Effective utilization of chest X-ray for follow-up of metastatic lung tumor due to soft tissue sarcoma

Recent Imaging Advancements for Lung Metastases in Children with Sarcoma

In children and adolescents affected by musculoskeletal sarcomas (both soft tissue and bone sarcomas), the presence of lung metastases is a frequent complication, that should be known since the patient's prognosis, as management, and treatment depend on it. During the staging phase, the detection of lung metastases should be sensitive and specific, and it should be carried out by minimizing the radiation exposure. To deal with this problem, imaging has reached important goals in recent years, thanks to the development of cone-beam CT or low-dose computed tomography, with some new iterative reconstruction methods, such as Veo and ASIR. Imaging is also fundamental for the possibility to perform lung biopsies under CT guidance, with less morbidity, less time-consumption, and shorter recovery time, compared to surgical biopsies.Moreover, important results have also been demonstrated in the treatment of lung metastases, due to the improvement of new mini-invasive image-guided percutaneous thermal ablation procedures, which proved to be safe and effective also in young patients.

Radiologic Assessment of Osteosarcoma Lung Metastases: State of the Art and Recent Advances

The lung is the most frequent site of osteosarcoma (OS) metastases, which are a critical point in defining a patient’s prognosis. Chest computed tomography (CT) represents the gold standard for the detection of lung metastases even if its sensitivity widely ranges in the literature since lung localizations are often atypical. ESMO guidelines represent one of the major references for the follow-up program of OS patients. The development of new reconstruction techniques, such as the iterative method and the deep learning-based image reconstruction (DLIR), has led to a significant reduction of the radiation dose with the low-dose CT. The improvement of these techniques has great importance considering the young-onset of the disease and the strict chest surveillance during follow-up programs. The use of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is still controversial, while volume doubling time (VDT) and computer-aided diagnosis (CAD) systems are recent diagnostic tools that could support radiologists for lung nodules evaluation. Their use, well-established for other malignancies, needs to be further evaluated, focusing on OS patients.

Follow-up after initial surgical treatment of soft tissue sarcomas in the extremities and trunk wall

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.

ACR Appropriateness Criteria Follow-Up of Malignant or Aggressive Musculoskeletal Tumors

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.