Management of small pulmonary nodules in patients with sarcoma

The clinical significance of indeterminate pulmonary nodules in patients with primary bone sarcoma: a systematic review

OBJECTIVE

To report the incidence of indeterminate pulmonary nodules (IPN) and the rate of progression of IPNs to metastasis in patients with primary bone cancers. We also aimed to evaluate clinical or radiological parameters that may identify IPNs more likely to progress to metastatic disease and their effect on overall or event-free survival in patients with primary bone sarcoma.

METHODS

A systematic search of the electronic databases Medline, Embase, and Cochrane Library was undertaken for eligible articles on IPNs in patients with primary bone sarcomas, published in the English language from inception of the databases to 2023. The Newcastle-Ottawa Quality Assessment Form for Cohort Studies was utilized to evaluate risk of bias in included studies.

RESULTS

Six studies, involving 1667 patients, were included in this systematic review. Pooled quantitative analysis found the rate of incidence of IPN to be 18.1% (302 out of 1667) and the rate of progression to metastasis to be 45.0% (136 out of 302). Nodule size (more than 5 mm diameter), number (more than or equal to 4), distribution (bilaterally distributed), incomplete calcification, and lobulated margins were associated with an increased likelihood of IPNs progressing to metastasis, however, their impact on overall or event-free survival remains unclear.

CONCLUSION

The risk of IPNs progressing to metastasis in patients with primary bone sarcoma is non-negligible. Large IPNs have a high risk to be an actual metastasis. We suggest that IPNs in these patients be followed up for a minimum of 2 years with CT imaging at 3, 6, and 12 month intervals, particularly for nodules measuring >5 mm in average diameter.

ADVANCES IN KNOWLEDGE

This is the first systematic review on IPNs in patients with primary bone sarcomas only and proposes viable management strategies for such patients.

Exploring the Diagnostic Dilemma of Indeterminate Pulmonary Nodules in Patients with Primary Sarcoma of Bone

Introduction

Bone sarcomas are known to have a predilection for pulmonary metastasis. Surveillance protocols are thus focused on periodic chest imaging, typically with CT scan. Pulmonary nodules can be easily identified with this modality, but smaller nodules are not readily biopsied and may not represent metastatic disease. These are called indeterminate. The natural history of indeterminate nodules in a bone sarcoma population and factors associated with progression to true metastatic disease are not clearly defined.

Methods

All bone sarcoma patients treated at a single institution from 2010 to 2020 were eligible for inclusion. We treated 327 patients over this period; 119 were excluded for age less than 16 years, 31 were excluded for evident metastatic disease at presentation, and 60 were excluded for incomplete clinical follow-up or CT chest imaging either at staging or in surveillance. We assessed chest CT images for presence of pulmonary nodules and selected variables both at the staging and on surveillance images. Nodules were considered metastatic if proven histologically with a biopsy or by clinical interpretation by the multidisciplinary sarcoma team. Clinical and imaging factors were assessed for the association of indeterminate nodule progression to true metastatic disease.

Results

Seventy three of the 117 patients had indeterminate nodules on their staging CT scan; 41.1% of those patients progressed to metastatic disease compared to 43.2% of the patients that did not have indeterminate nodules on staging CT. Fifty eight of the 117 patients developed indeterminate nodules on surveillance chest CT, and 55.2% of those patients progressed to metastatic disease. There were no clinical or imaging factors that predicted the development of metastatic disease in the group that had indeterminate nodules at presentation; however, the number and size of nodules did correlate with progression to metastasis in those that developed indeterminate nodules on surveillance.

Conclusion

Indeterminate pulmonary nodules are common on staging CT scans in patients with a bone sarcoma. The presence or absence of these indeterminate nodules was not predictive of progression to true metastatic disease in this cohort. However, the development of indeterminate nodules on surveillance imaging was associated with progression to metastatic disease with the size and number of nodules being important factors.

Osteosarcoma immune prognostic index can indicate the nature of indeterminate pulmonary nodules and predict the metachronous metastasis in osteosarcoma patients

Purpose

The relationship between indeterminate pulmonary nodules (IPNs) and metastasis is difficult to determine. We expect to explore a predictive model that can assist in indicating the nature of IPNs, as well as predicting the probability of metachronous metastasis in osteosarcoma patients.

Patients and methods

We conducted a retrospective study including 184 osteosarcoma patients at West China Hospital from January 2016 to January 2021. Hematological markers and clinical features of osteosarcoma patients were collected and analyzed.

Results

In this study, we constructed an osteosarcoma immune prognostic index (OIPI) based on the lung immune prognostic index (LIPI). Compared to other hematological markers and clinical features, OIPI had a better ability to predict metastasis. OIPI divided 184 patients into four groups, with the no-OIPI group (34 patients), the light-OIPI group (35 patients), the moderate-OIPI group (75 patients), and the severe-OIPI group (40 patients) (P < 0.0001). Subgroup analysis showed that the OIPI could have a stable predictive effect in both the no-nodule group and the IPN group. Spearman’s rank correlation test and Kruskal–Wallis test demonstrated that the OIPI was related to metastatic site and metastatic time, respectively. In addition, patients with IPNs in high-OIPI (moderate and severe) groups were more likely to develop metastasis than those in low-OIPI (none and light) groups. Furthermore, the combination of OIPI with IPNs can more accurately identify patients with metastasis, in which the high-OIPI group had a higher metastasis rate, and the severe-OIPI group tended to develop metastasis earlier than the no-OIPI group. Finally, we constructed an OIPI-based nomogram to predict 3- and 5-year metastasis rates. This nomogram could bring net benefits for more patients according to the decision curve analysis and clinical impact curve.

Conclusion

This study is the first to assist chest CT in diagnosing the nature of IPNs in osteosarcoma based on hematological markers. Our findings suggested that the OIPI was superior to other hematological markers and that OIPI can act as an auxiliary tool to determine the malignant transformation tendency of IPNs. The combination of OIPI with IPNs can further improve the metastatic predictive ability in osteosarcoma patients.

How Are Indeterminate Pulmonary Nodules at Diagnosis Associated with Survival in Patients with High-Grade Osteosarcoma?

BACKGROUND

Pulmonary metastases are a poor prognostic factor in patients with osteosarcoma; however, the clinical significance of subcentimeter lung nodules and whether they represent a tumor is not fully known. Because the clinician is faced with decisions regarding biopsy, resection, or observation of lung nodules and the potential impact they have on decisions about resection of the primary tumor, this remains an area of uncertainty in patient treatment. Surgical management of the primary tumor is tailored to prognosis, and it is unclear how aggressively patients with indeterminate pulmonary nodules (IPNs), defined as nodules smaller than 1 cm at presentation, should be treated. There is a clear need to better understand the clinical importance of these nodules.

QUESTIONS/PURPOSES

(1) What percentage of patients with high-grade osteosarcoma and spindle cell sarcoma of bone have IPNs at diagnosis? (2) Are IPNs at diagnosis associated with worse metastasis-free and overall survival? (3) Are there any clinical or radiologic factors associated with worse overall survival in patients with IPN?

METHODS

Between 2008 and 2016, 484 patients with a first presentation of osteosarcoma or spindle cell sarcoma of bone were retrospectively identified from an institutional database. Patients with the following were excluded: treatment at another institution (6%, 27 of 484), death related to complications of neoadjuvant chemotherapy (1%, 3 of 484), Grade 1 or 2 on final pathology (4%, 21 of 484) and lack of staging chest CT available for review (0.4%, 2 of 484). All patients with abnormalities on their staging chest CT underwent imaging re-review by a senior radiology consultant and were divided into three groups for comparison: no metastases (70%, 302 of 431), IPN (16%, 68 of 431), and metastases (14%, 61 of 431) at the time of diagnosis. A random subset of CT scans was reviewed by a senior radiology registrar and there was very good agreement between the two reviewers (κ = 0.88). Demographic and oncologic variables as well as treatment details and clinical course were gleaned from a longitudinally maintained institutional database. The three groups did not differ with regard to age, gender, subtype, presence of pathological fracture, tumor site, or chemotherapy-induced necrosis. They differed according to local control strategy and tumor size, with a larger proportion of patients in the metastases group presenting with larger tumor size and undergoing nonoperative treatment. There was no differential loss to follow-up among the three groups. Two percent (6 of 302) of patients with no metastases, no patients with IPN, and 2% (1 of 61) of patients with metastases were lost to follow-up at 1 year postdiagnosis but were not known to have died. Individual treatment decisions were determined as part of a multidisciplinary conference, but in general, patients without obvious metastases received (neo)adjuvant chemotherapy and surgical resection for local control. Patients in the no metastases and IPN groups did not differ in local control strategy. For patients in the IPN group, staging CT images were inspected for IPN characteristics including number, distribution, size, location, presence of mineralization, and shape. Subsequent chest CT images were examined by the same radiologist to reevaluate known nodules for interval change in size and to identify the presence of new nodules. A random subset of chest CT scans were re-reviewed by a senior radiology resident (κ = 0.62). The association of demographic and oncologic variables with metastasis-free and overall survival was first explored using the Kaplan-Meier method (log-rank test) in univariable analyses. All variables that were statistically significant (p < 0.05) in univariable analyses were entered into Cox regression multivariable analyses.

RESULTS

Following re-review of staging chest CTs, IPNs were found in 16% (68 of 431) of patients, while an additional 14% (61 of 431) of patients had lung metastases (parenchymal nodules 10 mm or larger). After controlling for potential confounding variables like local control strategy, tumor size, and chemotherapy-induced necrosis, we found that the presence of an IPN was associated with worse overall survival and a higher incidence of metastases (hazard ratio 1.9 [95% CI 1.3 to 2.8]; p = 0.001 and HR 3.6 [95% CI 2.5 to 5.2]; p < 0.001, respectively). Two-year overall survival for patients with no metastases, IPN, or metastases was 83% [95% CI 78 to 87], 65% [95% CI 52 to 75] and 45% [95% CI 32 to 57], respectively (p = 0.001). In 74% (50 of 68) of patients with IPNs, it became apparent that they were true metastatic lesions at a median of 5.3 months. Eighty-six percent (43 of 50) of these patients had disease progression by 2 years after diagnosis. In multivariable analysis, local control strategy and tumor subtype correlated with overall survival for patients with IPNs. Patients who were treated nonoperatively and who had a secondary sarcoma had worse outcomes (HR 3.6 [95% CI 1.5 to 8.3]; p = 0.003 and HR 3.4 [95% CI 1.1 to 10.0]; p = 0.03). The presence of nodule mineralization was associated with improved overall survival in the univariable analysis (87% [95% CI 39 to 98] versus 57% [95% CI 43 to 69]; p = 0.008), however, because we could not control for other factors in a multivariable analysis, the relationship between mineralization and survival could not be determined. We were unable to detect an association between any other nodule radiologic features and survival.

CONCLUSION

The findings show that the presence of IPNs at diagnosis is associated with poorer survival of affected patients compared with those with normal staging chest CTs. IPNs noted at presentation in patients with high-grade osteosarcoma and spindle cell sarcoma of bone should be discussed with the patient and be considered when making treatment decisions. Further work is required to elucidate how the nodules should be managed.

LEVEL OF EVIDENCE

Level III, prognostic study.

Clinical and Radiologic Features Together Better Predict Lung Nodule Malignancy in Patients with Soft-Tissue Sarcoma

We test the hypothesis that a model including clinical and computed tomography (CT) features may allow discrimination between benign and malignant lung nodules in patients with soft-tissue sarcoma (STS). Seventy-one patients with STS undergoing their first lung metastasectomy were examined. The performance of multiple logistic regression models including CT features alone, clinical features alone, and combined features, was tested to evaluate the best model in discriminating malignant from benign nodules. The likelihood of malignancy increased by more than 11, 2, 6 and 7 fold, respectively, when histological synovial sarcoma sub-type was associated with the following CT nodule features: size ≥ 5.6 mm, well defined margins, increased size from baseline CT, and new onset at preoperative CT. Likewise, in the case of grade III primary tumor, the odds ratio (OR) increased by more than 17 times when the diameter of pulmonary nodules (PNs) was >5.6 mm, more than 13 times with well-defined margins, more than 7 times with PNs increased from baseline CT, and more than 20 times when there were new-onset nodules. Finally, when CT nodule was ≥5.6 in size, it had well-defined margins, it increased in size from baseline CT, and when new onset nodules at preoperative CT were concomitant to residual primary tumor R2, the risk of malignancy increased by more than 10, 6, 25 and 28 times, respectively. The combination of clinical and CT features has the highest predictive value for detecting the malignancy of pulmonary nodules in patients with soft tissue sarcoma, allowing early detection of nodule malignancy and treatment options.

The diagnostic significance of pulmonary nodules on CT thorax in chondrosarcoma of bone

AIM

To provide a diagnostic approach to pulmonary nodules in patients with chondrosarcoma.

MATERIALS AND METHODS

A search of the oncology database at a specialist orthopaedic oncology referral centre was performed to identify all patients who were treated surgically for chondrosarcoma between January 2007 and December 2018. Reports from the computed tomography (CT) examinations of the thorax of these patients were reviewed. In patients who had pulmonary nodules/metastases identified on CT, data on the primary chondrosarcoma and pulmonary nodule characteristics were collected.

RESULTS

Twenty point two percent of patients had a pulmonary nodule identified on either initial or follow-up staging CT of the thorax, of which 8.1% were pulmonary metastases. Patients with grade 3 and dedifferentiated chondrosarcoma were more likely to have pulmonary metastases than patients with grade 1/2 chondrosarcoma. The time interval to developing metastases was shorter in patients with grade 2/3 and dedifferentiated chondrosarcoma versus patients with grade 1 chondrosarcoma. A low proportion of patients with grade 1 chondrosarcoma developed metastases (12.5%), all of which were identified at the time of a local recurrence. Nodules ≥10mm, nodules with lobulate margins, nodules containing irregular or subtle calcification, and nodules seen bilaterally or both centrally and peripherally were more likely to represent pulmonary metastases than benign nodules.

CONCLUSION

The diagnostic significance of pulmonary nodules (i.e., whether they represent pulmonary metastases or not) can be predicted by taking into account a number of factors, in particular, the histological grade of the patient's chondrosarcoma, the size and margins of the nodules, and the presence of subtle/irregular calcification.

Lung visualisation on PET/MRI: implementing a protocol with a short echo-time and low flip-angle volumetric interpolated breath-hold examination sequence

AIM

To assess the diagnostic performance in detecting lung lesions of a short echo-time (TE) and low flip-angle (FA) volumetric interpolated breath-hold examination (VIBE) sequence included in the integrated positron-emission tomography (PET)/magnetic resonance imaging (MRI) protocol.

METHOD AND MATERIALS

Thirty-seven oncological patients who underwent computed tomography (CT) and PET/MRI, including both a dedicated short TE, low FA VIBE (modified VIBE) and a standard VIBE of the lung, were enrolled. Modified VIBE images were reviewed retrospectively and independently by three raters, to detect pulmonary nodules, parenchymal consolidation, and bands. Three other groups examined standard VIBE, PET, and CT images. MRI and PET findings were compared to CT using Krippendorff's alpha using patient-based and a lesion-based analysis. Krippendorff's alpha was calculated to assess the interobserver agreement among the three raters of the modified VIBE.

RESULTS

In the patient-based analysis (positivity ≥1 lesion), the comparison of modified VIBE with CT showed an alpha of 0.54 for nodules <6 mm (versus 0.41 for standard VIBE and 0.09 for PET) and an alpha of 0.88 for nodules ≥6 mm (versus 0.74 for standard VIBE and 0.42 for PET). On a lesion-based analysis (presence/absence of each lesion), modified VIBE compared to CT showed an alpha of0.58 for nodules <6 mm (versus 0.44 for standard VIBE and 0.09 for PET) and an alpha of 0.90 for nodules ≥6 mm (versus 0.79 for standard VIBE and 0.50 for PET). The alpha value for the interobserver agreement was 0.90 for nodules <6 mm, 0.91 for nodules ≥6 mm, 1.00 for consolidations, and 0.95 for bands in the patient-based analysis and 0.89, 0.93, 1.00, and 0.95 in the lesion-based analysis.

CONCLUSIONS

Modified VIBE proved to be reproducible, showed better accuracy than standard VIBE and PET, and very good concordance with CT in assessing lung nodules ≥6 mm, whereas the agreement was less satisfactory for smaller nodules.

What Is the Clinical Importance of Incidental Findings on Staging CT Scans in Patients With Sarcoma?

BACKGROUND

Baseline staging CT scans are performed on nearly every patient after the diagnosis of a sarcoma to evaluate for the presence of metastatic disease. These scans often identify abnormalities that may or may not be related to the known malignancy. Despite the high frequency of incidental findings, there is little guidance for clinicians faced with assessing these radiographic abnormalities. The interpretation of incidental findings is important because it may influence decisions regarding surveillance frequency, prognostic estimation, and surgical and medical intervention.

QUESTIONS/PURPOSES

The purpose of this study was to determine (1) the frequency of abnormal findings and indeterminate nodules on staging CT scans; (2) the natural history of indeterminate nodules identified at the time of sarcoma diagnosis; and (3) the factors associated with indeterminate nodules representing true metastatic disease.

METHODS

Between September 2010 and February 2016 we treated 233 patients with bone and soft tissue sarcomas. Of those, 227 (97%) had a staging CT scan of the chest or chest/abdomen/pelvis performed within 2 months of diagnosis. To be eligible for this retrospective study, a patient had to have a minimum of 6 months of radiographic followup after that initial CT scan. A total of 36 (16%) were lost to followup or did not have radiographic surveillance at least 6 months later, and 48 (21%) were excluded for other prespecified reasons, leaving 149 patients for evaluation. We recorded all abnormal findings listed in the official radiology CT report of the lung, bone, liver, and lymph nodes. We assessed progression of indeterminate nodules by reviewing radiology reports, which listed both size and number of findings, and clinical notes outlining the current assessment of disease status and treatment plan. If indeterminate nodules grew in size or number consistent with metastatic disease or were confirmed histologically, they were considered to represent true metastasis. Bivariate methods were used to investigate an association between various clinical factors, which were obtained from chart review, and progression of indeterminate nodules to clear metastatic disease.

RESULTS

One hundred thirty-five of 149 patients (91%) had at least one abnormal finding on a staging CT scan. Forty-nine patients (33%) presented with indeterminate lung nodules, 15 (10%) with indeterminate liver lesions, four (3%) with indeterminate bone lesions, and 57 (38%) with enlarged lymph nodes. Fifteen of the 49 patients with indeterminate lung nodules (31%), one of 15 liver nodules, zero of four bone lesions, four of 13 lymph nodes 1 to 2 cm in size, and two of 44 subcentimeter lymph nodes (4.5%) were clearly metastatic on followup. A primary tumor size ≥ 14 cm in greatest dimension was more suggestive of indeterminate nodules representing true metastatic disease compared with smaller primary tumors in both lung (eight of 10 compared with seven of 36 [19%]; odds ratio, 16.6; 95% confidence interval, 2.9-95.9; p < 0.001) and lymph nodes (six of 18 compared with zero of 36 [0%], p < 0.001).

CONCLUSIONS

It is extremely common for abnormal findings and incidental nodules to be present at the time of a staging CT scan in patients with sarcoma. Although patients with indeterminate nodules should have continued surveillance, it appears from this study that the majority of these findings do not represent true metastatic disease. Given a minimum followup of 6 months, it is possible the actual proportion of indeterminate lesions representing true metastatic disease may increase over time.

LEVEL OF EVIDENCE

Level III, prognostic study.

Indeterminate nodules in osteosarcoma: what's the follow-up?

BACKGROUND

Indeterminate pulmonary nodules in patients diagnosed with osteosarcoma present a challenge for accurate staging and prognosis. The aim of this study was to explore the significance of this finding.

METHODS

A retrospective cohort study of 120 patients with osteosarcoma was performed in the North East of England. Chest computed tomographies (CTs) at presentation were reviewed and the incidence of 'indeterminate' nodules recorded. Follow-up scans were reviewed and survival as well as prognostic features were analysed.

RESULTS

25% of our cohort presented with indeterminate nodules. Of these, 33% were subsequently confirmed as metastases, the majority within a year. Kaplan-Meier survival analysis showed that patients with indeterminate nodules fared better than those with frank metastatic disease, and similar to those who presented with a normal chest CT. We found no radiographic features that predicted survival.

CONCLUSIONS

Indeterminate nodules remain a clinical and diagnostic dilemma. Close monitoring of patients is advised during the first year from presentation, and there is potential for indeterminate nodules to develop into frank metastases later than five years from presentation.

Analysis of pulmonary nodules in patients with high-grade soft tissue sarcomas

Nowadays, small pulmonary nodules are easily detectable in patients with soft tissue sarcomas (STSs) because of highly improved computed tomography (CT) technologies. The purpose of this study was to determine the frequency and significance of the pulmonary nodules detected by CT in high-grade STS patients. 124 patients with high-grade STS were retrospectively reviewed. There were 72 males (57%) and 52 females (43%). Patients’ average age was 61 years (median (quartiles) 66 years (48–75), range 8–94 years). Pulmonary nodules were detected in 49 (39.5%) of 124 patients by CT scanning at first presentation. Of 49 patients with nodules at first presentation, 34 (69.4%) had benign lesions, and 13 (26.5%) had metastatic nodules. One patient (2%) had primary lung cancer and the remaining one with one nodule could not be definitively diagnosed due to a short follow-up time. 30 patients (24.1%) of 124 patients developed pulmonary nodules during their clinical progression. Seven (23.3%) had benign lesions, whereas 21 (70%) had metastatic lesions. Primary lung cancer was detected in two patients (6.7%). The size and timing of detection of a pulmonary nodule significantly affected the final clinical diagnosisby multivariate analysis. We conclude that pulmonary nodules can be detected highly frequently in patients with high-grade STSs because of improved CT technologies. Careful follow-up is needed if nodules are detected after initial treatment or during the clinical course of the disease.

Impact of tumor volume doubling time on post-metastatic survival in bone or soft-tissue sarcoma patients treated with metastasectomy and/or radiofrequency ablation of the lung

Metastasectomy represents the standard treatment for improving survival in patients with lung metastases (LMs) from bone (BS) or soft-tissue sarcoma (STS). Recently, radiofrequency ablation (RFA) of the LMs has been proved to be a useful option which can promise the similar effect to metastasectomy. The aim of this study was to determine prognostic factors, including tumor volume doubling time (TVDT), for post-metastatic survival in BS and STS patients treated with metastasectomy and/or RFA of the lung. Forty-eight patients with LMs were retrospectively reviewed. The mean age of the patients at the time of LMs was 56 years. The cohort comprised 27 male and 21 female patients. Eight of the 48 patients had LMs at the point of initial presentation. The mean follow-up period after commencing the treatment for LMs was 37 months. The mean maximum diameter of the initial LMs was 11 mm. The mean number of LMs was 4. The TVDT was calculated using a method originally described by Schwartz. At last follow-up, 5 patients had no evidence of disease, 3 patients were still alive with disease, and 32 patients had died of disease. The 3-year and 5-year post-metastatic survival rates were 32% and 16.8%, respectively. In a Cox univariate analysis, the size (P=0.04) and number of LMs (P<0.001), disease-free interval (P=0.04), curability of the initial LMs (P<0.001), and TVDT (P<0.001) were significantly identified as factors which affect prognosis. In the multivariate analysis, TVDT (P<0.001) and curability of the initial LMs (P<0.001) were confirmed as independent predictors of survival. There was a significant association between the number and curability of the initial LMs (P<0.001). In conclusion, metastasectomy and/or RFA of LMs is recommended for improving survival. However, TVDT and the curability of the LMs should be taken into consideration.

Prognostic role of elevated preoperative systemic inflammatory markers in localized soft tissue sarcoma

BACKGROUND

Systemic inflammation has been implicated in cancer development and progression. The aim of the present study was to evaluate whether pre-operative systemic inflammatory markers can predict outcomes in bone and soft tissue sarcomas.

METHODS

Relevant literature was mainly identified using Pubmed, EMBASE and CNKI. Patients' clinical characteristics, overall survival (OS), disease/relapse free survival (DFS/RFS) with high-level CRP or neutrophils to lymphocytes ratio (NLR) were extracted. The statistics extracted from Kaplan-Meier survival curves with log-rank p value were calculated with methods developed by Parmar, Williamson, and Tierney; multivariate Cox hazard regression analysis data were used directly in STATA 10.0. Pooled hazard ratio (HR) and 95% CI were calculated to evaluate the prognostic role of these systemic inflammatory markers (CRP/NLR).

RESULTS

After full text review, 11 articles containing 1809 patients were identified as eligible articles. The meta-analysis for survival outcome showed significant prognostic value of systemic inflammatory markers including CRP and NLR in pre-operative blood. The combined HRs (95% CI) for five year overall survival (OS) and disease/recurrence free survival (DFS/RFS) were 2.54 [2.04, 3.16] and 2.28 [1.72, 3.04]. Specifically, higher NLR was associated with decreased 5-year OS (HR 3.75, 95% CI 1.24 to 11.37) and 3 year RFS/DFS (HR 2.43, 95% CI 0.84 to 7.05). Besides, the pooled HR showed a higher risk of 5-year disease progression (HR 2.55, 95% CI 1.60 to 4.08, I2 = 52%) and lower 5-year OS (HR 2.50, 95% CI 2.00 to 3.12, I2 = 0%) in sarcoma patients with high CRP level. We then grouped the meta-analysis by patient source (Asian and non-Asian), tumor stage (I/II or III/IV) and grade (high or low), respectively. All the subgroup analysis showed significant prognostic role in survival condition. The CRP/NLR levels are also found closely related with patient age, tumor stage and size.

CONCLUSION

Higher level of pre-operative CRP and NLR demonstrated a significantly higher risk of recurrence and overall decreased survival rates in sarcomas.

The role of C-reactive protein in predicting post-metastatic survival of patients with metastatic bone and soft tissue sarcoma

Although elevated preoperative serum C-reactive protein (CRP) level is an indicator of a poorer prognosis in many cancers including non-metastatic bone and soft tissue sarcoma, there have been no reports focused on sarcoma patients with advanced stage who had distant metastases. The aim of this study is to determine whether the serum CRP level after metastasis is associated with post-metastatic survival in patients with bone and soft tissue sarcoma. A total of 71 patients were studied including 38 male and 33 female. Of all patients, 22 patients had metastases at presentation. The remaining 49 patients developed initial metastasis after the treatment of primary tumor. The average age at the diagnosis of metastasis was 55 years. Blood was obtained after initial detection of metastasis. CRP levels ranged from 0.1 to 165 mg/L with an average of 16.4 mg/L in all patients. Elevated CRP levels (>3 mg/L) were seen in 31 patients (range 3.1-165). The disease-specific survival after metastasis estimates at 3 and 5 years was 17.1 and 17.1 % for those with an elevated CRP vs. 59.5 and 45.3 % for those with a normal CRP (p < 0.0001). In 49 patients who developed lung metastasis after initial primary treatment, patients with elevated CRP levels also had a poorer post-metastatic survival than patients with normal CRP levels (p < 0.0001). In conclusion, we recommend routine measurement of CRP level to identify the patients who have high risk of death after metastasis.

The Role of Neoadjuvant Therapy in Characterizing Indeterminate Lung Lesions in Patients with Resectable Colorectal Liver Metastases

BACKGROUND

Incidental pulmonary lesions are frequently found during the preoperative evaluation of patients considered for resection of colorectal liver metastases (CRLM), and their presence can confound management decisions. This study investigates the role of clinical and radiologic factors, including response to preoperative systemic chemotherapy, in determining the malignant probability of these lesions.

METHODS

Computed tomography (CT) scans of 33 patients with small (≤1 cm) lung lesions undergoing resection for CRLM after preoperative chemotherapy were reviewed. Radiological features were recorded from three sequential CT scans (baseline, postchemotherapy, and follow-up). Malignancy was diagnosed either by resection or serial imaging. Chemotherapy response comparing lung lesions and CRLM was categorized as: (1) concordant or (2) discordant. Chemotherapy response, imaging features, and other clinical factors were evaluated in multivariate analyses as predictors of malignancy.

RESULTS

Among the 86 indeterminate lung lesions identified, 23 % (20/86) were found to be metastases on follow-up. Lesions 6-10 mm were more likely to be metastases (odds ratio [OR] = 3.14, p = 0.045), as were lesions located in the lower lobes (OR = 4.50, p = 0.018). Concordant chemotherapy response was found in 13 of 86 (15 %) and was independently associated with metastatic disease (OR = 19.87, p < 0.001), with 11 of 13 (85 %) lesions determined to be metastases. In contrast, only 9 of 73 lesions (12 %) with discordant response were found to be metastases.

CONCLUSIONS

Lesion size, location, and chemotherapy response pattern were independent predictors of malignancy for patients with resectable CRLM and small indeterminate lung lesions. Utilization of preoperative chemotherapy can be a useful method of ruling out pulmonary metastases in these patients.

Clinical impact of the tumor volume doubling time on sarcoma patients with lung metastases

The volume doubling time (VDT) is an accurate and reproducible method for the quantitation of the rate and pattern of tumor growth in individual patients. The purpose of this study is to investigate the tumor VDT using chest CT in individual sarcoma patients with lung metastasis and to determine whether VDT is associated with survival after lung metastasis in bone and soft tissue sarcomas. Forty patients had measurable lung metastases in at least two sequential chest CT images taken at least 14 days apart. The VDT was calculated using the method originally described by Schwartz. The median and mean VDT in all 40 patients was 21.5 and 53 days, respectively. Similarly, the median and average VDT in 29 soft tissue sarcoma patients was 26 and 57 days, respectively. The median and mean VDT in 11 bone sarcoma patients was 13 and 42 days, respectively. The current univariate analysis revealed significantly poorer predictive values for VDT in all 40 sarcoma patients and 29 soft tissue sarcoma patients. A multivariate analysis showed the VDT to be an independent predictor of survival in 29 soft tissue sarcoma patients. These results suggest that patients with a shorter VDT and consequently a more rapid rate of tumor growth have a significantly lower chance for long term survival especially in soft tissue sarcoma. The patients with lung metastasis that have a longer VDT should therefore be considered for aggressive treatment even if the lesions are multiple and/or bilateral.