Cost-effectiveness of staging computed tomography of the chest in patients with T2 soft tissue sarcomas

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of soft tissue tumors 2020 - Secondary publication

BACKGROUND

These clinical practice guidelines are intended to provide recommendations based on the best evidence obtained to date on key issues in clinical practice to improve the prognosis, diagnostic and therapeutic processes for patients with soft tissue tumors.

METHODS

The Guidelines Development Committee and Systematic Review Committee were composed of a multidisciplinary team of specialists who play an important role in soft tissue tumor care. Clinical questions (CQs) were determined by choosing key decision-making points based on Algorithms for the diagnosis and treatment of soft tissue tumors. The guidelines were developed according to the "Medical Information Network Distribution Service (Minds) Handbook for Clinical Practice Guideline Development 2014" and "Minds Manual for Clinical Practice Guideline Development 2017." Recommendation strength was rated on two levels and the strength of evidence was rated on four levels. The recommendations were decided based on agreement by 70% or more voters.

RESULTS

Twenty-two CQs were chosen by the Guidelines Development Committee. The Systematic Review Committee reviewed the evidence concerning each CQ, a clinical value judgment was added by experts, and the text of each recommendation was determined.

CONCLUSION

We established 22 CQs and recommendations for key decision-making points in the diagnosis and treatment of soft tissue tumors according to the Minds Clinical Practice Guideline development methods. We hope that these guidelines will assist the decision-making of all medical staff engaged in the treatment and diagnosis of soft tissue tumors, and eventually lead to improved soft tissue tumor care in the country.

Follow-up Strategies for Primary Extremity Soft-tissue Sarcoma in Adults: A Systematic Review of the Published Literature

AIM

Follow-up strategies for primary extremity soft-tissue sarcomas (eSTS) in adults were evaluated in a systematic review of the published literature.

MATERIAL AND METHODS

The published literature was reviewed using PubMed. Of 136,646 studies published between 1985 and 2019, 78 original articles met the inclusion criteria. Articles were selected on the basis of the PRISMA guidelines. The selected articles were then cross-searched to identify further publications. August 1, 2019 was used as the concluding date of publication.

RESULTS

A variety of follow-up schedules have been reported in recently published literature. Two official guidelines have been approved by international societies. The guidelines distinguish between high- and low-grade STS, but mention a wide range of follow-up intervals. Established tools of follow-up include computed tomograph, X-rays of the chest, and magnetic resonance imaging of the primary tumor site in addition to clinical observation and physical examination.

CONCLUSION

Further research will be needed to establish evidence-based guidelines and schedules for follow-up strategies in patients with eSTS.

The diagnosis of pulmonary metastases on chest computed tomography in primary bone sarcoma and musculoskeletal soft tissue sarcoma

The lungs are the commonest site of metastasis for primary high-grade bone and soft tissue sarcoma, but current guidelines on the management of pulmonary nodules do not specifically cater for this group of patients. The current article reviews the literature from the past 20 years that has reported the CT features of pulmonary metastases in the setting of known primary bone and soft tissue sarcoma, with emphasis on osteosarcoma, chondrosarcoma, and trunk and extremity soft tissue sarcoma, the aim being to aid radiologists who report chest CT of musculoskeletal sarcoma patients in deciding which lesions should be considered metastatic, which lesions are indeterminate and require follow-up, and which lesions are of no concern.

A review of staging chest CT in trunk and extremity soft tissue sarcoma

OBJECTIVES

To determine the incidence of pulmonary metastases on chest CT in trunk and extremity soft tissue sarcoma based on two size criteria, and to identify factors associated with metastases.

METHODS

Retrospective review of chest CT studies in patients with trunk and extremity soft tissue sarcoma over an 18-month period. Data collected included patient age/sex, tumour location, size and relationship to fascia. All chest CTs were reviewed for the presence of metastases which were diagnosed according to two size criteria: multiple nodules > 5 mm in size or multiple nodules > 10 mm in size. Follow-up CT studies were reviewed in cases initially considered indeterminate.

RESULTS

127 males and 73 females were included (mean age 57.1 years; range 10-90 years). 147 (73.5%) tumours were deep to the fascia and 53 (26.5%) superficial. Tumour size classified according to the 12 AJCC 2019 criteria was: T1 = 52, T2 = 76, T3 = 39, T4 = 33. Based on nodule size >5 mm, 73 (36.5%) patients had no metastases, 42 (21%) had metastases, while 85 (42.5%) studies were indeterminate. Based on nodule size >10 mm, 73 (36.5%) patients had no metastases, 28 (14%) had metastases, while 99 (49.5%) studies were indeterminate. Larger maximum dimension of the primary tumour was a risk factor for pulmonary metastases using both size criteria.

CONCLUSION

The incidence of pulmonary metastases at presentation in trunk and extremity soft tissue sarcoma is 14-21%. 42.5-49.5% of chest CTs were indeterminate.

ADVANCES IN KNOWLEDGE

The incidence of pulmonary metastases at presentation in trunk and extremity soft tissue sarcoma is 14-21%. Indeterminate pulmonary nodules are also very common.

The value of re-staging chest CT at first local recurrence of extremity and trunk soft tissue sarcoma

OBJECTIVE

To determine the prevalence of pulmonary metastases on re-staging chest CT at the time of first local recurrence (LR) of trunk or extremity soft tissue sarcoma (STS).

MATERIALS AND METHODS

Retrospective review of all patients diagnosed with recurrent STS between May 2007 and April 2018. Data collected included patient age and sex, site of primary STS, time to LR, recurrence site, initial tumour grade, recurrent tumour grade, findings of initial staging chest CT, and prevalence of pulmonary metastases on re-staging chest CT.

RESULTS

The study included 109 patients (males = 68, females = 41; mean age 56 years, range 9-92 years). The commonest tumour sub-types were myxofibrosarcoma (27.5%), undifferentiated pleomorphic/spindle cell sarcoma (20.2%), synovial sarcoma (10.1%), and malignant peripheral nerve sheath tumour (10.1%). Initial staging chest CT demonstrated pulmonary metastases in 1 of 77 (1.3%) patients for whom CT was available for review. The mean time to LR was 30.8 months (range 3-224 months). Pulmonary metastases were diagnosed on re-staging chest CT in 26 of 109 cases (23.9%), being commonest with grade 3 STS (36.1%). Pleomorphic sarcoma (85.7%) and undifferentiated spindle cell sarcoma (33.3%) were the 2 commonest tumour sub-types associated with pulmonary metastases at first LR.

CONCLUSION

Re-staging chest CT at the time of first LR of STS identified a prevalence of 23.9% pulmonary metastases, which supports the need for chest CT at the time of LR in line with the UK guidelines for the management of bone and soft tissue sarcoma.

KEY POINTS

• Pulmonary metastases were diagnosed in 1.3% of soft tissue sarcomas at presentation. • Pulmonary metastases were identified in ~ 24% of patients at first local recurrence of soft tissue sarcoma, most commonly with pleomorphic sarcoma and Trojani grade tumours. • No patient with a low-grade recurrence had pulmonary metastases.

Evaluating the Impact of Surveillance Follow-Up Intervals in Patients Following Resection of Primary Well-Differentiated Liposarcoma of the Retroperitoneum

BACKGROUND

Resection of recurrent retroperitoneal well-differentiated liposarcoma (RP-WDLPS) is unlikely to result in cure. Thus, most clinicians delay surgery after recurrence until symptom intolerance or increasing rate of disease progression. The aim of this study was to determine whether longer surveillance intervals in this population would impact outcomes or delay treatment in those who recur.

METHODS

A retrospective review of patients with primary RP-WDLPS who underwent resection between April 1996 and April 2017 and surveillance at MDACC (n = 91) was performed.

RESULTS

Median age at diagnosis of primary RP-WDLPS was 61 years; median tumor size was 30 cm. Complete resection was achieved in 85 (93.4%) patients. Among patients who underwent complete resection, recurrence occurred in 53 (60.2%) with median time to recurrence of 27.0 months. Thirty-six (69.6%) of these patients underwent resection of recurrent disease at a median 40.2 months from primary tumor resection. Surveillance imaging at 4-month (vs 3-month) intervals would not have impacted recurrence management in 84 (95.5%) patients; imaging at 6-month (vs 3-month) intervals would not have impacted management of recurrence in 80 (90.9%).

CONCLUSIONS

Recurrence was common, often occurring beyond the early postoperative period following primary RP-WDLPS resection. More frequent surveillance imaging (q3-4 vs q6 months) in the first 2 years following primary RP-WDLPS resection may not significantly impact timing of surgery or systemic therapy for recurrence. If longer surveillance intervals were shown to be safe with equivalent outcomes in prospective studies, the resulting change in practice could lead to decreased anxiety and cost for patients and healthcare systems.

Surveillance Imaging Patterns and Outcomes Following Radiation Therapy and Radical Resection for Localized Extremity and Trunk Soft Tissue Sarcoma

BACKGROUND

Optimal surveillance imaging (SI) regimens following radiation therapy (RT) and radical resection for localized soft tissue sarcoma (STS) are unknown and practice patterns vary.

METHODS

Between 2006 and 2014, 94 patients with localized STS of the extremity/trunk treated with preoperative RT and radical resection were identified. Timing of local recurrence (LR), distant recurrence (DR), and SI were evaluated. The Kaplan-Meier method was used to determine recurrence-free and overall survival (OS), and the method of recurrence detection (SI or due to signs/symptoms) was determined.

RESULTS

Median tumor size was 7.5 cm, and 92% were intermediate/high grade. After a median follow-up of 60 months for surviving patients, 30 patients (32%) recurred, including 5 LRs and 26 DRs. The median time to LR and DR was 36.2 months (range 14.4-65.7) and 10.4 months (range 5.2-76.9), respectively, and the 5-year local recurrence-free survival (RFS), distant RFS, and OS was 95, 71, and 76%, respectively. Local SI was performed for 90% of patients, mostly by magnetic resonance imaging (MRI; 91%). Of the five LRs, two were detected by SI and three had signs/symptoms preceding imaging. All patients underwent distant SI. Of the 26 DRs, 23 (88%) were in the lung. SI detected 22 (85%) DRs, and only 4 of 26 had signs/symptoms prompting imaging.

CONCLUSION

Given excellent local control with RT and radical resection for intermediate/high-grade STS of the extremity/trunk, SI of the primary site should be reserved for select patients at high risk of LR. Conversely, due to frequent occurrence of asymptomatic DR in the lungs, periodic lung SI is appropriate. Routine abdominopelvic SI may not be indicated for most histologies.

Soft tissue tumors of the trunk: management of local disease in the breast and chest and abdominal walls

Soft tissue sarcomas of the trunk are rare lesions, generally managed using an algorithm similar to that employed for extremity sarcomas. This review summarizes the standard treatment of truncal sarcomas and considers how these recommendations differ for each of the various common histologic subtypes observed on the trunk: desmoid, dermatofibrosarcoma protuberans (DFSP), and angiosarcoma.

Follow-up of the soft tissue sarcoma patient

Despite optimal treatment, patients with soft tissue sarcoma are at risk for recurrence and therefore appropriate surveillance is critical. At minimum, regularly scheduled clinical assessments and chest X-rays are necessary. Consensus guidelines are available; however, surveillance strategies must be personalized based on the risk for recurrence and inherent disease biology. Further research is needed on a number of issues, including the impact of surveillance on clinical outcome and the utility of molecular surveillance.

Retroperitoneal sarcoma involving unilateral double ureter: management, treatment and psychological implications

The case of a 45-year-old woman who was admitted to our university hospital for polymenorrhea, weight gain and pain in the left iliac region is reported. An abdominal ultrasound revealed a 9.5 × 5.2-cm, hypoechoic and inhomogeneous mass located on the left side of the pelvis and behind the ovary. The patient underwent surgery. The pelvic mass was firmly anchored to the small intestine, colon, sigma and uterine fundus. After removing the adhesions, double ureters, which had been incorporated in the mass, were observed on the left side. Resection of the unilateral double ureters was necessary in order to remove the entire mass, and thereafter, a left salpingoophorectomy was performed. A histological examination showed a malignant retroperitoneal mass. Termino-terminal ureteral anastomosis with two double-J stents was carried out. Total hysterectomy with preservation of the right adenexum and regional lymphadenectomy was performed. The purpose of this case report is to discuss the physical and psychological implications related to the combination of two rare entities: leiomyosarcoma and a double ureter located within the mass. A literature review on the clinical management and psychological aspects from a female cancer patient's perspective undergoing surgery with the aforementioned disorders will be discussed.

What is the role of routine follow-up for localised limb soft tissue sarcomas? A retrospective analysis of 174 patients

Background:

There are neither prospective data nor agreement on the optimal routine follow-up procedures in patients treated for soft tissue sarcoma of the limb.

Methods:

Data on 174 consecutive patients with a soft tissue sarcoma of the limb undergoing follow-up by oncologists at a single centre from 2003 to 2009 were included in this analysis. The rate and site of recurrence and mode of detection were analysed. Outcome of the patients was assessed.

Results:

Eighty-two patients (47%) experienced relapse of any type. Isolated local recurrence occurred in 26 patients and local relapse with synchronous pulmonary metastases in five patients. Local recurrences were detected clinically in 30 of these 31 patients; magnetic resonance imaging identified only one local recurrence. Twenty-eight patients developed isolated lung metastases; in nine patients these were amenable to resections, seven of whom are currently free of disease after treatment. Lung metastases were detected by chest x-ray (CXR) in 19 patients, computed tomography scanning in 3 patients, and clinically in 11 patients. Twenty-three patients developed non-pulmonary metastases. More than 80% of relapses occurred in the first 2 years of follow-up; however, later recurrences were also observed.

Conclusions:

Routine follow-up CXR can detect lung metastases suitable for surgical resection, although the optimal interval of imaging has yet to be defined. Local relapse is almost always detected by patients or physicians, and routine scanning of the primary site is of doubtful benefit. Patient and physician education to detect local relapse may be helpful. Prospective evaluation of follow-up is recommended.

Current concepts in multimodality therapy for retroperitoneal sarcoma

Radical surgical resection currently represents the most effective therapy for patients with retroperitoneal sarcoma. Unfortunately, margin-negative resection often mandates extirpation of multiple retroperitoneal viscera, and such operations are nonetheless fraught with high rates of locoregional recurrence. In an attempt to improve local control and ultimately survival, adjuvant strategies of radiation and chemotherapy have been increasingly employed, with promising results. To date, however, the rarity of the disease has limited large, prospective studies investigating the efficacy of these adjuvant modalities. In this article, we review the current literature pertaining to the diagnosis, staging and treatment of retroperitoneal sarcoma and demonstrate the critical need for future large, multi-institutional studies to advance our knowledge of this uncommon disease.

Sarcoma

Sarcomas are a diverse group of malignancies originating in the connective tissue. The approach of a patient with a mass suspect for sarcoma starts with performing a biopsy to obtain tissue for evaluation by pathology. The main role of the current imaging modalities, in general, is to recognize patients with typically benign disease, in whom further invasive staging can be omitted, and select patients with a suspected malignancy, who should be referred for biopsy. Since soft tissue sarcoma tends to be large and heterogeneous, there is growing interest in using imaging modalities to guide these biopsies. Together with pathology, imaging modalities are the basis for accurate staging, evaluation of locoregional extent of the primary lesion, screening for occult metastases, evaluation of response to cancer treatment, and the detection of tumor recurrence. In this chapter, an overview is given of the use of 18F-FDG PET in these settings, its strengths as well as its limitations.

Unusual metastases from extremity soft tissue sarcomas

The most common metastatic route for extremity soft-tissue sarcomas is via the venous system to the lungs. Metastases to other sites such as the brain, liver, and soft tissue distant from the primary tumor are rare. A tumor registry, prospectively kept since 1986, was reviewed for unusual metastatic spread. Of 3671 tumors, 346 high-grade extremity soft-tissue sarcomas were evaluated. A total of 15 patients (4.3%) presented with initial recurrence of disease that was extrapulmonary and distant from the site of the primary tumor. Four of these patients (27%) were successfully treated for their recurrence. Based on these findings, a different strategy for follow-up of patients after treatment of a high-grade extremity soft-tissue sarcoma is suggested.

[Post-treatment surveillance for potentially curable malignancies]

Through an enormous research effort over the past five decades and especially due to early screening, an increasing number of cancers are potentially curable. Patients expand immeasurable energy in adhering to treatment plans and supportive care. Unfortunately, nothing prepares them for the anxiety that often comes with completion of therapy. More importantly, physicians are not properly equipped with data from controlled trials to define appropriate post-treatment surveillance, data with which they could educate patients and allay their fears. The goal of post-treatment surveillance is to enable the early detection of relapses and thus enhance the possibility of subsequent cure. Accordingly special follow-up is appropriate only for patients who can receive a second-line therapy. Clinical trials support conservative, rather than aggressive, surveillance to detect curable local relapse of breast tumors and potentially surgically curable metastases (mainly in the liver) of colon cancer. For germ-cell tumors, second-line treatments are potentially curative in nearly all instances. Follow-up for other cancers depends on patients' anxiety levels and on the costs of surveillance.

F-18 FDG PET/CT evaluation of osseous and soft tissue sarcomas

INTRODUCTION

Osseous and soft tissue sarcomas (OSTS) represent a histologic heterogeneous group of malignant tumors. Most of the current clinical data on the role of F-18 FDG PET in sarcomas come from patients studied with dedicated PET and less frequently with hardware fusion PET/CT. Therefore, we were prompted to review our experience with F-18 FDG PET/CT in OSTS.

METHODS

This is a retrospective study (January 2003-December 2005) of 44 patients with histologic diagnoses of OSTS who had F-18 FDG PET/CT at our institution. The group included 22 men and 22 women with an age range of 2 of 84 years (average, 37 +/- 20.2 years). The administered doses of F-18 FDG range 4.1 to 19.5 mCi (average, 14.3 +/- 3 mCi). Reinterpretation of the imaging studies for accuracy and data analysis from medical records was performed.

RESULTS

The sensitivity and specificity of combined F-18 FDG PET/CT were 100% (95% confidence interval [CI] = 75.7-100) and 93.3% (95% CI = 78.7-98.1) for the primary OSTS, and 80% (95% CI = 58.4-91.9) and 86.4% (95% CI = 66.7-95.2) for metastases. When interpreted separately, CT outperformed PET for pulmonary metastases detection: CT was 76.5% sensitive and 88% specific, whereas PET was only 57.1% sensitive but 96.4% specific. For detection of other metastases, CT was 82.3% sensitive and 76% specific, with PET demonstrating 78.6% sensitivity and 92.8% specificity.

CONCLUSION

Relatively similar results (except better specificity for PET and PET/CT) were noted when examining the rate of metastases detection, excluding pulmonary lesions. However, CT had a better detection rate for pulmonary metastases when compared with PET alone. A negative PET scan in the presence of suspicious CT findings in the chest cannot reliably exclude pulmonary metastases from OSTS.

18F-FDG PET and PET/CT for detection of pulmonary metastases from musculoskeletal sarcomas

OBJECTIVE

Sarcomas represent a significant therapeutic challenge and their potential for distant pulmonary metastases is well known. [(18)F]Fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) has a role in differentiating sarcomas from benign tumours and assessing the response to therapy in advanced sarcomas. However, PET appears to be less accurate in detection of pulmonary metastases. We were therefore prompted to review our experience with PET and PET/computed tomography (CT) in osseous and soft tissue sarcomas (OSTSs).

METHODS

This is a retrospective study (January 1995 to December 2004) of 106 patients with histological diagnosis of OSTS, who had PET and PET/CT at our institution. The group included 52 men and 54 women, aged 12-92 years (average, 45+/-20 years).

RESULTS

For all the patients in the analysis, the sensitivity and specificity were 68.3% (95% CI: 53-80.4) and 98.4% (95% CI: 91.8-99.7) for PET, with 95.1% sensitivity (95% CI: 83.8-98.6) and 92.3% specificity (95% CI: 83.2-96.7) for CT. Pulmonary metastases were seen in 40 patients. CT identified 17 lesions larger than 1.0 cm, while PET identified 13 of them (76.5%).

CONCLUSIONS

Chest CT is more sensitive than PET in detecting pulmonary metastases from OSTS. A significant portion of known pulmonary metastases greater than 1.0 cm on CT, are PET negative. Sub-centimetre CT lesions should not be considered false positive if inactive on PET. A negative PET scan in the presence of suspicious CT findings in the chest cannot reliably exclude pulmonary metastases from OSTS.

Retroperitoneal sarcomas: Combined-modality treatment approaches

Retroperitoneal sarcomas (RPS) are rare tumors, accounting for approximately 15% of soft tissue sarcomas. Surgical resection of localized tumors with gross and microscopically negative margins remains the standard of care. However, because RPS are frequently large and locally advanced, resections are often incomplete, resulting in local recurrence. Investigators are evaluating combined-modality therapies to improve local control and disease-specific survival. This review outlines current concepts and evolving treatment strategies in the diagnosis, staging, and management of RPS.

Sarcomes des tissus mous des extrémités. Rôle de l'imagerie dans la prise en charge initiale

Soft tissue sarcomas are uncommon heterogeneous group of tumour derived from mesenchym. The most common location is the lower extremity, but they can occur in the upper extremity, and abdominal and chest walls. The first radiological evaluation may include plain films and ultrasonography in viewing to assess the probability of soft tissue sarcomas. MRI with contrast is the main modality to evaluate these lesions and choose which part of tumour must be biopsied. Computer tomography (CT) is secondary used to perform core needle biopsy and detect lung metastases. The role of PET begins to be more clear in case of need global assessment before radical surgery. A multidisciplinary approach is essential to perform rational treatment planning and avoid partial surgery.

[Soft sarcoma tissue of extremities: medical imagery in post-therapeutic follow-up]

After treatment of primary soft tissue sarcoma, a third of patients will develop local or distant (lung in 90% of cases) recurrence. For an individual patient, the issue of cancer recurrence is a binary event. However, when developing surveillance strategies for large groups of patients, knowledge of the risks (tumor biology, natural history of the disease), the benefits (potential efficacy of salvage therapy) and diagnosis test performances is necessary to formulate a rationale and resource effective follow-up algorithm.

A multicenter evaluation of utility of chest computed tomography and bone scans in liver transplant candidates with stages I and II hepatoma

OBJECTIVE

To determine utility of practice of chest computed tomography (CCT) and bone scan (BS) in patients with early-stage hepatoma evaluated for transplantation (LT).

SUMMARY BACKGROUND DATA

Consensus-based policy mandates routine CCT and BS in LT candidates with hepatoma. No data exist either to support or refute this policy.

METHODS

From January 1999 to December 2002, stages I and II hepatoma patients evaluated at 4 centers were included. Scan interpretation was positive, indeterminate, or negative. Outcomes of evaluation and transplantation were compared between groups based on scans. Total charges incurred were derived from mean of charges at the centers.

RESULTS

One hundred seventeen stages I and II patients were evaluated. None had positive scans, 78 had negative, 29 had at least 1 indeterminate, and 10 did not have 1 or both scans. Twelve patients were declined listing, 6 from progression of hepatoma but none from CCT or BS findings. Two listed patients were delisted for progression of the hepatoma. Proportion of patients listed, transplanted, clinical and pathologic stage of hepatoma, and recurrence after LT were similar in groups with negative and indeterminate scans. Indeterminate scans led to 6 invasive procedures, 1 patient died of complications of a mediastinal biopsy, and none of the 6 showed metastases. Charges of $2933 were generated per patient evaluated.

CONCLUSIONS

Positive yield of routine CCT and BS in patients with hepatoma is very low despite substantial charges and potential complications. CCT and BS performed only when clinically indicated will be a more cost-effective and safer approach.

Cost savings associated with improving appropriate and reducing inappropriate preventive care: cost-consequences analysis

Background

Outreach facilitation has been proven successful in improving the adoption of clinical preventive care guidelines in primary care practice. The net costs and savings of delivering such an intensive intervention need to be understood. We wanted to estimate the proportion of a facilitation intervention cost that is offset and the potential for savings by reducing inappropriate screening tests and increasing appropriate screening tests in 22 intervention primary care practices affecting a population of 90,283 patients.

Methods

A cost-consequences analysis of one successful outreach facilitation intervention was done, taking into account the estimated cost savings to the health system of reducing five inappropriate tests and increasing seven appropriate tests. Multiple data sources were used to calculate costs and cost savings to the government. The cost of the intervention and costs of performing appropriate testing were calculated. Costs averted were calculated by multiplying the number of tests not performed as a result of the intervention. Further downstream cost savings were determined by calculating the direct costs associated with the number of false positive test follow-ups avoided. Treatment costs averted as a result of increasing appropriate testing were similarly calculated.

Results

The total cost of the intervention over 12 months was $238,388 and the cost of increasing the delivery of appropriate care was $192,912 for a total cost of $431,300. The savings from reduction in inappropriate testing were $148,568 and from avoiding treatment costs as a result of appropriate testing were $455,464 for a total savings of $604,032. On a yearly basis the net cost saving to the government is $191,733 per year (2003 $Can) equating to $3,687 per physician or $63,911 per facilitator, an estimated return on intervention investment and delivery of appropriate preventive care of 40%.

Conclusion

Outreach facilitation is more expensive but more effective than other attempts to modify primary care practice and all of its costs can be offset through the reduction of inappropriate testing and increasing appropriate testing. Our calculations are based on conservative assumptions. The potential for savings is likely considerably higher.

Surveillance strategies for patients following surgical resection of soft tissue sarcomas

PURPOSE OF REVIEW

To examine the factors predictive of recurrence for soft tissue sarcomas, the role of salvage therapy, and the data in support of current surveillance strategies.

RECENT FINDINGS

There are multiple primary tumor characteristics and other factors that can stratify patients into low- or high-risk groups for developing recurrent disease. The available data also support a limited role for salvage therapy in the setting of isolated local recurrence or distant metastases. The use of routine chest computed tomography as opposed to conventional chest x-ray for pulmonary surveillance is costly and provides little additional benefit if the risk for lung metastases is low. When examined scientifically, standard laboratory studies and surveillance imaging of the primary tumor site for extremity soft tissue sarcomas add little to the detection of recurrent disease. In addition to predictive variables, physician experience and opinion influence surveillance strategies.

SUMMARY

For soft tissue sarcomas, patient education and office visits with thorough history and physical examination will detect the vast majority of recurrent disease. Routine surveillance imaging is only of significant benefit if the risk for asymptomatic recurrence is high or if other factors make clinical assessment difficult. There is no benefit to basic laboratory studies in standard follow-up regimens.

The follow-up of adult soft-tissue sarcomas

Soft-tissue sarcomas are a rare and heterogeneous group of diseases with variable biology and pattern of metastases. These characteristics make it challenging to conduct large, randomized studies that could be used to generate evidence-based guidelines for unique subsets. Much of the data summarized here therefore represents standard practice based on the consensus of a group of experienced specialists and retrospective analysis of large databases. A surveillance guideline should be based on known prognostic factors, outcomes in individual subsets, and patterns of recurrence. It has to be practical and relatively cost-effective. The major goals of such an algorithm for soft-tissue sarcomas would be early identification of potentially curable recurrences, identification of therapy-related complications, and patient reassurance.

Combined-modality treatment of localized soft tissue sarcomas of the extremities

Over the past 20 years, considerable progress has been made in the treatment of patients with extremity soft tissue sarcomas. There has been a migration away from amputation toward treatment by excision plus radiation for most patients with localized tumors. Decisions about the optimal use and sequencing of surgery and radiation remain complex. Whereas it is clear that local control is probably not impacted significantly by the treatment sequence, rates of wound complication, fibrosis, and edema are affected by the treatment sequence. In addition, recent single-institution reports indicate that some carefully selected patients can be treated by surgery alone. The recent data evaluating treatment by surgery alone and treatment sequencing variables do not lead to a situation in which clear, uniform recommendations for treatment can be made for many patients with extremity soft tissue sarcomas. Indeed, treatment planning for patients with extremity soft tissue sarcoma in the new millennium is infinitely more complex than it was in the era when amputation was the primary treatment for these patients. Considerable clinical experience and multidisciplinary input are required for optimal treatment planning for these patients. Future research should be directed at refining the indications for specific therapies, reducing the toxicities of local therapies, and developing more effective systemic therapies.

Metastasectomy for limited metastases from soft tissue sarcoma

The development of metastatic soft tissue sarcoma (American Joint Committee on Cancer stage IV) is associated with a poor prognosis. Surgical resection of isolated solitary or multiple metastases is the only curative treatment; all other forms of treatment are considered palliative. As with all surgical procedures, patient selection is important to maximize the clinical benefit of metastasectomy and to minimize the risk for treatment-related morbidity. Over the past decade, nonresectional ablative approaches have been developed to manage visceral metastatic disease. These ablative procedures include cryosurgery, radiofrequency tumor ablation, and alcohol injection. All such procedures are considered investigational; outcome should be compared to that achievable with traditional surgical metastasectomy. The optimal sequence of treatments and role for perioperative (combined with metastasectomy) chemotherapy are unknown. Given the potential curative nature of metastasectomy, all patients with metastatic soft tissue sarcoma should be evaluated for the possibility of surgical resection. Patients with good performance status who have radiographically resectable disease should be considered for metastasectomy.

Retroperitoneal sarcomas: combined modality treatment approaches

Retroperitoneal soft tissue sarcomas are rare tumors estimated to account for 15%of all patients with soft tissue sarcoma seen in referral populations. The standard of care for patients with localized, resectable retroperitoneal sarcomas is surgical resection with gross and microscopically negative margins. However, owing to the large size and locally advanced nature of these tumors, this goal is difficult to achieve in most patients. As a result, the disease is characterized by a high propensity for local recurrence and a grade-specific risk for distant metastasis. Over the past decade, there has been considerable research into combined modality treatment of these tumors. The present report outlines current concepts relating to the diagnosis, staging, and management of retroperitoneal sarcomas. Emphasis is placed on evolving combined modality treatment approaches and current investigational strategies.