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Salminen S, Jäämaa S, Nevala R, Sormaala MJ, Koivikko M, Tukiainen E, Repo J, Blomqvist C, Sampo M. Ultra-low-dose computed tomography and chest X-ray in follow-up of high-grade soft tissue sarcoma-a prospective comparative study. Sci Rep 2024; 14:7181. [PMID: 38531939 DOI: 10.1038/s41598-024-57770-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 03/21/2024] [Indexed: 03/28/2024] Open
Abstract
Ultra-low-dose computed tomography (ULD-CT) may combine the high sensitivity of conventional computed tomography (CT) in detecting sarcoma pulmonary metastasis, with a radiation dose in the same magnitude as chest X-ray (CXR). Fifty patients with non-metastatic high-grade soft tissue sarcoma treated with curative intention were recruited. Their follow-up involved both CXR and ULD-CT to evaluate their different sensitivity. Suspected findings were confirmed by conventional CT if necessary. Patients with isolated pulmonary metastases were treated with surgery or stereotactic body radiation therapy (SBRT) with curative intent if possible. The median effective dose from a single ULD-CT study was 0.27 mSv (range 0.12 to 0.89 mSv). Nine patients were diagnosed with asymptomatic lung metastases during the follow-up. Only three of them were visible in CXR and all nine in ULD-CT. CXR had therefore only a 33% sensitivity compared to ULD-CT. Four patients were operated, and one had SBRT to all pulmonary lesions. Eight of them, however, died of the disease. Two patients developed symptomatic metastatic recurrence involving extrapulmonary sites+/-the lungs between two imaging rounds. ULD-CT has higher sensitivity for the detection of sarcoma pulmonary metastasis than CXR, with a radiation dose considerably lower than conventional CT.Clinical trial registration: NCT05813808. 04-14-2023.
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Affiliation(s)
- Samuli Salminen
- Comprehensive Cancer Center, Helsinki University Hospital (HUH), Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Sari Jäämaa
- Comprehensive Cancer Center, Helsinki University Hospital (HUH), Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Riikka Nevala
- Comprehensive Cancer Center, Helsinki University Hospital (HUH), Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Markus J Sormaala
- Department of Radiology, Helsinki University Hospital, Meilahti Campus Topeliuksenkatu 32, N0029, Helsinki, Finland
| | - Mika Koivikko
- Department of Radiology, Helsinki University Hospital, Meilahti Campus Topeliuksenkatu 32, N0029, Helsinki, Finland
| | - Erkki Tukiainen
- Department of Plastic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jussi Repo
- Department of Orthopedics and Traumatology, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Carl Blomqvist
- Comprehensive Cancer Center, Helsinki University Hospital (HUH), Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Mika Sampo
- HUSLAB Pathology and University of Helsinki, Helsinki, Finland.
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2
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Srinivasan S, Keerthivasagam S, Kumar S, Puri A. Impact of Surveillance Imaging in Detecting Local and Metastatic Lung Recurrences Among Patients with Sarcomas of the Extremities: A Systematic Review and Meta-analysis. Ann Surg Oncol 2024; 31:213-227. [PMID: 37865942 DOI: 10.1245/s10434-023-14429-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The surveillance guidelines following treatment completion for patients with high-grade sarcomas of the extremities are based largely upon expert opinions and consensus. In the current meta-analysis, we aim to study the utility of surveillance imaging to diagnose local and metastatic pulmonary relapses among patients with extremity soft tissue sarcomas and primary bone sarcomas. PATIENTS AND METHODS A meta-analysis was performed to assess the sensitivity, specificity and diagnostic odds ratio (DOR) of surveillance imaging to diagnose local and metastatic pulmonary relapse among patients with sarcoma of the extremities. In addition, impact of surveillance imaging on overall survival was assessed. Heterogeneity among eligible studies was evaluated by I2 statistics. Sensitivity analysis was assessed using influence plots and Baujat plots. RESULTS Ten studies including 2160 patients with sarcoma were found eligible. For diagnoses of local recurrence based on surveillance imaging (nine studies, 1917 patients), the estimated sensitivity, specificity, and DOR were 13.6%, 99.5%, and 78.15, respectively. Only 16.7% of local recurrences were diagnosed based on imaging. For diagnoses of metastatic pulmonary recurrence (eight studies; 1868 patients), estimated sensitivity, specificity, and DOR were 76.1%, 99.3%, and 1059.9, respectively. A sensitivity analysis showed significant heterogeneity among included studies. None of the included studies showed an overall-survival benefit with the use of surveillance imaging. CONCLUSION The current meta-analysis challenges the notion of routine use of imaging to detect local relapse, while favoring chest imaging, using either chest radiography or computed tomography scan, for surveillance. Further studies are required to study the ideal surveillance strategy including timing and imaging modality.
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Affiliation(s)
- Shyam Srinivasan
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, ACTREC/Tata Memorial Hospital, Mumbai, India.
| | - Swaminathan Keerthivasagam
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, ACTREC/Tata Memorial Hospital, Mumbai, India
| | - Shathish Kumar
- Department of Anaesthesiology, Manipal Hospital Whitefield, Bangalore, India
| | - Ajay Puri
- Department of Orthopedic Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Tata Memorial Hospital, Mumbai, India
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3
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Examining patient perspectives on sarcoma surveillance: The Sarcoma Surveillance Survey. Surg Oncol 2022; 45:101861. [DOI: 10.1016/j.suronc.2022.101861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/24/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
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Stanborough R, Demertzis JL, Wessell DE, Lenchik L, Ahlawat S, Baker JC, Banks J, Caracciolo JT, Garner HW, Hentz C, Lewis VO, Lu Y, Maynard JR, Pierce JL, Scott JA, Sharma A, Beaman FD. ACR Appropriateness Criteria® Malignant or Aggressive Primary Musculoskeletal Tumor-Staging and Surveillance: 2022 Update. J Am Coll Radiol 2022; 19:S374-S389. [PMID: 36436964 DOI: 10.1016/j.jacr.2022.09.015] [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: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Malignant or aggressive primary musculoskeletal tumors are rare and encompass a wide variety of bone and soft tissue tumors. Given the most common site for metastasis from these primary musculoskeletal tumors is to the lung, chest imaging is integral in both staging and surveillance. Extrapulmonary metastases are rarely encountered with only a few exceptions. Following primary tumor resection, surveillance of the primary tumor site is generally recommended. Local surveillance imaging recommendations differ between primary tumors of bone origin versus soft tissue origin. This document consolidates the current evidence and expert opinion for the imaging staging and surveillance of these tumors into five clinical scenarios. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Jennifer L Demertzis
- Diagnostic Imaging Associates, Chesterfield, Missouri; Partner, ProSight Radiology.
| | | | - Leon Lenchik
- Panel Vice-Chair, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Shivani Ahlawat
- The Johns Hopkins University School of Medicine, Baltimore, Maryland; member
| | - Jonathan C Baker
- MSK Imaging and Interventions Fellowship Director, Mallinckrodt Institute of Radiology Washington University School of Medicine, Saint Louis, Missouri
| | - James Banks
- Nova Southeastern University, Fort Lauderdale, Florida; FRS 2023 Program Chair; ACR alternate counselor from Florida; MSK Section Chair for group; Medical student radiology rotation clerkship director for HCA Florida Aventura and Kendall Hospitals
| | - Jamie T Caracciolo
- Section Head, MSK Imaging, Moffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; MSK-RADS (Bone) Committee; Chairman
| | - Hillary W Garner
- Mayo Clinic Florida, Jacksonville, Florida; Committee Chair, Society of Skeletal Radiology and International Skeletal Society
| | - Courtney Hentz
- Stritch School of Medicine Loyola University Chicago, Maywood, Illinois; Commission on Radiation Oncology
| | - Valerae O Lewis
- University of Texas Health Science Center, Houston, Texas; American Academy of Orthopaedic Surgeons; Chair, Department of Orthopaedic Surgery
| | - Yi Lu
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts; American Association of Neurological Surgeons/Congress of Neurological Surgeons; Director, Neurosurgical Trauma; Codirector, Spinal Deformity and Scoliosis Surgery Brigham and Women's Hospital; Cochair, Spinal Cord Injury Section, North American Spine Society; Chair, Payor Response
| | - Jennifer R Maynard
- Mayo Clinic Florida, Jacksonville, Florida; Primary care physician; Jacksonville Sports Medicine Program, Chair of the Governing Board; Program Director Sports Medicine Fellowship, Mayo Clinic Florida
| | - Jennifer L Pierce
- University of Virginia, Charlottesville, Virginia; Associate Division Chair, Musculoskeletal Radiology, University of Virginia; Radiology Residency Global Health Leadership Track Program Director, University of Virginia
| | - Jinel A Scott
- Chief Quality Officer, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Akash Sharma
- Mayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging; Chair, Research Committee, Radiology, Mayo Clinic Florida; Chair, PET-MRI Workgroup, Mayo Clinic Florida
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5
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Dammerer D, VAN Beeck A, Schneeweiss V, Schwabegger A. Follow-up Strategies for Primary Extremity Soft-tissue Sarcoma in Adults: A Systematic Review of the Published Literature. In Vivo 2021; 34:3057-3068. [PMID: 33144410 DOI: 10.21873/invivo.12140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 01/22/2023]
Abstract
AIM Follow-up strategies for primary extremity soft-tissue sarcomas (eSTS) in adults were evaluated in a systematic review of the published literature. MATERIAL AND METHODS The published literature was reviewed using PubMed. Of 136,646 studies published between 1985 and 2019, 78 original articles met the inclusion criteria. Articles were selected on the basis of the PRISMA guidelines. The selected articles were then cross-searched to identify further publications. August 1, 2019 was used as the concluding date of publication. RESULTS A variety of follow-up schedules have been reported in recently published literature. Two official guidelines have been approved by international societies. The guidelines distinguish between high- and low-grade STS, but mention a wide range of follow-up intervals. Established tools of follow-up include computed tomograph, X-rays of the chest, and magnetic resonance imaging of the primary tumor site in addition to clinical observation and physical examination. CONCLUSION Further research will be needed to establish evidence-based guidelines and schedules for follow-up strategies in patients with eSTS.
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Affiliation(s)
- Dietmar Dammerer
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Viktoria Schneeweiss
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anton Schwabegger
- Department of Plastic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Sedaghat S, Sedaghat M, Meschede J, Jansen O, Both M. Diagnostic value of MRI for detecting recurrent soft-tissue sarcoma in a long-term analysis at a multidisciplinary sarcoma center. BMC Cancer 2021; 21:398. [PMID: 33849475 PMCID: PMC8042876 DOI: 10.1186/s12885-021-08113-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/29/2021] [Indexed: 12/19/2022] Open
Abstract
Background Soft-tissue sarcomas (STS) are rare tumors of the soft tissue. Recent diagnostic studies on STS mainly dealt with only few cases of STS and did not investigate the post-therapeutic performance of MRI in a routine clinical setting. Therefore, we assessed the long-term diagnostic accuracy of MRI for detecting recurrent STS at a multidisciplinary sarcoma center. Methods In all, 1055 postoperative follow-up MRIs of 204 patients were included in the study. MRI follow-up scans were systematically reviewed for diagnostic values (true-positive/−negative and false-positive/−negative results) in detecting recurrences. Pathological reports and follow-up MRIs were set as baseline references. Results The median age of the patients was 55.3 ± 18.2 years. Of the patients, 34.8% presented with recurrences. Here, 65 follow-up scans were true positive, 23 false positive, 6 false negative, and 961 true negative. The overall sensitivity and specificity of MRI for detecting recurrences were 92 and 98%, respectively, with an accuracy of 97%. For intramuscular lesions and after surgery alone the sensitivity was higher (95 and 97%, respectively) than for subcutaneous lesions and surgery with additional radiation therapy (83 and 86%, respectively), at similarly high specificities (96–98%). The 6 false-negative results were found in streaky (n = 2) and small ovoid/nodular (n = 4) recurring lesions. The false-positive lesions imitated streaky (n = 14), ovoid/nodular (n = 8), and polycyclic/multilobulated recurring tumors (n = 1). All false-positive results were found in patients in whom the primary tumors were polycyclic/multilobulated in appearance. Conclusion MRI shows a high diagnostic accuracy for detecting recurrent STS, with a high sensitivity and specificity. The diagnostic accuracy decreases in subcutaneous lesions and after surgery with radiation therapy, compared to intramuscular lesions and surgery alone. Radiologists should pay particular attention to streaky and small ovoid/nodular recurring lesions and patients with polycyclic/multilobulated primary tumors.
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Affiliation(s)
- Sam Sedaghat
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - Maya Sedaghat
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.,Institute of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789, Bochum, Germany
| | - Jens Meschede
- Institute of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Bergmannsheil, Bürkle de la Camp-Platz 1, 44789, Bochum, Germany.,Department for Radiology and Neuroradiology, Klinikum Dortmund, Beurhausstraße 40, 44137, Dortmund, Germany
| | - Olav Jansen
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Marcus Both
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
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7
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Tetta C, Carpenzano M, Algargoush ATJ, Algargoosh M, Londero F, Maessen JG, Gelsomino S. Non-surgical Treatments for Lung Metastases in Patients with Soft Tissue Sarcoma: Stereotactic Body Radiation Therapy (SBRT) and Radiofrequency Ablation (RFA). Curr Med Imaging 2021; 17:261-275. [PMID: 32819261 DOI: 10.2174/1573405616999200819165709] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/04/2020] [Accepted: 06/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Radio-frequency ablation (RFA) and Stereotactic Body Radiation Therapy (SBRT) are two emerging therapies for lung metastases. INTRODUCTION Aliterature review was performed to evaluate the outcomes and complications of these procedures in patients with lung metastases from soft tissue sarcoma (STS). METHODS After selection, seven studies were included for each treatment encompassing a total of 424 patients: 218 in the SBRT group and 206 in the RFA group. RESULTS The mean age ranged from 47.9 to 64 years in the SBRT group and from 48 to 62.7 years in the RFA group. The most common histologic subtype was, in both groups, leiomyosarcoma. In the SBRT group, median overall survival ranged from 25.2 to 69 months and median disease- free interval was from 8.4 to 45 months. Two out of seven studies reported G3 and one G3 toxicity, respectively. In RFA patients, overall survival ranged from 15 to 50 months. The most frequent complication was pneumothorax. Local control showed a high percentage for both procedures. CONCLUSION SBRT is recommended in patients unsuitable to surgery, in synchronous bilateral pulmonary metastases, in case of deep lesions and patients receiving high-risk systemic therapies. RFA is indicated in case of a long disease-free interval, in oligometastatic disease, when only the lung is involved, in small size lesions far from large vessels. Further large randomized studies are necessary to establish whether these treatments may also represent a reliable alternative to surgery.
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Affiliation(s)
- Cecilia Tetta
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Maria Carpenzano
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, Netherlands
| | - Areej T J Algargoush
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, Netherlands
| | - Marwah Algargoosh
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, Netherlands
| | - Francesco Londero
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, Netherlands
| | - Jos G Maessen
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, Netherlands
| | - Sandro Gelsomino
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, Netherlands
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Wilson DAJ, Gazendam A, Visgauss J, Perrin D, Griffin AM, Chung PW, Catton CN, Shultz D, Ferguson PC, Wunder JS. Designing a Rational Follow-Up Schedule for Patients with Extremity Soft Tissue Sarcoma. Ann Surg Oncol 2020; 27:2033-2041. [PMID: 32152780 DOI: 10.1245/s10434-020-08240-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE The risk of tumor recurrence after resection of soft tissue sarcoma (STS) necessitates surveillance in follow-up. The objective of this study was to determine the frequency/timing of metastasis and local recurrence following treatment for soft tissue sarcoma, and to use these data to justify an evidence-based follow-up schedule. METHODS Utilizing a prospective database, a retrospective single center review was performed of all patients with minimum 2-year follow-up after resection of a localized extremity STS. Kaplan-Meier estimates were used to calculate the incidence of local recurrence and metastases on an annual basis for 10 years. RESULTS We identified a total of 230 low-grade, 626 intermediate-grade and 940 high-grade extremity STS and a total of 721 events, 150 local recurrences and 571 metastases. Based on tumor size and grade, follow-up cohorts were developed that had similar metastatic risk. Using pre-determined thresholds for metastatic event, a follow-up schedule was established for each cohort. CONCLUSION Based on our results we recommend that patients with small low-grade tumors undergo annual follow-up for 5 years following definitive local treatment. Patients with large low-grade tumors, small intermediate-grade and small high-grade tumors should have follow-up every 6 months for the first 2 years, then yearly to 10 years. Only patients with large intermediate- or high-grade tumors require follow-up every 3 months for the first 2 years, then every 6 months for years 3-5, followed by annually until 10 years.
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Affiliation(s)
- David A J Wilson
- Division of Orthopaedic Surgery, Department of Surgery, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada.
| | - Aaron Gazendam
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Julia Visgauss
- Department of Orthopedic Surgery, Duke University Medical Center, Duke University, Durham, NC, USA
| | - David Perrin
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Anthony M Griffin
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Peter W Chung
- Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Charles N Catton
- Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - David Shultz
- Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Bae S, Karnon J, Crane G, Bessen T, Desai J, Crowe P, Neuhaus S. Cost-effectiveness analysis of imaging surveillance in stage II and III extremity soft tissue sarcoma: an Australian perspective. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:5. [PMID: 32042270 PMCID: PMC6998821 DOI: 10.1186/s12962-020-0202-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/23/2020] [Indexed: 12/30/2022] Open
Abstract
Background Surveillance imaging is used to detect local and/or distant recurrence following primary treatment of localised soft tissue sarcoma (STS), however evidence supporting optimal surveillance modality or frequency is lacking. We used prospectively collected sarcoma data to describe current surveillance imaging practice in patients with AJCC stage II and III extremity STS and evaluate its cost-effectiveness. Methods From three selected Australian sarcoma referral centres, we identified patients with stage II and III extremity STS treated between 2009 and 2013. Medical records were reviewed to ascertain surveillance imaging practices, including modality, frequency and patient outcomes. A discrete event simulation model was developed and calibrated using clinical data to estimate health service costs and quality adjusted life years (QALYs) associated with alternative surveillance strategies. Results Of 133 patients treated for stage II and III extremity STS, the majority were followed up with CT chest (86%), most commonly at 3-monthly intervals and 62% of patients had the primary site imaged with MRI at 6-monthly. There was limited use of chest-X-ray. A discrete event simulation model demonstrated that CT chest screening was the most cost effective surveillance strategy, gaining additional QALYs at a mean incremental cost of $30,743. MRI alone and PET-CT alone were not cost-effective, whilst a combined strategy of CT + MRI had an incremental cost per QALY gained of $96,556. Conclusions Wide variations were observed in surveillance imaging practices in this high-risk STS cohort. Modelling demonstrated the value of CT chest for distant recurrence surveillance over other forms of imaging in terms of cost and QALYs. Further work is required to evaluate cost-effectiveness in a prospective manner.
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Affiliation(s)
- Susie Bae
- 1Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000 Australia.,2Sir Peter MacCallum, Department of Oncology, The University of Melbourne, Parkville, VIC 3010 Australia
| | - Jonathan Karnon
- 3College of Medicine and Public Health, Flinders University, 1 Flinders Dr, Bedford Park, SA 5042 Australia
| | - Glenis Crane
- 4The University of Adelaide, Adelaide, SA 5005 Australia
| | - Taryn Bessen
- 5Department of Radiology, Royal Adelaide Hospital, Adelaide, SA 5000 Australia
| | - Jayesh Desai
- 1Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000 Australia.,2Sir Peter MacCallum, Department of Oncology, The University of Melbourne, Parkville, VIC 3010 Australia
| | - Phillip Crowe
- 6Prince of Wales Hospital, Sydney, 320-346 Barker St, Randwick, NSW 2031 Australia
| | - Susan Neuhaus
- 4The University of Adelaide, Adelaide, SA 5005 Australia
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Tetta C, Londero F, Micali LR, Parise G, Algargoush AT, Algargoosh M, Albisinni U, Maessen JG, Gelsomino S. Stereotactic Body Radiotherapy Versus Metastasectomy in Patients With Pulmonary Metastases From Soft Tissue Sarcoma. Clin Oncol (R Coll Radiol) 2020; 32:303-315. [PMID: 32024603 DOI: 10.1016/j.clon.2020.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/23/2019] [Accepted: 11/14/2020] [Indexed: 10/25/2022]
Abstract
The lung is the preferred site of metastasis from soft tissue sarcoma (STS). This systematic review aims to evaluate the outcomes of stereotactic body radiotherapy (SBRT) and metastasectomy (MTS) for the treatment of lung metastases from STS. A systematic review was carried out according to the PRISMA protocol. PubMed, Medline, EMBASE, Cochrane Library, Ovid and Web of Knowledge databases were searched for English-language articles to December 2018 using a predefined strategy. Retrieved studies were independently screened and rated for relevance. Data were extracted by two researchers. In total, there were 1306 patients with STS: 1104 underwent MTS and 202 had SBRT. The mean age ranged from 40 to 55.8 years in the MTS group and from 47.9 to 64 years in the SBRT group. The cumulative death rate was 72% (95% confidence interval 59-85%) in the MTS group and 56% (38-74%) in the SBRT group. The cumulative mean overall survival time was 46.7 months (36.4-57.0%) in the MTS group and 47.6 months (33.7-61.5%) in the SBRT group. The cumulative rate of patients alive with disease was 5% (2-9%) in the MTS group and 15% (6-36%) in the SBRT group. Finally, the cumulative rate of patients alive without disease in the two groups was 19% (9-29%) and 20% (10-50%), respectively. Our study showed that local treatment of pulmonary metastases from STS with SBRT, compared with surgery, was associated with a lower cumulative overall death rate and similar overall survival time and survival rates without disease. By contrast, SBRT was associated with a higher survival rate with disease than MTS. Large randomised trials are necessary to confirm these findings and to establish whether SBRT may be a reliable option for early stage disease.
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Affiliation(s)
- C Tetta
- Rizzoli Orthopedic Institute, Bologna, Italy.
| | - F Londero
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - L R Micali
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - G Parise
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A T Algargoush
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - M Algargoosh
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - U Albisinni
- Rizzoli Orthopedic Institute, Bologna, Italy
| | - J G Maessen
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - S Gelsomino
- Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
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11
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Park JW, Yoo HJ, Kim HS, Choi JY, Cho HS, Hong SH, Han I. MRI surveillance for local recurrence in extremity soft tissue sarcoma. Eur J Surg Oncol 2018; 45:268-274. [PMID: 30352764 DOI: 10.1016/j.ejso.2018.08.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/07/2018] [Accepted: 08/31/2018] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The role of MRI in surveillance for local recurrence (LR) remains uncertain in extremity soft tissue sarcoma (STS). The aims of this study were 1) to examine the usefulness of MRI in detecting LR, 2) to identify the characteristics of LR detected by MRI, and 3) to examine whether MRI surveillance is associated with oncologic outcome. MATERIALS AND METHODS 477 patients who had regular surveillance for LR after surgery for extremity STS were reviewed. Surveillance was performed by routine MRI in 325 patients or other imaging modalities in 152 patients. RESULTS The rate of MRI-detected LR, defined as clinically undetectable LR identified on MRI, was 10.5% in the MRI surveillance cohort. The detection rates of MRI-detected LR were significantly higher in the patients with high risk of LR. MRI-detected LRs were more commonly located in the thigh or buttock (p = 0.005), were smaller (p = 0.001) and had LRs without mass formation (p = 0.007) than non-MRI-detected LRs. On Kaplan-Meier analysis, patients with MRI-detected LR tended to have better post-LR survival (p = 0.104). CONCLUSION Routine MRI surveillance can detect a significant number of clinically undetectable LRs in extremity STS especially for LRs in the thigh or buttock, small LRs or LRs without mass formation.
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Affiliation(s)
- Jong Woong Park
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea; Orthopaedic Oncology Clinic, National Cancer Center, Goyang, South Korea
| | - Hye Jin Yoo
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Han-Soo Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea; Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Ja-Young Choi
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Hwan Seong Cho
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sung Hwan Hong
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Ilkyu Han
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea; Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea.
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12
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Puri A, Ranganathan P, Gulia A, Crasto S, Hawaldar R, Badwe RA. Does a less intensive surveillance protocol affect the survival of patients after treatment of a sarcoma of the limb? Bone Joint J 2018; 100-B:262-268. [DOI: 10.1302/0301-620x.100b2.bjj-2017-0789.r1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aims A single-centre prospective randomized trial was conducted to investigate whether a less intensive follow-up protocol would not be inferior to a conventional follow-up protocol, in terms of overall survival, in patients who have undergone surgery for sarcoma of the limb. Initial short-term results were published in 2014. Patients and Methods The primary objective was to show non-inferiority of a chest radiograph (CXR) group compared with a CT scan group, and of a less frequent (six-monthly) group than a more frequent (three-monthly) group, in two-by-two comparison. The primary outcome was overall survival and the secondary outcome was a recurrence-free survival. Five-year survival was compared between the CXR and CT scan groups and between the three-monthly and six-monthly groups. Of 500 patients who were enrolled, 476 were available for follow-up. Survival analyses were performed on a per-protocol basis (n = 412). Results The updated results recorded 12 (2.4%) local recurrences, 182 (36.8%) metastases, and 56 (11.3%) combined (local + metastases) recurrence at a median follow-up of 81 months (60 to 118). Of 68 local recurrences, 60 (88%) were identified by the patients themselves. The six-monthly regime (overall survival (OS) 54%, recurrence-free survival (RFS) 46%) did not lead to a worse survival and was not inferior to the three-monthly regime (OS 55%, RFS 47%) in terms of detecting recurrence. Although CT scans (OS 53%, RFS 54%) detected pulmonary metastasis earlier, it did not lead to a better survival compared with CXR (OS 56%, RFS 59%). Conclusion The overall survival of patients who are treated for a sarcoma of the limb is not inferior to those followed up with a less intensive regimen than a more intensive protocol, in terms of frequency of visits and mode of imaging. CXR at six-monthly intervals and patient education about examination of the site of the surgery will detect most recurrences without deleterious effects on the eventual outcome. Cite this article: Bone Joint J 2018;100-B:262–8.
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Affiliation(s)
- A. Puri
- Tata Memorial Centre, HBNI, Dr
E. Borges Road, Parel, Mumbai
400 012, India
| | - P. Ranganathan
- Tata Memorial Centre, HBNI, Dr
E. Borges Road, Parel, Mumbai
400 012, India
| | - A. Gulia
- Tata Memorial Centre, HBNI, Dr
E. Borges Road, Parel, Mumbai
400 012, India
| | - S. Crasto
- Tata Memorial Centre, HBNI, Dr
E. Borges Road, Parel, Mumbai
400 012, India
| | - R. Hawaldar
- Tata Memorial Centre, HBNI, Dr
E. Borges Road, Parel, Mumbai
400 012, India
| | - R. A. Badwe
- Tata Memorial Centre, HBNI, Dr
E. Borges Road, Parel, Mumbai
400 012, India
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13
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Royce TJ, Punglia RS, Chen AB, Patel SA, Thornton KA, Raut CP, Baldini EH. Cost-Effectiveness of Surveillance for Distant Recurrence in Extremity Soft Tissue Sarcoma. Ann Surg Oncol 2017; 24:3264-3270. [PMID: 28718037 DOI: 10.1245/s10434-017-5996-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Optimal distant recurrence (DR) surveillance strategies for extremity soft tissue sarcoma (STS) are unknown. We performed a cost-effectiveness analysis of different imaging modalities performed at guideline-specified intervals. METHODS We developed a Markov model simulating lifetime outcomes for 54-year-old patients after definitive treatment for American Joint Committee on Cancer stage II-III extremity STS using four surveillance strategies: watchful waiting (WW), chest X-ray (CXR), chest computed tomography (CCT), and positron emission tomography-computed tomography (PET/CT). Probabilities, utilities, and costs were extracted from the literature and Medicare claims to determine incremental cost-effectiveness ratios (ICER). RESULTS CCT was the most effective and most costly strategy with CXR the most cost-effective strategy at a societal willing-to-pay (WTP) of $100,000/quality-adjusted life year (QALY). The ICER was $12,113/QALY for CXR versus $104,366/QALY for CCT while PET/CT was never cost-effective. Sensitivity analyses demonstrated CCT becomes the preferred imaging modality as the lifetime risk of DR increases beyond 33% or as the WTP increases beyond $120,000/QALY. CONCLUSIONS Optimal DR surveillance imaging for stage II-III extremity STS should be individualized based on patients' risks for DR. These results suggest CXR, or CCT performed at more protracted intervals, may be preferred for lower-risk patients (i.e., DR risk <33%), whereas CCT may be preferred for higher-risk patients (i.e., DR risk >33%). Further study of optimal strategies is needed. In the interim, these findings may help to refine guidelines to reduce resource overutilization during routine surveillance of lower-risk sarcoma patients.
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Affiliation(s)
- Trevor J Royce
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA. .,Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.
| | - Rinaa S Punglia
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Aileen B Chen
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Sagar A Patel
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA.,Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Katherine A Thornton
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Chandrajit P Raut
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Division of Surgical Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
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14
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Hovgaard TB, Nymark T, Skov O, Petersen MM. Follow-up after initial surgical treatment of soft tissue sarcomas in the extremities and trunk wall. Acta Oncol 2017; 56:1004-1012. [PMID: 28287011 DOI: 10.1080/0284186x.2017.1299937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND/OBJECTIVES Evaluation of our surveillance program for soft tissue sarcomas (STS) and borderline tumors (BT) for identification of local recurrence and lung metastases the first 2 years postoperatively. METHODS We retrospectively assessed the medical files of all patients (n = 232) with STS and BT of the extremities and trunk wall who underwent surgery from 2010 to 2013. Two-hundred-and-thirty-two patients were included in the local recurrence study and 116 patients in the lung metastasis study. We extracted information on how local recurrence and lung metastases were detected. Kaplan-Meier survival analysis and 2 × 2-contingency table with Chi-square test were used. Local recurrence and lung metastases were analyzed separately. RESULTS Twenty-five of 232 patients experienced local recurrence and 19 of 116 patients experienced lung metastases. Compared to clinical examination, local imaging led to a larger amount of local recurrence suspicions (37/560 vs. 8/706). Suspicions occurring on local imaging were more accurate than on clinical examination (17/37 vs. 0/8 affirmed). Local imaging identified a larger amount of local recurrence than clinical examination (17/560 vs. 0/706). Thirty-three patients suspected local recurrence themselves, 8 were affirmed. Compared to x-ray, computerized tomography (CT) led to a larger amount of lung metastasis suspicions (22/284 vs. 6/276). Suspicions occurring on CT seemed more accurate than on x-ray (15/22 vs. 2/6 affirmed). CT found a larger amount of lung metastases than x-ray (15/284 vs. 2/276). Three patients suspected lung metastases themselves, 1 was affirmed. CONCLUSION Bi-annual local imaging and CT the first 2 years after surgery of STS detect local recurrence and lung metastases better than clinical examination and x-ray. Clinical examination and x-ray between these examinations is unnecessary. Patients' own suspicion of local recurrence and lung metastases is still important.
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Affiliation(s)
- Thea Bechmann Hovgaard
- Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Denmark
| | - Tine Nymark
- ITAR Section, Department of Orthopedic Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Ole Skov
- ITAR Section, Department of Orthopedic Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Michael Mørk Petersen
- Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, Denmark
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15
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Cipriano C, Griffin AM, Ferguson PC, Wunder JS. Developing an Evidence-based Followup Schedule for Bone Sarcomas Based on Local Recurrence and Metastatic Progression. Clin Orthop Relat Res 2017; 475:830-838. [PMID: 27339121 PMCID: PMC5289192 DOI: 10.1007/s11999-016-4941-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The potential for local recurrence and pulmonary metastasis after treatment of primary bone sarcomas necessitates careful patient followup; however, minimal data exist regarding the incidence and timing of these events, and therefore an evidence-based surveillance protocol has not been developed. QUESTIONS/PURPOSES The purposes of this study were to (1) describe the frequency and timing of local recurrence by histologic grade over time; (2) describe the frequency and timing of metastasis by histologic grade and diagnosis over time; and (3) use these data to either justify current surveillance schedules and/or propose modifications that may improve the rate of new pulmonary metastatic events detected per examination. METHODS A retrospective review was performed of all patients who underwent resection of a primary, nonmetastatic bone sarcoma (excluding chordoma) at a single tertiary oncology center from 1989 to 2010. Of the 680 patients identified, 15 were excluded for loss of followup in the first 2 years, leaving 665 eligible for study. Of these, 437 patients were alive with no evidence of disease at the conclusion of the study (mean followup, 136 months; range, 25-321 months). Cox regression analysis was performed to evaluate and control for patient age, tumor size, tumor location, and surgical margins. With patients stratified by sarcoma grade, Kaplan-Meier survival curves were constructed for the endpoints of local recurrence and metastasis, and log-rank tests were used to compare the rates of these events between grades and diagnoses. The number of new pulmonary metastatic events per patient-year was calculated for each sarcoma grade over the time intervals used in current surveillance protocols (0-2, 2-5, 5-10, and > 10 years) to facilitate development of a surveillance schedule that would maximize events detected per imaging study performed. In addition, to determine the effect of disease type, subset analysis was performed for osteosarcoma (OSA) and chondrosarcoma because these were the only diagnoses with sufficient numbers to support individual statistical analysis. RESULTS With the numbers available for study, the overall local recurrence-free survival did not differ between sarcoma grades at any time points (p = 0.864). Metastasis-free survival curves differed between sarcoma grades (p < 0.001), and the pattern of Grade 2 OSA metastasis was more consistent with other Grade 3 sarcomas, so it was subsequently classified as high grade. No metastases of Grade 1 sarcomas occurred after 3 years, whereas Grade 2 and 3 sarcomas continued to metastasize until 10 years and rarely thereafter. According to the number of new pulmonary metastatic events per patient-year in each group, we propose that chest surveillance be performed according to the following schedule: annually only until 5 years for low-grade sarcomas; every 3 months for 2 years and annually from 2 to 10 years for intermediate-grade sarcomas; and every 3 months for 2 years, every 6 months from 2 to 5 years, and annually from 5 to 10 years for high-grade sarcomas. CONCLUSIONS Pulmonary screening beyond 5 years may not be necessary for Grade 1 tumors but should be continued until 10 years for Grade 2 and 3 bone sarcomas. The surveillance frequency listed here, which is based on the number of new pulmonary metastatic events per patient-year in each grade, would increase the number of such events detected per examination performed. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Cara Cipriano
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Washington University in St Louis, 660 S Euclid Avenue, Campus Box 8233, St Louis, MO, 63110, USA.
| | - Anthony M Griffin
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, ON, Canada
| | - Peter C Ferguson
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jay S Wunder
- University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, ON, Canada
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
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16
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Paioli A, Rocca M, Cevolani L, Rimondi E, Vanel D, Palmerini E, Cesari M, Longhi A, Eraldo AM, Marchesi E, Picci P, Ferrari S. Osteosarcoma follow-up: chest X-ray or computed tomography? Clin Sarcoma Res 2017; 7:3. [PMID: 28228934 PMCID: PMC5307808 DOI: 10.1186/s13569-017-0067-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 02/02/2017] [Indexed: 12/22/2022] Open
Abstract
Background In patients with relapsed osteosarcoma, the surgical excision of all metastases, defined as second complete remission (CR-2), is the factor that mainly influences post-relapse survival (PRS). Currently a validated follow-up policy for osteosarcoma is not available, both chest X-ray and computed tomography (CT) are suggested for lung surveillance. The purpose of this study is to evaluate whether the type of imaging technique used for chest surveillance, chest X-ray or CT, influenced the rate of CR-2 and prognosis in patients with recurrent osteosarcoma. Methods Patients up to 40 years with extremity osteosarcoma enrolled in consecutive clinical trials and treated at the Rizzoli Institute from 1986 to 2009 were identified. Only patients who had lung metastases alone as first pattern of recurrence were considered for the analysis. The rate of CR-2, overall survival (OS) and PRS were the end-points of the study. Results The median follow-up was 47 months (1–300), 215 patients were eligible. Lung metastases were detected by chest X-ray in 100 (47%) patients, by CT in 112 (52%) and by symptoms in 3 (1%). CR-2 rate was 60% for patients followed by X-rays and 88% for those followed by CT (p < .0001). 5-year PRS was 30% (95% CI 21–39) in the X-ray group and 49% (95% CI 39–59) in the CT group (p = .0004). 5-year OS was 35% (95% CI 26–44) in the X-ray group and 60% (95% CI 51–70) in the CT group (p = .004). Conclusions A follow-up strategy with chest CT leads to a higher rate of CR-2 and significantly improves PRS and OS in osteosarcoma, compared to chest X-ray.
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Affiliation(s)
- Anna Paioli
- Chemotherapy Unit, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Michele Rocca
- General Surgery Unit, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Luca Cevolani
- Department of Orthopaedic Oncology, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Eugenio Rimondi
- Diagnostic and Interventional Radiology, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Daniel Vanel
- Diagnostic and Interventional Radiology, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Emanuela Palmerini
- Chemotherapy Unit, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Marilena Cesari
- Chemotherapy Unit, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Alessandra Longhi
- Chemotherapy Unit, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Abate Massimo Eraldo
- Chemotherapy Unit, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Emanuela Marchesi
- Chemotherapy Unit, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
| | - Piero Picci
- Department of Pathology, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136 Bologna, Italy
| | - Stefano Ferrari
- Chemotherapy Unit, Istituto Ortopedico Rizzoli, via Pupilli, 1, 40136 Bologna, Italy
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17
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Patel SA, Royce TJ, Barysauskas CM, Thornton KA, Raut CP, Baldini EH. Surveillance Imaging Patterns and Outcomes Following Radiation Therapy and Radical Resection for Localized Extremity and Trunk Soft Tissue Sarcoma. Ann Surg Oncol 2017; 24:1588-1595. [PMID: 28058559 DOI: 10.1245/s10434-016-5755-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Optimal surveillance imaging (SI) regimens following radiation therapy (RT) and radical resection for localized soft tissue sarcoma (STS) are unknown and practice patterns vary. METHODS Between 2006 and 2014, 94 patients with localized STS of the extremity/trunk treated with preoperative RT and radical resection were identified. Timing of local recurrence (LR), distant recurrence (DR), and SI were evaluated. The Kaplan-Meier method was used to determine recurrence-free and overall survival (OS), and the method of recurrence detection (SI or due to signs/symptoms) was determined. RESULTS Median tumor size was 7.5 cm, and 92% were intermediate/high grade. After a median follow-up of 60 months for surviving patients, 30 patients (32%) recurred, including 5 LRs and 26 DRs. The median time to LR and DR was 36.2 months (range 14.4-65.7) and 10.4 months (range 5.2-76.9), respectively, and the 5-year local recurrence-free survival (RFS), distant RFS, and OS was 95, 71, and 76%, respectively. Local SI was performed for 90% of patients, mostly by magnetic resonance imaging (MRI; 91%). Of the five LRs, two were detected by SI and three had signs/symptoms preceding imaging. All patients underwent distant SI. Of the 26 DRs, 23 (88%) were in the lung. SI detected 22 (85%) DRs, and only 4 of 26 had signs/symptoms prompting imaging. CONCLUSION Given excellent local control with RT and radical resection for intermediate/high-grade STS of the extremity/trunk, SI of the primary site should be reserved for select patients at high risk of LR. Conversely, due to frequent occurrence of asymptomatic DR in the lungs, periodic lung SI is appropriate. Routine abdominopelvic SI may not be indicated for most histologies.
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Affiliation(s)
- Sagar A Patel
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA
| | - Trevor J Royce
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA
| | - Constance M Barysauskas
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Katherine A Thornton
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Chandrajit P Raut
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.,Division of Surgical Oncology, Brigham and Women's Hospital/Dana-Farber Cancer-Institute, Boston, MA, USA
| | - Elizabeth H Baldini
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA. .,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA.
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18
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Roberts CC, Kransdorf MJ, Beaman FD, Adler RS, Amini B, Appel M, Bernard SA, Fries IB, Germano IM, Greenspan BS, Holly LT, Kubicky CD, Lo SSM, Mosher TJ, Sloan AE, Tuite MJ, Walker EA, Ward RJ, Wessell DE, Weissman BN. ACR Appropriateness Criteria Follow-Up of Malignant or Aggressive Musculoskeletal Tumors. J Am Coll Radiol 2016; 13:389-400. [PMID: 26922595 DOI: 10.1016/j.jacr.2015.12.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/16/2015] [Indexed: 02/07/2023]
Abstract
Appropriate imaging modalities for the follow-up of malignant or aggressive musculoskeletal tumors include radiography, MRI, CT, (18)F-2-fluoro-2-deoxy-D-glucose PET/CT, (99m)Tc bone scan, and ultrasound. Clinical scenarios reviewed include evaluation for metastatic disease to the lung in low- and high-risk patients, for osseous metastatic disease in asymptomatic and symptomatic patients, for local recurrence of osseous tumors with and without significant hardware present, and for local recurrence of soft tissue tumors. The timing for follow-up of pulmonary metastasis surveillance is also reviewed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
| | | | | | - Ronald S Adler
- New York University Center for Musculoskeletal Care, New York, New York
| | - Behrang Amini
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marc Appel
- Warwick Valley Orthopedic Surgery, Warwick, New York, American Academy of Orthopaedic Surgeons
| | - Stephanie A Bernard
- Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Ian Blair Fries
- Bone, Spine and Hand Surgery, Chartered, Brick, New Jersey, American Academy of Orthopaedic Surgeons
| | | | | | - Langston T Holly
- University of California Los Angeles Medical Center, Los Angeles, California
| | | | - Simon Shek-Man Lo
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Timothy J Mosher
- Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Andrew E Sloan
- University Hospital Case Medical Center, Cleveland, Ohio
| | | | - Eric A Walker
- Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Tseng WW, Amini B, Madewell JE. Follow-up of the soft tissue sarcoma patient. J Surg Oncol 2014; 111:641-5. [PMID: 25322963 DOI: 10.1002/jso.23814] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/14/2014] [Indexed: 12/16/2022]
Abstract
Despite optimal treatment, patients with soft tissue sarcoma are at risk for recurrence and therefore appropriate surveillance is critical. At minimum, regularly scheduled clinical assessments and chest X-rays are necessary. Consensus guidelines are available; however, surveillance strategies must be personalized based on the risk for recurrence and inherent disease biology. Further research is needed on a number of issues, including the impact of surveillance on clinical outcome and the utility of molecular surveillance.
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Affiliation(s)
- William W Tseng
- Department of Surgery, Division of Upper GI/General Surgery, Section of Surgical Oncology, University of Southern California, Los Angeles, California; Hoag Family Cancer Institute, Hoag Memorial Hospital Presbyterian, Newport Beach, California
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20
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Puri A, Gulia A, Hawaldar R, Ranganathan P, Badwe RA. Does intensity of surveillance affect survival after surgery for sarcomas? Results of a randomized noninferiority trial. Clin Orthop Relat Res 2014; 472:1568-75. [PMID: 24249538 PMCID: PMC3971232 DOI: 10.1007/s11999-013-3385-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 11/08/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Whether current postoperative surveillance regimes result in improved overall survival (OS) of patients with extremity sarcomas is unknown. QUESTIONS/PURPOSES We hypothesized that a less intensive followup protocol would not be inferior to the conventional followup protocol in terms of OS. We (1) assessed OS of patients to determine if less intensive followup regimens led to worsened survival and asked (2) whether chest radiograph followup group was inferior to CT scan followup group in detecting pulmonary metastasis; and (3) whether less frequent (6-monthly) followup interval was inferior to more frequent (3-monthly) followup in detecting pulmonary metastasis and local recurrence. METHODS A prospective randomized single-center noninferiority trial was conducted between January 2006 and June 2010. On the basis of 3-year survival of 60% with intensive, more frequent followup, 500 nonmetastatic patients were randomized to demonstrate noninferiority by a margin (delta) of 10% (hazard ratio [HR], 1.36). The primary end point was OS at 3 years. The secondary objective was to compare disease-free survival (DFS) (time to recurrence) at 3 years. At minimum followup of 30 months (median, 42 months; range, 30-81 months), 178 deaths were documented. RESULTS Three-year OS and DFS for all patients was 67% and 52%, respectively. Three-year OS was 67% and 66% in chest radiography and CT groups, respectively (HR, 0.9; upper 90% confidence interval [CI], 1.13). DFS rate was 54% and 49% in chest radiography and CT groups, respectively (HR, 0.82; upper 90% CI, 0.97). Three-year OS was 64% and 69% in 6-monthly and 3-monthly groups, respectively (HR, 1.2; upper 90% CI, 1.47). DFS was 51% and 52% in 6-monthly and 3-monthly groups, respectively (HR, 1.01; upper 90% CI, 1.2). Almost 90% of local recurrences were identified by patients themselves. CONCLUSIONS Inexpensive imaging detects the vast majority of recurrent disease in patients with sarcoma without deleterious effects on eventual outcomes. Patient education regarding self-examination will detect most instances of local recurrence although this was not directly assessed in this study. Although less frequent visits adequately detected metastasis and local recurrence, this trial could not conclusively demonstrate noninferiority in OS for a 6-monthly interval of followup visits against 3-monthly visits. LEVEL OF EVIDENCE Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ajay Puri
- />Orthopaedic Oncology, Tata Memorial Hospital, Room No. 45, E Borges Road, Mumbai, India
| | - Ashish Gulia
- />Orthopaedic Oncology, Tata Memorial Hospital, Room No. 45, E Borges Road, Mumbai, India
| | | | - Priya Ranganathan
- />Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India
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Rothermundt C, Whelan JS, Dileo P, Strauss SJ, Coleman J, Briggs TW, Haile SR, Seddon BM. What is the role of routine follow-up for localised limb soft tissue sarcomas? A retrospective analysis of 174 patients. Br J Cancer 2014; 110:2420-6. [PMID: 24736584 PMCID: PMC4021531 DOI: 10.1038/bjc.2014.200] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/13/2014] [Accepted: 03/20/2014] [Indexed: 11/23/2022] Open
Abstract
Background: There are neither prospective data nor agreement on the optimal routine follow-up procedures in patients treated for soft tissue sarcoma of the limb. Methods: Data on 174 consecutive patients with a soft tissue sarcoma of the limb undergoing follow-up by oncologists at a single centre from 2003 to 2009 were included in this analysis. The rate and site of recurrence and mode of detection were analysed. Outcome of the patients was assessed. Results: Eighty-two patients (47%) experienced relapse of any type. Isolated local recurrence occurred in 26 patients and local relapse with synchronous pulmonary metastases in five patients. Local recurrences were detected clinically in 30 of these 31 patients; magnetic resonance imaging identified only one local recurrence. Twenty-eight patients developed isolated lung metastases; in nine patients these were amenable to resections, seven of whom are currently free of disease after treatment. Lung metastases were detected by chest x-ray (CXR) in 19 patients, computed tomography scanning in 3 patients, and clinically in 11 patients. Twenty-three patients developed non-pulmonary metastases. More than 80% of relapses occurred in the first 2 years of follow-up; however, later recurrences were also observed. Conclusions: Routine follow-up CXR can detect lung metastases suitable for surgical resection, although the optimal interval of imaging has yet to be defined. Local relapse is almost always detected by patients or physicians, and routine scanning of the primary site is of doubtful benefit. Patient and physician education to detect local relapse may be helpful. Prospective evaluation of follow-up is recommended.
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Affiliation(s)
- C Rothermundt
- Division of Oncology/Haematology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland
| | - J S Whelan
- London Sarcoma Service, University College London Hospitals, London NW1 2BU, UK
| | - P Dileo
- London Sarcoma Service, University College London Hospitals, London NW1 2BU, UK
| | - S J Strauss
- London Sarcoma Service, University College London Hospitals, London NW1 2BU, UK
| | - J Coleman
- Department of Orthopaedic Surgery, Royal National Orthopaedic Hospital, Middlesex HA7 4LP, UK
| | - T W Briggs
- Department of Orthopaedic Surgery, Royal National Orthopaedic Hospital, Middlesex HA7 4LP, UK
| | - S R Haile
- Clinical Trials Unit, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland
| | - B M Seddon
- London Sarcoma Service, University College London Hospitals, London NW1 2BU, UK
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Chou YS, Liu CY, Chen WM, Chen TH, Chen PCH, Wu HTH, Chiou HJ, Shiau CY, Wu YC, Liu CL, Chao TC, Tzeng CH, Yen CC. Follow-up after primary treatment of soft tissue sarcoma of extremities: Impact of frequency of follow-up imaging on disease-specific survival. J Surg Oncol 2012; 106:155-61. [DOI: 10.1002/jso.23060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Accepted: 01/12/2012] [Indexed: 11/05/2022]
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