG have been identified, as well as 12 conformity studies or audits. These conformity studies and audits demonstrate that the grade of adaptation of medical interventions with CPG, medical healthcare in reference centres and procedures of referrals to these centres, as well as the process of organising healthcare teams into Sarcoma Committees, have a significant influence on clinical outcome. We can conclude that excellent healthcare of STS implies the adaptation of healthcare practice to CPG, the existence of Reference Centres guided by Sarcoma Committees, and the observance of strict referral procedures within the Healthcare Area.
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Soft Tissue Sarcoma. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Christopher Windham T, Sondak VK. Soft Tissue Sarcoma. Oncology 2007. [DOI: 10.1007/0-387-31056-8_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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