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Noebauer-Huhmann IM, Vanhoenacker FM, Vilanova JC, Tagliafico AS, Weber MA, Lalam RK, Grieser T, Nikodinovska VV, de Rooy JWJ, Papakonstantinou O, Mccarthy C, Sconfienza LM, Verstraete K, Martel-Villagrán J, Szomolanyi P, Lecouvet FE, Afonso D, Albtoush OM, Aringhieri G, Arkun R, Aström G, Bazzocchi A, Botchu R, Breitenseher M, Chaudhary S, Dalili D, Davies M, de Jonge MC, Mete BD, Fritz J, Gielen JLMA, Hide G, Isaac A, Ivanoski S, Mansour RM, Muntaner-Gimbernat L, Navas A, O Donnell P, Örgüç Ş, Rennie W, Resano S, Robinson P, Sanal HT, Ter Horst SAJ, van Langevelde K, Wörtler K, Koelz M, Panotopoulos J, Windhager R, Bloem JL. Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2023-overview, and primary local imaging: how and where? Eur Radiol 2024; 34:4427-4437. [PMID: 38062268 PMCID: PMC11213759 DOI: 10.1007/s00330-023-10425-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/08/2023] [Accepted: 09/26/2023] [Indexed: 06/29/2024]
Abstract
OBJECTIVES Early, accurate diagnosis is crucial for the prognosis of patients with soft tissue sarcomas. To this end, standardization of imaging algorithms, technical requirements, and reporting is therefore a prerequisite. Since the first European Society of Musculoskeletal Radiology (ESSR) consensus in 2015, technical achievements, further insights into specific entities, and the revised WHO-classification (2020) and AJCC staging system (2017) made an update necessary. The guidelines are intended to support radiologists in their decision-making and contribute to interdisciplinary tumor board discussions. MATERIALS AND METHODS A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements were scored online by level of agreement (0 to 10) during two iterative rounds. Either "group consensus," "group agreement," or "lack of agreement" was achieved. RESULTS Eight sections were defined that finally contained 145 statements with comments. Overall, group consensus was reached in 95.9%, and group agreement in 4.1%. This communication contains the first part consisting of the imaging algorithm for suspected soft tissue tumors, methods for local imaging, and the role of tumor centers. CONCLUSION Ultrasound represents the initial triage imaging modality for accessible and small tumors. MRI is the modality of choice for the characterization and local staging of most soft tissue tumors. CT is indicated in special situations. In suspicious or likely malignant tumors, a specialist tumor center should be contacted for referral or teleradiologic second opinion. This should be done before performing a biopsy, without exception. CLINICAL RELEVANCE The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability both in individual patients and in future studies on individualized strategies. KEY POINTS • Ultrasound remains the best initial triage imaging modality for accessible and small suspected soft tissue tumors. • MRI is the modality of choice for the characterization and local staging of soft tissue tumors in most cases; CT is indicated in special situations. Suspicious or likely malignant tumors should undergo biopsy. • In patients with large, indeterminate or suspicious tumors, a tumor reference center should be contacted for referral or teleradiologic second opinion; this must be done before a biopsy.
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Affiliation(s)
- Iris-Melanie Noebauer-Huhmann
- Department of Biomedical Imaging and Image Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria.
| | - Filip M Vanhoenacker
- Department of Radiology AZ Sint Maarten Mechelen, University Hospital Antwerp, Antwerp, Belgium
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Joan C Vilanova
- Department of Radiology, Clínica Girona, Institute of Diagnostic Imaging (IDI) Girona, University of Girona, Girona, Spain
| | - Alberto S Tagliafico
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Department of Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Radhesh K Lalam
- Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - Thomas Grieser
- Dept. for Diagnostic and Interventional, Radiology University Hospital Augsburg, Augsburg, Germany
| | - Violeta Vasilevska Nikodinovska
- Medical Faculty, Ss. Cyril and Methodius University, Skopje, Macedonia
- Department of Radiology, University Surgical Clinic "St. Naum Ohridski" Skopje, Skopje, Macedonia
| | - Jacky W J de Rooy
- Department of Imaging, Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olympia Papakonstantinou
- 2Nd Department of Radiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Catherine Mccarthy
- Oxford Musculoskeletal Radiology and Oxford University Hospitals, Oxford, UK
| | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Milan, Italy
| | | | | | - Pavol Szomolanyi
- High Field MR Center, Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
- Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Frédéric E Lecouvet
- Department of Radiology and Medical Imaging, Cliniques Universitaires Saint Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Diana Afonso
- Hospital Particular da Madeira, and Hospital da Luz Lisboa, Lisbon, Portugal
| | - Omar M Albtoush
- Department of Radiology, University of Jordan, Ammam, Jordan
| | - Giacomo Aringhieri
- Academic Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Remide Arkun
- Ege University Medical School Izmir, Izmir, Turkey Star Imaging Center Izmir, Izmir, Turkey
| | - Gunnar Aström
- Department of Immunology, Genetics and Pathology (Oncology) and Department of Surgical Sciences (Radiology), Uppsala University, Uppsala, Sweden
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Rajesh Botchu
- Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK
| | | | | | - Danoob Dalili
- Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), London, UK
| | - Mark Davies
- Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK
| | - Milko C de Jonge
- Department of Radiology, St. Antonius Hospital, Utrecht, The Netherlands
| | - Berna D Mete
- Department of Radiology School of Medicine, Izmir Demokrasi University, Izmir, Turkey
| | - Jan Fritz
- Department of Radiology, NYU Grossman School of Medicine, New York, USA
- Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Tübingen, Germany
| | - Jan L M A Gielen
- Department of Radiology and Medical Imaging, University Hospital Antwerp, Edegem, Belgium
| | - Geoff Hide
- Department of Radiology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Amanda Isaac
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Slavcho Ivanoski
- St. Erasmo Hospital for Orthopaedic Surgery and Traumatology Ohrid, Ohrid, Macedonia
| | | | | | - Ana Navas
- Department of Radiology, Division of Musculoskeletal Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Winston Rennie
- Clinical MSK Radiology, Loughborough University, Leicester Royal Infirmary, Leicester, UK
| | | | - Philip Robinson
- Musculoskeletal Radiology Department Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Hatice T Sanal
- Radiology Department, University of Health Sciences, Gülhane Training and Research Hospital, Istanbul, Turkey
| | - Simone A J Ter Horst
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Klaus Wörtler
- Musculoskeletal Radiology Section, Klinikum Rechts der Isar, Technical University of Munich - TUM School of Medicine, Munich, Germany
| | - Marita Koelz
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Joannis Panotopoulos
- Departement of Orthopaedics and Traumatology, Division of Orthopaedics, Medical University of Vienna, Vienna, Austria
| | - Reinhard Windhager
- Departement of Orthopaedics and Traumatology, Medical University of Vienna, Vienna, Austria
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Chmiel P, Rutkowski P, Spałek M, Szumera-Ciećkiewicz A, Czarnecka AM. What is the Optimal Treatment Strategy after Sarcoma R2 Surgery? Curr Treat Options Oncol 2024; 25:798-812. [PMID: 38809411 PMCID: PMC11222198 DOI: 10.1007/s11864-024-01218-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 05/30/2024]
Abstract
OPINION STATEMENT Soft tissue sarcomas (STS) are rare tumours of mesenchymal origin, most commonly occurring in the extremity but also in the retroperitoneum. The curative treatment for STS is radical surgery with wide margins, in some cases in combination with perioperative radiotherapy and chemotherapy. Nonradical resection (R2) of STS has been an emerging issue in recent decades, as optimal subsequent management remains debatable. Similarly, there is still no consensus on optimal surgical margins. Combining multiple treatment modalities in adjuvant therapy can achieve local and distant control in patients following surgery with positive margins. Patients who have undergone nonradical resection therefore require additional surgical interventions, and adjuvant radiotherapy resulting in a better prognosis but a higher number of complications. Following non-radical treatment, patients with limb and trunk wall sarcomas and retroperitoneal sarcomas should also undergo increased oncological surveillance. Given the potential issues that may emerge in such clinical situations, it is crucial to up-date the current guidelines to enhance the long-term prognosis of these patients.
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Affiliation(s)
- Paulina Chmiel
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
- Faculty of Medicine, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
| | - Mateusz Spałek
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
- Department of Radiotherapy I, Maria Sklodowska-Curie National Research Institute of Oncology, 02-718, Warsaw, Poland
| | - Anna Szumera-Ciećkiewicz
- Department of Pathology, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
- Biobank Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland
| | - Anna M Czarnecka
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, 02-781, Warsaw, Poland.
- Department of Experimental Pharmacology, Mossakowski Medical Research Institute Polish Academy of Sciences, 02-106, Warsaw, Poland.
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Gómez-Álvarez J, Lamo-Espinosa JM, San-Julián M. Do Patients Treated With an Unplanned Resection for Small Superficial Soft Tissue Sarcomas Have Worse Long-term Survival Than Those Initially Treated With an Oncologic Resection? Clin Orthop Relat Res 2024; 482:00003086-990000000-01483. [PMID: 38277495 PMCID: PMC11124722 DOI: 10.1097/corr.0000000000002974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/08/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Histologic grade, size, and depth are well-known prognostic factors in soft tissue sarcomas (STS). Small (< 5 cm) and superficial STS generally have an excellent prognosis when treated with appropriate surgery. However, they are often misdiagnosed and mistreated. We reported that in midterm follow-up (5 to 7 years), patients with unplanned resections of tumors with positive margins who immediately underwent a reoperation with margin-widening re-resection and postoperative radiotherapy had survival comparable to that of patients who were initially treated correctly. In that article, we included STS larger than 5 cm, deep STS, and individuals with local recurrence. However, we wanted to evaluate the impact of unplanned resection on the survival of patients who had STS with the best prognosis, small and superficial STS, with two groups that were as homogeneous as possible. QUESTION/PURPOSE Do patients with small and superficial STS who underwent an unplanned resection have worse prognosis in the long term than those who were initially treated correctly? METHODS We exclusively evaluated patients with small (< 5 cm) and superficial (to the deep fascia) STS. We systematically excluded deep STS. Among this subset, we identified 93 patients with superficial STS. We excluded patients with local relapse, metastatic disease, superficial STS of the head or neck, those with insufficient clinical or dosimetric information, and patients with follow-up of less than 2 years. Furthermore, our focus on investigating the most benign and homogeneous STS prompted us to exclude patients with superficial tumors greater than or equal to 5 cm. This selection was driven by the presumed better prognosis associated with smaller tumors, inevitably leading to a smaller pool of patients for direct comparison with patients who had unplanned resections. The initial expectation was to observe similar survival outcomes between cohorts. Between 1990 and 2019, a total of 17 patients underwent surgical treatment at our private, medium-size center. Of those, 29% (5 patients) were lost to follow-up before 2 years without meeting a study endpoint (relapse, metastasis or revision, reoperation, or death), leaving a total of 71% (12 patients) of the original group who had either follow-up of at least 2 years or who met a study endpoint before that minimum surveillance duration. They were treated with surgery alone. During that same period, another 51 patients were referred to us after undergoing an unplanned resection of a lesion that subsequently was determined to be a soft tissue malignancy. Of those, 18% (9 patients) were lost to follow-up before 2 years without meeting a study endpoint, leaving 82% (42 patients) of the original group who had either follow-up of at least 2 years or who met a study endpoint before that minimum surveillance duration. They were treated with re-excision and postoperative radiotherapy. Patients with unplanned resections had an older mean age (51± 5 versus 44 ± 7 years; p = 0.1) and a higher proportion of female patients (58% versus 38%; p = 0.07), but the groups did not differ in terms of largest diameter, histologic type, or tumor location. However, patients with planned resections had a higher proportion of high-grade STS (75% versus 55%; p = 0.07). No metastases were present in either group at diagnosis. We performed a univariate analysis of the groups. We could not perform a multivariate analysis because of the small sample. We compared the groups in terms of local recurrence and all-cause mortality using the Kaplan-Meier survivorship estimator. RESULTS According to the Kaplan-Meier survivorship estimator, survivorship free from local recurrence at a mean of 20 years of follow-up was better in the planned resection group than in the unplanned resection group (92% [95% CI 63% to 100%] versus 69% [95% CI 54% to 81%]; p = 0.04). Furthermore, overall survivorship at 5 years was higher in the planned resection group than in the unplanned resection group (100% [95% CI 72% to 100%] versus 70% [95% CI 54% to 81%]; p = 0.04). Similarly, the planned resection group exhibited superior survivorship at 20 years of follow-up (100% [95% CI 72% to 100%] versus 62% [95% CI 47% to 75%]; p = 0.01). Metastatic disease was absent in the planned resection group, while it occurred in 12 patients in the unplanned resection group (28% [95% CI 17% to 44%]). CONCLUSION Unplanned resection for patients with small and superficial STS was associated with a decrease in overall survival in the long term, despite the use of postoperative radiotherapy. An unplanned resection may be an important prognostic factor. Nevertheless, larger and prospective studies are needed to validate our findings. Although small and superficial lumps are usually benign, nonsarcoma surgeons should be aware that some masses may be malignant, and if in doubt, MR imaging, a biopsy before excision, or consultation with or referral to a sarcoma center should be considered before removing the mass. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Jorge Gómez-Álvarez
- Department of Orthopedic Surgery, Clínica Universidad de Navarra, Pamplona, Spain
| | | | - Mikel San-Julián
- Department of Orthopedic Surgery, Clínica Universidad de Navarra, Pamplona, Spain
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Hong AM, Sundaram A, Perianayagam G, Lo H, Lawless A, Zhou D, McDonough J, Thompson SR, Maclean F, Connolly EA, Coker D, Mar J, Lazarakis S, Johnston A. Surgery at specialised sarcoma centres improves patient outcomes - A systematic review by the Australia and New Zealand sarcoma association clinical practice guidelines working party. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106951. [PMID: 37301636 DOI: 10.1016/j.ejso.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Optimal management of sarcoma requires multidisciplinary team input throughout the process of diagnosis, treatment and follow up. This systematic review aimed to evaluate the impact of surgery performed at specialised sarcoma centres on outcomes. METHODS A systematic review was conducted using the population, intervention, comparison and outcome (PICO) model. Medline, Embase, Cochrane Central databases were queried for publications that evaluated the local control, limb salvage rate, 30-day and 90-day surgical mortality, and overall survival in patients undergoing surgery in a specialist sarcoma centre compared with non-specialist centre. Each study was screened by two independent reviewers for suitability. A qualitative synthesis of the results was performed. RESULTS Sixty-six studies were identified. The majority of studies were Level III-3 as assessed by the NHMRC Evidence Hierarchy, whilst just over half of the studies were of good quality. Definitive surgery performed at specialised sarcoma centres was associated with improved local control as defined by lower rate of local relapse, higher rate of negative surgical margins, improved local recurrence free survival and higher limb conservation rate. Available evidences show a favourable pattern of lower 30-day and 90-day mortality rates, and greater overall survival when surgery was performed in specialist sarcoma centres compared with non-specialised centres. CONCLUSIONS Evidences support better oncological outcomes when surgery is performed at specialised sarcoma centre. Patients with suspected sarcoma should be referred early to a specialised sarcoma centre for multidisciplinary management, which includes planned biopsy and definitive surgery.
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Affiliation(s)
- Angela M Hong
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia; Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia.
| | - Abay Sundaram
- Department of Orthopaedic Surgery, Sir Charles Gardiner Hospital, Nedlands, WA, 6009, Australia
| | - Ganaps Perianayagam
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Helen Lo
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia; Mid North Coast Cancer Institute, Port Macquarie, NSW, 2444, Australia
| | - Anna Lawless
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia; Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia
| | - Deborah Zhou
- NHMRC Clinical Trials Centre, The University of Sydney, NSW, 2006, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia
| | | | - Stephen R Thompson
- Faculty of Medicine, University of New South Wales, Randwick, NSW, 2131, Australia; Department of Radiation Oncology, Prince of Wales Hospital, Randwick, NSW, 2132, Australia
| | - Fiona Maclean
- Douglass Hanly Moir Pathology, North Ryde, NSW, 2113, Australia
| | - Elizabeth A Connolly
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Camperdown, NSW, 2050, Australia
| | - David Coker
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia; Department of Melanoma and Surgical Oncology, and Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Jasmine Mar
- Australia and New Zealand Sarcoma Association, Parkville, Victoria, 3010, Australia
| | - Smaro Lazarakis
- Health Sciences Library, Royal Melbourne Hospital, Parkville, Victoria, 3010, Australia
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Strönisch A, Märdian S, Flörcken A. Centralized and Interdisciplinary Therapy Management in the Treatment of Sarcomas. Life (Basel) 2023; 13:life13040979. [PMID: 37109507 PMCID: PMC10144040 DOI: 10.3390/life13040979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
Sarcoma treatment requires a high level of expertise due to its rarity and heterogeneity. Sarcoma patients should, therefore, be referred to an expert centre as early as possible to ensure optimal treatment. Numerous studies have been carried out to provide evidence for this strategy. In compliance with the 2020 PRISMA guidelines, a systematic search was conducted in PubMed, EMBASE, Ovid Medline, ClinicalTrials.gov and Cochrane Library databases. The subject of these studies was the centralised treatment of adult sarcoma patients at expert centres and the use of interdisciplinary tumour boards. Uncertainty in therapy, delays in referral to expert centres, and limited access to therapeutic modalities continue to be a challenge in sarcoma therapy. At expert centres, diagnostic procedures were more frequently and adequately performed, and treatment was associated with an improvement in outcomes in the majority of studies: patients benefited from longer survival, lower local recurrence rates and a better postoperative outcome. The implementation of an interdisciplinary tumour board was associated with discrepant results. In a greater number of studies, it was associated with a lower local relapse rate, better overall survival and surgical outcome. In two studies, however, a shorter overall survival was observed. The establishment of expert centres and the consistent use of interdisciplinary tumour boards are important structures for ensuring multidisciplinary therapy approaches. There is growing evidence that this holds great potential for optimising sarcoma therapy.
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Affiliation(s)
- Annika Strönisch
- Department of Hematology, Oncology, and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Sven Märdian
- Centre for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Anne Flörcken
- Department of Hematology, Oncology, and Tumor Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, German Cancer Consortium (DKTK), Partner Site Berlin, and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
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Mosku N, Heesen P, Studer G, Bode B, Spataro V, Klass ND, Kern L, Scaglioni MF, Fuchs B. Biopsy Ratio of Suspected to Confirmed Sarcoma Diagnosis. Cancers (Basel) 2022; 14:cancers14071632. [PMID: 35406402 PMCID: PMC8996854 DOI: 10.3390/cancers14071632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary Determining the biology of mesenchymal tumor, imaging alone is usually not enough, and the final diagnosis is established through tissue analysis If the indication to perform a biopsy is not established frequently enough, an undesired unplanned resection of a sarcoma may result, and conversely, a patient’s discomfort as well as costs may increase. In here, using a real-world data registry of quality, we included the absolute number of a consecutive series of patients, to determine the prevalence of biopsies and its related diagnosis, to establish a reference, which may allow for the definition of a quality indicator for the work-up within a multidisciplinary team. Abstract The ratio of malignancy in suspicious soft tissue and bone neoplasms (RMST) has not been often addressed in the literature. However, this value is important to understand whether biopsies are performed too often, or not often enough, and may therefore serve as a quality indicator of work-up for a multidisciplinary team (MDT). A prerequisite for the RMST of an MDT is the assessment of absolute real-world data to avoid bias and to allow comparison among other MDTs. Analyzing 950 consecutive biopsies for sarcoma-suspected lesions over a 3.2-year period, 55% sarcomas were confirmed; 28% turned out to be benign mesenchymal tumors, and 17% non-mesenchymal tumors, respectively. Of these, 3.5% were metastases from other solid malignancies, 1.5% hematologic tumors and 13% sarcoma simulators, which most often were degenerative or inflammatory processes. The RMST for biopsied lipomatous lesions was 39%. The ratio of unplanned resections was 10% in this series. Reorganizing sarcoma work-up into integrating practice units (IPU) allows the assessment of real-world data with absolute values over the geography, thereby enabling the definition of quality indicators and addressing cost efficiency aspects of sarcoma care.
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Affiliation(s)
- Nasian Mosku
- Faculty of Medicine, University of Lucerne, 6000 Lucerne, Switzerland; (N.M.); (G.S.); (M.F.S.)
- Swiss Sarcoma Network, 6000 Lucerne, Switzerland; (P.H.); (B.B.); (V.S.); (N.D.K.); (L.K.)
| | - Philip Heesen
- Swiss Sarcoma Network, 6000 Lucerne, Switzerland; (P.H.); (B.B.); (V.S.); (N.D.K.); (L.K.)
| | - Gabriela Studer
- Faculty of Medicine, University of Lucerne, 6000 Lucerne, Switzerland; (N.M.); (G.S.); (M.F.S.)
- Swiss Sarcoma Network, 6000 Lucerne, Switzerland; (P.H.); (B.B.); (V.S.); (N.D.K.); (L.K.)
| | - Beata Bode
- Swiss Sarcoma Network, 6000 Lucerne, Switzerland; (P.H.); (B.B.); (V.S.); (N.D.K.); (L.K.)
| | - Vito Spataro
- Swiss Sarcoma Network, 6000 Lucerne, Switzerland; (P.H.); (B.B.); (V.S.); (N.D.K.); (L.K.)
| | - Natalie D. Klass
- Swiss Sarcoma Network, 6000 Lucerne, Switzerland; (P.H.); (B.B.); (V.S.); (N.D.K.); (L.K.)
| | - Lars Kern
- Swiss Sarcoma Network, 6000 Lucerne, Switzerland; (P.H.); (B.B.); (V.S.); (N.D.K.); (L.K.)
| | - Mario F. Scaglioni
- Faculty of Medicine, University of Lucerne, 6000 Lucerne, Switzerland; (N.M.); (G.S.); (M.F.S.)
- Swiss Sarcoma Network, 6000 Lucerne, Switzerland; (P.H.); (B.B.); (V.S.); (N.D.K.); (L.K.)
| | - Bruno Fuchs
- Faculty of Medicine, University of Lucerne, 6000 Lucerne, Switzerland; (N.M.); (G.S.); (M.F.S.)
- Swiss Sarcoma Network, 6000 Lucerne, Switzerland; (P.H.); (B.B.); (V.S.); (N.D.K.); (L.K.)
- Correspondence: ; Tel.: +41-41-229-50-00
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Jo OI, Choong PFM. Centre-Based Care for Bone and Soft Tissue Sarcoma. Sarcoma 2021. [DOI: 10.1007/978-981-15-9414-4_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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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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Gantzer J, Di Marco A, Fabacher T, Weingertner N, Delhorme JB, Brinkert D, Bierry G, Ghnassia JP, Jégu J, Kurtz JE. Conformity to Clinical Practice Guidelines at Initial Management in Adult Soft Tissue and Visceral Tumors since the Implementation of the NetSarc Network in Eastern France. Oncologist 2019; 24:e775-e783. [PMID: 31073021 DOI: 10.1634/theoncologist.2018-0751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/03/2019] [Accepted: 03/18/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Soft tissue sarcomas are rare and heterogenous tumors that are hard to diagnose. The aim of this study was to evaluate local practices and conformity to clinical practice guidelines (CPGs) for their initial diagnostic management. MATERIALS AND METHODS Patients were carriers of a soft tissue or visceral tumor, presented at a sarcoma tumor board (STB) between 2010 and 2016. Conformity to CPGs was evaluated using ten criteria designed for this purpose. Associations between different factors and conformity to composite criteria, reflecting the three main diagnostic steps (imaging, biopsy and histological report) were analyzed. RESULTS A total of 643 patients were included. A preoperative tumor imaging assessment and a biopsy were performed according to CPGs in 80.8% and 36.8% of the cases, respectively. When done, the first surgical resection was R0 in 30.3% of cases, R1 in 28.6%, and R2 in 10.9%. The rest of the operated patients with sarcoma had a second surgical excision (11.4%), an intraoperative fragmentation (4.3%), or margins were unknown (14.4%). Six of the ten quality criteria presented a conformity rate higher than 70%. Two criteria with a conformity rate lower than 20% were the most controversial: presentation at a STB before biopsy and freezing of a tumor fragment. A multivariate analysis revealed that the common predictor of nonconformity to composite criteria was the initial management in a nonexpert center. CONCLUSION Initial diagnostic management requires improvement, especially outside of specialized centers. IMPLICATIONS FOR PRACTICE This article supports the essential need to refer patients with soft tissue tumors to specialized centers to improve the management of sarcomas beginning at the diagnostic phase. Indeed, the reported data were very similar to those already described at the national level of the NetSarc network and indicate the necessity to keep raising awareness about this simple issue: early referral to reference centers will save lives.
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Affiliation(s)
- Justine Gantzer
- Department of Medical Oncology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Antonio Di Marco
- Department of Orthopedic Surgery and Traumatology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Thibaut Fabacher
- Department of Public Health, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Noelle Weingertner
- Department of Pathology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jean-Baptiste Delhorme
- Department of Digestive Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - David Brinkert
- Department of Orthopedic Surgery and Traumatology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Guillaume Bierry
- Department of Radiology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Jérémie Jégu
- Department of Public Health, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jean-Emmanuel Kurtz
- Department of Medical Oncology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Sarcomas in the United States: Recent trends and a call for improved staging. Oncotarget 2019; 10:2462-2474. [PMID: 31069009 PMCID: PMC6497437 DOI: 10.18632/oncotarget.26809] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/19/2019] [Indexed: 02/06/2023] Open
Abstract
Background and objectives Sarcomas represent a heterogeneous group of tumors, and there is lack of data describing contemporary changes in patterns of care. We evaluated the epidemiology of sarcomas over 12 recent years. Methods The Surveillance, Epidemiology and End Results (SEER) database was queried for sarcoma cases from 2002-2014. Patient, tumor and treatment factors, and trends over time were studied overall and by subtype. Univariable and multivariable logistic regression models and 5-year survival and cause-specific mortality (CSM) were summarized. Results There were 78,527 cases of sarcomas with an overall incidence of 7.1 cases per 100,000 people, increasing from 6.8 in 2002 to 7.7 in 2014. Sarcoma NOS(14.8%) and soft tissue(43.4%) were the most common histology and primary site, respectively. A majority of tumors were high-grade(33.6%) and >5 cm(51.3%). CSM was 28.6% and 5-year survival was 71.4%. Many patients had unknown-grade(42.2%), which associated with 2.6 times increased odds of no surgical intervention. Conclusions This comprehensive national study highlights important trends including increasing incidence, changing histologic types, and underestimation of true incidence. A large proportion of sarcomas are inadequately staged (unknown-grade 42.2%) with lack of appropriate surgical treatment. Our study highlights need for standardization of care for sarcomas.
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Villano AM, Zeymo A, McDermott J, Barrak D, Unger KR, Shara NM, Chan KS, Al-Refaie WB. Regionalization of Retroperitoneal Sarcoma Surgery to High-Volume Hospitals: Missed Opportunities for Outcome Improvement. J Oncol Pract 2019; 15:e247-e261. [DOI: 10.1200/jop.18.00349] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE: Surgery continues to be the dominant therapy for the management of retroperitoneal soft-tissue sarcoma (RPS). Many groups advocate performing these resections at high-volume hospitals (HVHs), given their complexity. We therefore sought to explore whether RPS surgery has indeed begun to regionalize to HVHs in the same manner as pancreatic cancer (PC) surgery during the last decade. METHODS: We identified 70,763 patients who underwent surgical resection for RPS or PC using the National Cancer Database (2004 to 2015). Patients were stratified by hospital surgical volume. We performed an adjusted time trend analysis to compare trends in performance of surgery at HVHs for RPS versus PC. Multivariable logistic analyses were then performed, controlling for covariables, to elucidate relationships between patient-, hospital-, and treatment-related variables that may contribute to these observed trends. RESULTS: Only 9.6% of patients underwent RPS surgery at HVHs. During this time period, the odds ratio of undergoing RPS compared with pancreatectomy at HVHs was 0.65 ( P < .05). Time trend analysis estimated that whereas both procedures are regionalizing, the rate of RPS regionalization grew at 30.5% of the rate of PC (1.017 v 1.056; P < .001) and remained consistent after using several hospital volume thresholds and hospital volume as a continuous variable. CONCLUSION: Results from this retrospective multi-institutional analysis uncovered a lag in the regionalization of surgery for RPS compared with PC surgery. These findings reinforce the call to regionalize surgery for RPS to HVHs in a manner that is similar to that of other procedures in complex cancer surgery.
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Affiliation(s)
- Anthony M. Villano
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar-Georgetown University Hospital, Washington, DC
| | - Alexander Zeymo
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar Health Research Institute, Hyattsville, MD
| | - James McDermott
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Dany Barrak
- Medstar-Washington Hospital Center, Washington, DC
| | | | - Nawar M. Shara
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar Health Research Institute, Hyattsville, MD
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC
| | - Kitty S. Chan
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Waddah B. Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
- MedStar-Georgetown University Hospital, Washington, DC
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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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Woods RH, Potter JA, Reid JL, Louise J, Bessen T, Farshid G, Neuhaus SJ. Patterns of head and neck sarcoma in Australia. ANZ J Surg 2017; 88:901-906. [DOI: 10.1111/ans.14018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 02/15/2017] [Accepted: 03/04/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Roger H. Woods
- Department of Plastic Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
- Department of Plastic Surgery; Women's and Children's Hospital; North Adelaide South Australia Australia
| | - J. Alexa Potter
- Department of Plastic Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Jessica L. Reid
- Department of Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Jennie Louise
- The University of Adelaide; Adelaide South Australia Australia
| | - Taryn Bessen
- Department of Radiology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Gelareh Farshid
- The University of Adelaide; Adelaide South Australia Australia
- SA Pathology; Adelaide South Australia Australia
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14
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Dyrop HB, Safwat A, Vedsted P, Maretty-Kongstad K, Hansen BH, Jørgensen PH, Baad-Hansen T, Keller J. Characteristics of 64 sarcoma patients referred to a sarcoma center after unplanned excision. J Surg Oncol 2016; 113:235-9. [PMID: 26776152 DOI: 10.1002/jso.24137] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 12/05/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND METHODS Unplanned excision of sarcoma before referral to specialist centers can affect prognosis and surgical outcome. The diagnostic pathway of these patients is uncertain and needs to be reviewed. We aimed to describe patient and tumor characteristics, initial symptoms, initial and final diagnosis, and explore reasons for unplanned excision in this patient group. From a previous study on 258 sarcoma patients, we identified 64 patients referred after surgery. Medical records were reviewed. RESULTS The majority were soft tissue sarcomas, most often with thoracic location. Leiomyosarcoma was the most frequent final diagnosis, lipoma, and fibroma/dermatofibroma the most frequent initial diagnoses. Fifty percent were superficial small tumors, and 60.9% had not received diagnostic imaging before surgery. Fifty percent were referred from public surgical departments, and 1/3 from private specialists. Twenty-three patients had initial presence of alarm symptoms registered before surgery, the remaining 2/3 fell outside referral criteria or alarm symptoms were not discovered. CONCLUSIONS Patients referred after unplanned excision often have small superficial tumors and the majority fall outside of defined referral criteria. Referral criteria are not a guarantee for detection of all sarcomas and surgeons should always be aware of the possibility of malignancy when removing a tumor.
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Affiliation(s)
- Heidi Buvarp Dyrop
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus C, Denmark.,Department of Orthopedics, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | - Akmal Safwat
- Department of Oncology, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | - Peter Vedsted
- The Research Unit for General Practice, Aarhus University, Aarhus C, Denmark
| | - Katja Maretty-Kongstad
- Department of Pathology, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | - Bjarne Hauge Hansen
- Department of Orthopedics, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | | | - Thomas Baad-Hansen
- Department of Orthopedics, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
| | - Johnny Keller
- Department of Orthopedics, Sarcoma Center of Aarhus University Hospital, Aarhus C, Denmark
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Honoré C, Méeus P, Stoeckle E, Bonvalot S. Le sarcome des tissus mous en France en 2015 : épidémiologie, classification et structuration de la prise en charge. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.jchirv.2015.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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16
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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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Honoré C, Méeus P, Stoeckle E, Bonvalot S. Soft tissue sarcoma in France in 2015: Epidemiology, classification and organization of clinical care. J Visc Surg 2015; 152:223-30. [PMID: 26088366 DOI: 10.1016/j.jviscsurg.2015.05.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Four thousand new cases of soft tissue sarcomas are diagnosed each year in France, 23% of which are localized in the abdomen and pelvis; the treatment of non-metastatic tumor is based on wide surgical resection, the quality of which determines the long-term outcome. To ensure appropriate care, the European Society of Medical Oncology (ESMO) recommends that any patient with an unexplained soft tissue mass (of any size for deep lesions or of>5cm for superficial lesions) be referred to a specialized center with capacities for multidisciplinary team decision; appropriate imaging should be performed prior to treatment and a percutaneous image-guided needle biopsy should be routinely performed. In France, clinical and pathology networks (NetSarc and RRePS) currently offer patients a structured means to make a systematic diagnosis of soft tissue sarcoma and help to provide access to appropriate treatment in a specialized center.
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Affiliation(s)
- C Honoré
- Département de chirurgie générale, Gustave Roussy Cancer Center, 114, rue Édouard-Vaillant, 94805 Villejuif, France.
| | - P Méeus
- Département de chirurgie, centre Léon-Bérard, 69008 Lyon, France
| | - E Stoeckle
- Institut Bergonié, département de chirurgie, 33076 Bordeaux, France
| | - S Bonvalot
- Institut Curie, Service de chirurgie, 26, rue d'Ulm, 75005 Paris, France
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18
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Kneisl JS, Coleman MM, Raut CP. Outcomes in the management of adult soft tissue sarcomas. J Surg Oncol 2014; 110:527-38. [PMID: 24965077 DOI: 10.1002/jso.23685] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/02/2014] [Indexed: 12/14/2022]
Abstract
Adult soft tissue sarcomas (STSs) are heterogeneous neoplasms that account for 11,410 new diagnoses and 4,390 deaths per year. This article summarizes recent NCCN guidelines for diagnosis and management of STSs of the extremities and retroperitoneum, as well as gastrointestinal stromal tumors (GIST). AJCC staging and recently reported NCDB data regarding outcomes are reviewed. Currently accepted STS prognostic variables are presented, as are future directions regarding the utility of molecular prognosticators and nomograms.
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Affiliation(s)
- Jeffrey S Kneisl
- Department of Orthopaedic Surgery, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
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Ramos-Pascua L, Sánchez-Herráez S, Casas-Ramos P, Izquierdo-García F, Maderuelo-Fernández J. Health care circuit for patients with soft tissue sarcomas of the extremities. A tortuous and slow road to referral units. Rev Esp Cir Ortop Traumatol (Engl Ed) 2014. [DOI: 10.1016/j.recote.2014.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Ramos-Pascua LR, Sánchez-Herráez S, Casas-Ramos P, Izquierdo-García FJ, Maderuelo-Fernández JA. [Health care circuit for patients with soft tissue sarcomas of the extremities. A tortuous and slow road to referral units]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2014; 58:160-70. [PMID: 24629725 DOI: 10.1016/j.recot.2014.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/26/2014] [Accepted: 01/27/2014] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To analyse the waiting periods elapsed since soft tissue sarcomas become symptomatic until their specific treatment in our unit, and to determine new strategies for the improvement of referral circuits. MATERIAL AND METHODS This is an ambispective observational study of a cohort of 61 patients, with previously untreated soft tissue sarcomas, obtained from our Musculoskeletal Tumors Database. Several variables related to the patient, tumour, and health care circuit were analysed, as well as the different periods between the initial symptoms of the disease and the first consultation in our unit. The significance level was α=0.05. RESULTS The mean size of the sarcomas was 11.3 cm. Thirty-six patients (59%) followed the usual circuit of the National Health System in Spain. The time elapsed since the disease became symptomatic until the first medical consultation was greater than 9.5 months, and nearly another 8.5 months to the consultation in our specific unit. Statistically significant relationships were found between the independent and dependent variables. DISCUSSION The study shows that the care of patients with soft tissue sarcomas in our environment is far away from the times of care in our neighbouring countries. CONCLUSIONS It is essential to make the population and health professionals aware of this disease, as well as to remember that there is a referral circuit that must be used.
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Affiliation(s)
- L R Ramos-Pascua
- Servicio de Cirugía Ortopédica y Traumatología, Complejo Asistencial Universitario de León, Gerencia Regional de Salud de Castilla y León (SACYL), León, España.
| | - S Sánchez-Herráez
- Servicio de Cirugía Ortopédica y Traumatología, Complejo Asistencial Universitario de León, Gerencia Regional de Salud de Castilla y León (SACYL), León, España
| | - P Casas-Ramos
- Servicio de Cirugía Ortopédica y Traumatología, Complejo Asistencial Universitario de León, Gerencia Regional de Salud de Castilla y León (SACYL), León, España
| | - F J Izquierdo-García
- Servicio de Anatomía Patológica, Complejo Asistencial Universitario de León, Gerencia Regional de Salud de Castilla y León (SACYL), León, España
| | - J A Maderuelo-Fernández
- Gerencia de Atención Primaria de Salamanca, Gerencia Regional de Salud de Castilla León (SACYL), Instituto de Investigación Biomédica de Salamanca (IBSAL), Red de Investigación de Actividades Preventivas y Promoción de la Salud (RedIAPP), Salamanca, España
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Holzapfel BM, Lüdemann M, Holzapfel DE, Rechl H, Rudert M. [Open biopsy of bone and soft tissue tumors : guidelines for precise surgical procedures]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2013; 24:403-15; quiz 416-7. [PMID: 23053027 DOI: 10.1007/s00064-012-0190-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of an open biopsy is to obtain a sufficient amount of representative tumor tissue in terms of adequate quality and quantity, without adverse effects on later therapy. INDICATIONS Suspected malignancy after non-invasive diagnostic procedures. Histopathologic evaluation of tumor entity and grading. Planning of the definitive tumor resection and initiation of neoadjuvant therapeutic regimen. Obtaining unfixed, fresh-frozen tumor samples for molecular/genetic analyses or tumor tissue bank. CONTRAINDICATIONS Hemorrhagic diathesis. Tumor is only accessible with a surgical approach leading to a significant damage of the surrounding tissue. High probability of tumor cell contamination with incisional biopsy. Poor physical status. Poor therapeutic compliance. SURGICAL TECHNIQUE The biopsy tract should be carefully planned according to oncological principles. The operation begins with a small incision in longitudinal direction to the extremity. The shortest path between skin and lesion that avoids contamination of other compartments is selected. The biopsy tract should be located within the surgical approach which is later used for definitive tumor resection. During the definitive procedure it should be possible to resect the biopsy approach with adequate surgical margins because it is considered to be contaminated with tumor cells. In principle, a wide resection of the biopsy tract should be possible. During the operation meticulous hemostasis has to be performed because any hematoma around a tumor may contaminate the entire extremity. In cases of an intraosseous tumor a cortical window should be made to obtain intramedullary tumor tissue. Drains should be located in continuity with the skin incision or in direct extension of the wound. Wound closure with intracutaneous suture technique. Excisional biopsy in terms of marginal resection should be performed only in the presence of small, epifascial lesions that are assumed to be benign after completion of basic diagnostic procedures. In cases of larger or subfascial tumors an incisional biopsy should be conducted. POSTOPERATIVE MANAGEMENT Compressive dressing to prevent postoperative hematoma. In cases of tumors affecting load-bearing bones, weight-bearing should be prohibited after biopsy, if there is any fracture risk. Upon receipt of the histopathological results the definitive tumor resection is planned.
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Affiliation(s)
- B M Holzapfel
- Orthopädische Klinik König-Ludwig Haus, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97074, Würzburg, Deutschland.
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Cost effectiveness of first-line treatment with doxorubicin/ifosfamide compared to trabectedin monotherapy in the management of advanced soft tissue sarcoma in Italy, Spain, and sweden. Sarcoma 2013; 2013:725305. [PMID: 24302852 PMCID: PMC3835776 DOI: 10.1155/2013/725305] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/20/2013] [Indexed: 11/23/2022] Open
Abstract
Background. Doxorubicin/ifosfamide is a first-line systemic chemotherapy for the majority of advanced soft tissue sarcoma (ASTS) subtypes. Trabectedin is indicated for the treatment of ASTS after failure of anthracyclines and/or ifosfamide; however it is being increasingly used off-label as a first-line treatment. This study estimated the cost effectiveness of these two treatments in the first-line management of ASTS in Italy, Spain, and Sweden. Methods. A Markov model was constructed to estimate the cost effectiveness of doxorubicin/ifosfamide compared to trabectedin monotherapy, defined as the cost per QALY gained, in each country. Results. First-line treatment with doxorubicin/ifosfamide resulted in lower two-year healthcare costs and more QALYs than first-line treatment with trabectedin monotherapy in all three countries. Probabilistic sensitivity analysis showed that at a cost per QALY threshold of €35,000, >90% of a cohort would be cost effectively treated with doxorubicin/ifosfamide compared to trabectedin monotherapy in all three countries. Conclusion. Within the model's limitations, first-line treatment of patients with ASTS with doxorubicin/ifosfamide instead of trabectedin monotherapy affords a cost-effective use of publicly funded healthcare resources in Italy, Spain, and Sweden and is therefore the preferred treatment in all three countries. These findings support the recommendation that trabectedin should remain a second-line treatment.
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[Partial pelvic resection (internal hemipelvectomy) and endoprosthetic replacement in periacetabular tumors]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2012; 24:196-214. [PMID: 22743633 DOI: 10.1007/s00064-012-0161-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Treatment of tumors of the pelvic girdle by resection of part or all of the innominate bone with preservation of the extremity. Implantation and stable fixation using a custom-made megaprosthesis to restore painless joint function and loading capacity. The surgical goal is to obtain a wide surgical margin and local tumor control. INDICATIONS Primary bone and soft tissue sarcomas, benign or semi-malignant aggressive lesions, metastatic disease (radiation resistance and/or good prognosis). CONTRAINDICATIONS Limited life expectancy and poor physical status, extensive metastatic disease, persistent deep infection or recalcitrant osteomyelitis, poor therapeutic compliance, local recurrence following a previous limb-sparing resection, extensive infiltration of the neurovascular structures and the intra- and extrapelvic soft tissues. SURGICAL TECHNIQUE Levels of osteotomy are defined preoperatively by a CT-controlled manufactured three-dimensional 1:1 model of the pelvis. Using these data, the custom-made prosthesis and osteotomy templates are then constructed by the manufacturer. The anterior (internal, retroperitoneal) and posterior (extrapelvic, retrogluteal) aspects of the pelvis are exposed using the utilitarian incision surgical approach. The external iliac and femoral vessels are mobilized as they cross the superior pubic ramus. The adductor muscles, the rectus femoris and sartorius muscle are released from their insertions on the pelvis and the obturator vessels and nerve are transected. If the tumor extends to the hip joint, the femur is transected at a level distal to the intertrochanteric line to ensure hip joint integrity and to prevent tumor contamination. A large myocutaneous flap with the gluteus maximus muscle is retracted posteriorly. The pelvitrochanteric and small gluteal muscles are divided near their insertion in the upper border of the femur. To release the hamstrings and the attachment of the sacrotuberous ligament, the ischial tuberosity is exposed. After osteotomy using the prefabricated templates, the pelvis is released and the specimen is removed en bloc. The custom made prosthesis can either be fixed to the remaining iliac bone or to the massa lateralis of the sacrum. The released muscles are refixated on the remaining bone or the implant. POSTOPERATIVE MANAGEMENT Time of mobilization and degree of weight-bearing depends on the extent of muscle resection. Usually partial loading of the operated limb with 10 kg for a period of 6-12 weeks, then increased loading with 10 kg per week. Thrombosis prophylaxis until full weight bearing. Physiotherapy and gait training. At follow-up, patients are monitored for local recurrence and metastases using history, physical examination, and radiographic studies. RESULTS Between 1994 and 2008, 38 consecutive patients with periacetabular tumors were treated by resection and reconstruction with a custom-made pelvic megaprosthesis. The overall survival of the patients was 58% at 5 years and 30% at 10 years. One or more operative revisions were performed in 52.6% of the patients. The rate of local recurrence was 15.8%. Deep infection (21%) was the most common reason for revision. In two of these cases (5.3%), a secondary external hemipelvectomy had to be performed. There were four cases of aseptic loosening (10.5%) in which the prosthesis had to be revised. Six patients had recurrent hip dislocation (15.8%). In four of them a modification of the inserted inlay and an implantation of a trevira tube had to be performed respectively. Peroneal palsy occurred in 6 patients (15.8%) with recovery in only two. There were 4 operative interventions because of postoperative bleeding (10.5%). The mean MSTS score for 12 of the 18 living patients was 43.7%. In particular, gait was classified as poor and almost all patients were reliant on walking aids. However, most patients showed good emotional acceptance.
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Holzapfel B, Pilge H, Toepfer A, Jakubietz R, Gollwitzer H, Rechl H, von Eisenhart-Rothe R, Rudert M. Proximaler Tibiaersatz und alloplastische Rekonstruktion des Streckapparats nach Resektion kniegelenksnaher Tumoren. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2012; 24:247-62. [DOI: 10.1007/s00064-012-0187-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Puri A, Gulia A. Multimodality management of extremity soft tissue sarcomas-an Indian perspective. Indian J Surg Oncol 2011; 2:291-7. [PMID: 23204784 PMCID: PMC3338133 DOI: 10.1007/s13193-012-0125-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 01/18/2012] [Indexed: 10/14/2022] Open
Abstract
Soft-tissue sarcomas are a rare and heterogeneous group of tumors. The last few decades have seen rapid strides in the management of these complex lesions. The presence of a soft-tissue sarcoma in the extremity is no longer an indication for amputation. Function preserving alternatives for local control in these lesions are the norm without compromising on overall disease survival. Good functional and oncological results can be achieved with a combination of excision of the tumor and where required, suitable adjuvant therapies. These lesions are best managed at specialty centres where the requisite multidisciplinary care can be offered to the patient to optimise results. This article outlines the current understanding and emphasises the multimodality management of these challenging tumors. We also present Indian data of the incidence and oncologic outcomes of these lesions and suggest a treatment algorithm.
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Affiliation(s)
- Ajay Puri
- Orthopaedic Oncologist, Tata Memorial Hospital, Room No: 26, E. Borges Road, Parel, Mumbai, 400 012 India
| | - Ashish Gulia
- Orthopaedic Oncologist, Tata Memorial Hospital, Room No: 26, E. Borges Road, Parel, Mumbai, 400 012 India
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Rechl H, Röper B, Wörtler K. Inadequate Initial Resection. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:553-4. [PMID: 21912575 DOI: 10.3238/arztebl.2011.0553b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Soft-tissue sarcomas are a rare and heterogeneous group of tumors. The last few decades have seen rapid strides in surgery with function preserving alternatives for local control in these lesions becoming the norm without compromising on overall disease survival. Good functional and oncological results can be achieved with a combination of excision of the tumor, and where required, suitable adjuvant therapies. These lesions are best managed at specialty centres where the requisite multidisciplinary care can be offered to the patient to optimise results. This overview is intended as a review of current understanding and the multimodality management of these challenging tumors.
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Affiliation(s)
- Ajay Puri
- Department of Orthopaedic Oncology, Tata Memorial Hospital, Mumbai, India,Address for correspondence: Prof. Ajay Puri, Room No: 26, Tata Memorial Hospital, E. Borges Road, Parel, Mumbai-400 012, India. E-mail:
| | - Ashish Gulia
- Department of Orthopaedic Oncology, Tata Memorial Hospital, Mumbai, India
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