Soft Tissue Tumors in Adults: ESSR-Approved Guidelines for Diagnostic Imaging

Abstract

Soft tissue sarcomas are rare, but early, accurate diagnosis with subsequent appropriate treatment is crucial for the clinical outcome. The ESSR guidelines are intended to help radiologists in their decision-making and support discussion among clinicians who deal with patients with suspected or proven soft tissue tumors. Potentially malignant lesions recognized by ultrasound should be referred for magnetic resonance imaging (MRI), which also serves as a preoperative local staging modality, with specific technical requirements and mandatory radiological report elements. Radiography may add information about matrix calcification and osseous involvement. Indeterminate lesions, or lesions in which therapy is dependent on histology results, should be biopsied. For biopsy, we strongly recommend referral to a specialist sarcoma center, where an interdisciplinary tumor group, with a specialized pathologist, radiologist, and the surgeon are involved. In sarcoma, a CT scan of the chest is mandatory. Additional staging modalities are entity-specific. There are no evidence-based recommendations for routine follow-up in surgically treated sarcomas. However, we would recommend regular follow-up with intervals dependent on tumor grade, for 10 years after the initial diagnosis.

Keywords

soft tissue tumor - guidelines - diagnostic algorithm - imaging methods - ESSR

Notes

Approved by the ESSR MSK Tumour Subcommittee.

• References

• 1 Fletcher CDM, Bridge JA, Hogendoorn P, Mertens F. WHO Classification of Tumours of Soft Tissue and Bone. 4th ed. Lyon, France: IARC Press; 2013
• 2 National Cancer Institute. SEER Stat Fact Sheets: Soft tissue including heart cancer. Available at: http://seer.cancer.gov/statfacts/html/soft.html . Accessed December 7, 2015
• 3 Nakamura T, Matsumine A, Matsubara T, Asanuma K, Uchida A, Sudo A. The symptom-to-diagnosis delay in soft tissue sarcoma influence the overall survival and the development of distant metastasis. J Surg Oncol 2011; 104 (7) 771-775
• 4 Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and triage of clinically suspicious soft-tissue masses. Clin Radiol 2009; 64 (6) 615-621
• 5 Rowbotham E, Bhuva S, Gupta H, Robinson P. Assessment of referrals into the soft tissue sarcoma service: evaluation of imaging early in the pathway process. Sarcoma 2012; 2012: 781723
• 6 Ritchie DA. Commentary on ultrasound for initial evaluation and triage of clinically suspicious soft-tissue masses. Clin Radiol 2009; 64 (6) 622-623
• 7 Campbell R. Ultrasound of soft tissue masses. In: Allan PL, Baxter GM, Weston MJ, eds. Clinical Ultrasound. 3rd ed. Philadelphia, PA: Churchill Livingstone/Elsevier; 2011
• 8 Klauser AS, Tagliafico A, Allen GM , et al. Clinical indications for musculoskeletal ultrasound: a Delphi-based consensus paper of the European Society of Musculoskeletal Radiology. Eur Radiol 2012; 22 (5) 1140-1148
• 9 Inampudi P, Jacobson JA, Fessell DP , et al. Soft-tissue lipomas: accuracy of sonography in diagnosis with pathologic correlation. Radiology 2004; 233 (3) 763-767
• 10 Wagner JM, Lee KS, Rosas H, Kliewer MA. Accuracy of sonographic diagnosis of superficial masses. J Ultrasound Med 2013; 32 (8) 1443-1450
• 11 Carra BJ, Bui-Mansfield LT, O'Brien SD, Chen DC. Sonography of musculoskeletal soft-tissue masses: techniques, pearls, and pitfalls. AJR Am J Roentgenol 2014; 202 (6) 1281-1290
• 12 Horton LK, Jacobson JA, Powell A, Fessell DP, Hayes CW. Sonography and radiography of soft-tissue foreign bodies. AJR Am J Roentgenol 2001; 176 (5) 1155-1159
• 13 Griffith JF, Wong TY, Wong SM, Wong MW, Metreweli C. Sonography of plantar fibromatosis. AJR Am J Roentgenol 2002; 179 (5) 1167-1172
• 14 Vanhoenacker FM, Eyselbergs M, Van Hul E, Van Dyck P, De Schepper AM. Pseudotumoural soft tissue lesions of the hand and wrist: a pictorial review. Insights Imaging 2011; 2 (3) 319-333
• 15 Beggs I. Sonography of muscle hernias. AJR Am J Roentgenol 2003; 180 (2) 395-399
• 16 Quinn TJ, Jacobson JA, Craig JG, van Holsbeeck MT. Sonography of Morton's neuromas. AJR Am J Roentgenol 2000; 174 (6) 1723-1728
• 17 Reynolds Jr DL, Jacobson JA, Inampudi P, Jamadar DA, Ebrahim FS, Hayes CW. Sonographic characteristics of peripheral nerve sheath tumors. AJR Am J Roentgenol 2004; 182 (3) 741-744
• 18 National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Available at: http://www.nccn.org/professionals/physician_gls/f_guidelines_nojava.asp . Accessed December 11, 2015
• 19 Galant J, Martí-Bonmatí L, Soler R , et al. Grading of subcutaneous soft tissue tumors by means of their relationship with the superficial fascia on MR imaging. Skeletal Radiol 1998; 27 (12) 657-663
• 20 Morel M, Taïeb S, Penel N , et al. Imaging of the most frequent superficial soft-tissue sarcomas. Skeletal Radiol 2011; 40 (3) 271-284
• 21 Datir A, James SL, Ali K, Lee J, Ahmad M, Saifuddin A. MRI of soft-tissue masses: the relationship between lesion size, depth, and diagnosis. Clin Radiol 2008; 63 (4) 373-378 ; discussion 379–380
• 22 Gartner L, Pearce CJ, Saifuddin A. The role of the plain radiograph in the characterisation of soft tissue tumours. Skeletal Radiol 2009; 38 (6) 549-558
• 23 De Schepper AM, Vanhoenacker F, Parizel PM, Gielen J eds. Imaging of Soft Tissue Tumors. Berlin, Germany: Springer-Verlag; 2006
• 24 Verstraete KL, Lang P. Bone and soft tissue tumors: the role of contrast agents for MR imaging. Eur J Radiol 2000; 34 (3) 229-246
• 25 White LM, Wunder JS, Bell RS , et al. Histologic assessment of peritumoral edema in soft tissue sarcoma. Int J Radiat Oncol Biol Phys 2005; 61 (5) 1439-1445
• 26 Manaster BJ. Soft-tissue masses: optimal imaging protocol and reporting. AJR Am J Roentgenol 2013; 201 (3) 505-514
• 27 Dinauer PA, Brixey CJ, Moncur JT, Fanburg-Smith JC, Murphey MD. Pathologic and MR imaging features of benign fibrous soft-tissue tumors in adults. Radiographics 2007; 27 (1) 173-187
• 28 Wu JS, Hochman MG. Soft-tissue tumors and tumorlike lesions: a systematic imaging approach. Radiology 2009; 253 (2) 297-316
• 29 European Society of Urogenital Radiology (ESUR) Guidelines on Contrast Media. Available from: http://www.esur.org/guidelines/ . Accessed December 11, 2015
• 30 van Rijswijk CS, Geirnaerdt MJ, Hogendoorn PC , et al. Soft-tissue tumors: value of static and dynamic gadopentetate dimeglumine-enhanced MR imaging in prediction of malignancy. Radiology 2004; 233 (2) 493-502
• 31 van Rijswijk CS, Kunz P, Hogendoorn PC, Taminiau AH, Doornbos J, Bloem JL. Diffusion-weighted MRI in the characterization of soft-tissue tumors. J Magn Reson Imaging 2002; 15 (3) 302-307
• 32 Subhawong TK, Jacobs MA, Fayad LM. Diffusion-weighted MR imaging for characterizing musculoskeletal lesions. Radiographics 2014; 34 (5) 1163-1177
• 33 Holzapfel K, Regler J, Baum T , et al. Local staging of soft-tissue sarcoma: emphasis on assessment of neurovascular encasement-value of MR imaging in 174 confirmed cases. Radiology 2015; 275 (2) 501-509
• 34 Papp DF, Khanna AJ, McCarthy EF, Carrino JA, Farber AJ, Frassica FJ. Magnetic resonance imaging of soft-tissue tumors: determinate and indeterminate lesions. J Bone Joint Surg Am 2007; 89 (Suppl. 03) 103-115
• 35 Vanhoenacker FM, Van Looveren K, Trap K , et al. Grading and characterization of soft tissue tumors on magnetic resonance imaging: the value of an expert second opinion report. Insights Imaging 2012; 3 (2) 131-138
• 36 Styring E, Billing V, Hartman L , et al. Simple guidelines for efficient referral of soft-tissue sarcomas: a population-based evaluation of adherence to guidelines and referral patterns. J Bone Joint Surg Am 2012; 94 (14) 1291-1296
• 37 Yang J, Frassica FJ, Fayad L, Clark DP, Weber KL. Analysis of nondiagnostic results after image-guided needle biopsies of musculoskeletal lesions. Clin Orthop Relat Res 2010; 468 (11) 3103-3111
• 38 Peer S, Freuis T, Loizides A, Gruber H. Ultrasound guided core needle biopsy of soft tissue tumors; a fool proof technique?. Med Ultrasound 2011; 13 (3) 187-194
• 39 Pohlig F, Kirchhoff C, Lenze U , et al. Percutaneous core needle biopsy versus open biopsy in diagnostics of bone and soft tissue sarcoma: a retrospective study. Eur J Med Res 2012; 17: 29
• 40 Koenig CW, Duda SH, Truebenbach J , et al. MR-guided biopsy of musculoskeletal lesions in a low-field system. J Magn Reson Imaging 2001; 13 (5) 761-768
• 41 Purandare NC, Kulkarni AV, Kulkarni SS , et al. 18F-FDG PET/CT-directed biopsy: does it offer incremental benefit?. Nucl Med Commun 2013; 34 (3) 203-210
• 42 De Marchi A, Brach del Prever EM, Linari A , et al. Accuracy of core-needle biopsy after contrast-enhanced ultrasound in soft-tissue tumours. Eur Radiol 2010; 20 (11) 2740-2748
• 43 Noebauer-Huhmann IM, Amann G, Krssak M , et al. Use of diagnostic dynamic contrast-enhanced (DCE)-MRI for targeting of soft tissue tumour biopsies at 3T: preliminary results. Eur Radiol 2015; 25 (7) 2041-2048
• 44 Yang YJ, Damron TA. Comparison of needle core biopsy and fine-needle aspiration for diagnostic accuracy in musculoskeletal lesions. Arch Pathol Lab Med 2004; 128 (7) 759-764
• 45 American Joint Committee on Cancer. How are soft tissue sarcomas staged?. Available from: http://www.cancer.org/cancer/sarcoma-adultsofttissuecancer/detailedguide/sarcoma-adult-soft-tissue-cancer-staging . Accessed December 11, 2015
• 46 Vincenzi B, Frezza AM, Schiavon G , et al. Bone metastases in soft tissue sarcoma: a survey of natural history, prognostic value and treatment options. Clin Sarcoma Res 2013; 3 (1) 6
• 47 Yoshikawa H, Myoui A, Ochi T , et al. Bone metastases from soft tissue sarcomas. Semin Musculoskelet Radiol 1999; 3 (2) 183-190
• 48 Sood S, Baheti AD, Shinagare AB , et al. Imaging features of primary and metastatic alveolar soft part sarcoma: single institute experience in 25 patients. Br J Radiol 2014; 87 (1036) 20130719
• 49 Gordon RW, Tirumani SH, Kurra V , et al. MRI, MDCT features, and clinical outcome of extremity leiomyosarcomas: experience in 47 patients. Skeletal Radiol 2014; 43 (5) 615-622
• 50 Mazeron JJ, Suit HD. Lymph nodes as sites of metastases from sarcomas of soft tissue. Cancer 1987; 60 (8) 1800-1808
• 51 Sherman KL, Kinnier CV, Farina DA , et al. Examination of national lymph node evaluation practices for adult extremity soft tissue sarcoma. J Surg Oncol 2014; 110 (6) 682-688
• 52 Haniball J, Sumathi VP, Kindblom LG , et al. Prognostic factors and metastatic patterns in primary myxoid/round-cell liposarcoma. Sarcoma 2011; 2011: 538085
• 53 Chase DR, Enzinger FM. Epithelioid sarcoma. Diagnosis, prognostic indicators, and treatment. Am J Surg Pathol 1985; 9 (4) 241-263
• 54 Meis-Kindblom JM, Kindblom LG. Angiosarcoma of soft tissue: a study of 80 cases. Am J Surg Pathol 1998; 22 (6) 683-697
• 55 Mankin HJ, Casas-Ganem J, Kim JI, Gebhardt MC, Hornicek FJ, Zeegen EN. Leiomyosarcoma of somatic soft tissues. Clin Orthop Relat Res 2004; (421) 225-231
• 56 Lieberman PH, Brennan MF, Kimmel M, Erlandson RA, Garin-Chesa P, Flehinger BY. Alveolar soft-part sarcoma. A clinico-pathologic study of half a century. Cancer 1989; 63 (1) 1-13
• 57 Portera Jr CA, Ho V, Patel SR , et al. Alveolar soft part sarcoma: clinical course and patterns of metastasis in 70 patients treated at a single institution. Cancer 2001; 91 (3) 585-591
• 58 Espat NJ, Bilsky M, Lewis JJ, Leung D, Brennan MF. Soft tissue sarcoma brain metastases. Prevalence in a cohort of 3829 patients. Cancer 2002; 94 (10) 2706-2711
• 59 Roberge D, Vakilian S, Alabed YZ, Turcotte RE, Freeman CR, Hickeson M. FDG PET/CT in initial staging of adult soft-tissue sarcoma. Sarcoma 2012; 2012: 960194
• 60 National Guideline Clearinghouse. ACR Appropriateness Criteria® follow-up of malignant or aggressive musculoskeletal tumors. Available at: https://acsearch.acr.org/docs/69428/Narrative/ . Accessed December 7, 2015
• 61 Grobmyer SR, Brennan MF. Predictive variables detailing the recurrence rate of soft tissue sarcomas. Curr Opin Oncol 2003; 15 (4) 319-326
• 62 Cancer Research UK. Follow up for soft tissue sarcoma. Available from: http://www.cancerresearchuk.org/about-cancer/type/sarcoma/treatment/follow-up-for-soft-tissue-sarcoma . Accessed December 11, 2015
• 63 AMSOS. Austrian Musculoskeletal Oncology Society. Available at: http://www.amsos.at . Accessed December 7, 2015
• 64 ESMO/European Sarcoma Network Working Group. Soft tissue and visceral sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 (Suppl. 03) iii102-iii112
• 65 Tagliafico A, Truini M, Spina B , et al. Follow-up of recurrences of limb soft tissue sarcomas in patients with localized disease: performance of ultrasound. Eur Radiol 2015; 25 (9) 2764-2770
• 66 Diana Afonso P, Kosinski AS, Spritzer CE. Following unenhanced MRI assessment for local recurrence after surgical resection of mesenchymal soft tissue tumors, do additional gadolinium-enhanced images change reader confidence or diagnosis?. Eur J Radiol 2013; 82 (5) 806-813
• 67 Vanel D, Shapeero LG, Tardivon A, Western A, Guinebretière JM. Dynamic contrast-enhanced MRI with subtraction of aggressive soft tissue tumors after resection. Skeletal Radiol 1998; 27 (9) 505-510
• 68 Del Grande F, Subhawong T, Weber K, Aro M, Mugera C, Fayad LM. Detection of soft-tissue sarcoma recurrence: added value of functional MR imaging techniques at 3.0 T. Radiology 2014; 271 (2) 499-511