First published online May 25, 2006
British Journal of Radiology (2006) 79, 799-800
© 2006 British Institute of Radiology
doi: 10.1259/bjr/69175634
Is routine chest radiography a useful test in the follow up of all adult patients with soft tissue sarcoma?
H K Lord, MRCP
1
D M Salter, MD, FRCPath, FRCPE
2
R H MacDougall, FRCS, FRCR, FRCPE
1 and
G R Kerr, MSc
1
1 Department of Clinical Oncology, Edinburgh Cancer Centre, Crewe Road, Edinburgh EH4 2XU, 2 Department of Pathology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
 |
Abstract
|
|---|
Following treatment for localized soft tissue sarcoma the risk of relapse is either locally or in the lungs. In Edinburgh patients are reviewed every 6 months with a chest X-ray (CXR). The radiation exposure over a 10 year follow up remains small, but it is unclear if all patients, irrespective of the initial grade of their primary tumour, require this. To determine the pick up rate of lung metastases by routine CXR over a 10 year period and to review the primary histology. Adult patients on routine follow up between 1994 and 2004 were identified and the notes of those with lung metastases reviewed. Data was collected on their initial histology, and date and method of diagnosis of lung metastases. 179 patients were under follow up. 24 (13%) developed lung metastases. For 2, notes were not found. 6 (27%) had metastases diagnosed by routine CXR, 9 (41%) had metastases diagnosed by non routine CXR and 7 (32%) had metastases diagnosed by CT. On review of histology none were grade 1, 4 (18%) were grade 2 and 18 (82%) were grade 3. 155 patients received. 6 monthly CXR for 10 years with no detection of lung metastases. Lung metastases occurred in a minority of patients (13%) and most (82%) occurred in patients with grade 3 tumours. No patients with grade 1 tumours developed lung metastases. Thus routine CXR may be appropriate on grade 3 tumours, but not on lower grade tumours where other risk factors are absent.
|
Introduction
|
|---|
Soft tissue sarcoma in adulthood is relatively rare. Following treatment for localized disease, the risk of relapse is either locally or in the lungs. Prognostic indicators for recurrence are well documented [1–6] and include age at diagnosis, tumour depth, tumour size, histological type, histological grade, positive surgical margins and tumour site. All patients in our centre are followed up for 10 years regardless of initial pathology, with 6 monthly chest radiographs (CXR). This is justified because surgical intervention may be curative if lung metastases are diagnosed early. The effective radiation dose from a single CXR is quoted as between 0.02 mSv and 0.1 mSv, which is the equivalent to between 2.4 days and 10 days of background radiation. Thus whilst the overall radiation dose over 10 years from 6 monthly CXR remains small, it was unclear if CXR was a useful screening tool in this setting, and if it was indicated in all patients regardless on initial pathology. This retrospective audit was therefore performed to answer these questions.
|
Methods and materials
|
|---|
Adult patients newly diagnosed with a localized primary soft tissue sarcoma and all patients on routine follow up between 1994 and 2004 were identified on the departmental database and the notes of those with lung metastases were reviewed.
Data were collected on the initial grade of tumour and the method of diagnosis of lung metastases. The pathology was reviewed where possible and graded according to Federation Nationale des Centre de Lutte Contre le Cancer (FNCLCC) classification.
|
Results
|
|---|
A total of 179 patients were under follow up during this 10 year period. 24 (13%) developed lung metastases, and 22 sets of notes were retrieved. Two sets of notes were unavailable. Histology was reviewed for 21 patients and known from documentation for 1 patient. None of the 22 cases with pulmonary metastases had grade 1 tumours. 4 cases (18%) had grade 2 tumours and 18 (82%) had grade 3 tumours at initial diagnosis (Table 1
). Six (27%) had their lung metastases diagnosed by routine screening CXR, 9 (42%) had their lung metastases diagnosed on a non-routine CXR, prompted by symptoms, and 7 (32%) had their metastases diagnosed by a CT scan, performed as part of re-staging for local recurrence or performed to investigate a decline in general health (Table 2). 155 patients received 6 monthly CXR for 10 years and remained relapse free. Total patient years at risk were 512.24, equating to 1 patient developing lung metastases for every 21 years of follow up.
|
Discussion
|
|---|
The small size of this cohort prevents meaningful statistical analysis, but the trend shown is in keeping with previously published data. Whilst this audit has not identified the metastatic potential for grade 1 tumours, there are data that this potential exists. In a paper by Le Doussal [1] the 5 year risk of metastases for grade 1 and 2 tumours together was 20%, although it is not clear how many were grade 1.
In a paper by Le [2] looking at prognostic factors in head and neck sarcomas, which included 65 patients, the 5 year cause specific survival was 100% for grade 1 tumours. This is in concordance with a series by Willers et al [7] demonstrating similar outcomes for grade 1 tumours.
However, the interplay of prognostic factors beyond tumour grade alone is relevant. Mandard et al [8] performed a multivariate analysis of 109 patients with soft tissue sarcoma. Four prognostic groups were identified depending on the presence or absence of necrosis, invasive tumour, adequate surgical margins and size of tumour less than or greater than 5 cm. Three patients with FNCLCC grade 1 tumours fell into a poor prognostic due to tumour size greater than 5 cm and/or inadequate surgical margins and 2 of these developed metastatic disease from which they died. A multivariate analysis performed by Heise [9] also demonstrated tumour site to be relevant, with retroperitoneal and mediastinal disease associated with poorer outcomes compared with disease in the extremities or head and neck. Thus it is clear that the prognosis of an individual patient is dependent on factors other than tumour grade.
The usefulness of routine CXR to diagnose metastatic disease in soft tissue sarcoma has been less well documented. Kane [10] has summarized the data demonstrating a lack of cost effectiveness for the use of CT, and highlights how regular clinic visits and thorough clinical examination detect the majority of recurrent disease. Early pulmonary disease is frequently asymptomatic however and, if detected, can still be cured by surgical intervention. The low cumulative dose of radiation received from 6 monthly CXR makes this a safe, simple and appropriate first tool [11]. The optimal follow up for patients with soft tissue sarcoma remains unknown [12], but in this series routine CXR detected 27% of the pulmonary metastatic cases and thus should be recommended. Whilst it may be omitted in patients with grade 1 tumours, other prognostic factors should also be borne in mind, and the decision based on the overall prognostic grouping, rather than grade alone.
Received for publication December 9, 2005.
Revision received February 16, 2006.
Accepted for publication March 10, 2006.
|
References
|
|---|
- Le Doussal V, Coindre JM, Leroux A, Hacene K, Terrier P, Bui NB, et al. Prognostic factors in patients with localised primary malignant fibrous histiocytoma: a multicenter study of 216 patients with multivariate analysis. Cancer 1996;77:1823–30.[CrossRef][Medline]
- Le QT, Fu KK, Kroll S, Fitts L, Massullo V, Ferrell L, et al. Prognostic factors in adult soft tissue sarcomas of the head and neck. Int J Radiat Oncol Biol Phys 1997;37:975–84.[CrossRef][Medline]
- Coindre JM, Terrier P, Guillou L, Le Doussal V, Collin F, Ranchere D, et al. Predictive value of grade for metastases development in the main histologic types of adult soft tissue sarcomas: a study of 1240 patients from the French Federation of Cancer Centers Sarcoma Group. Cancer 2001;91:1914–26.[CrossRef][Medline]
- Vraa S, Keller J, Nielson OS, Sneppen O, Jurik AJ, Jensen OM. Prognostic factors in soft tissue sarcomas: the Aarhus experience. Eur J Cancer 1998;34:1876–82.[CrossRef][Medline]
- Collin CF, Friedrich C, Godbold J, Hajdu S, Brennan MF. Prognostic factors for local recurrence and survival in patients with localised extremity soft tissue sarcoma. Semin Surg Oncol 1988;4:30–7.[Medline]
- Pezzi ME, Rawling MS, Esgro JJ, Pollock RE, Rohmsdahl MM. Prognostic factors in 227 patients with malignant fibrous histiocytoma. Cancer 1992;69:2098–103.[CrossRef][Medline]
- Willers H, Hug EB, Spiro IJ, Efird JT, Rosenberg AE, Wang CC. Adult soft tissue sarcomas of the head and neck treated by radiation and surgery or radiation alone: patterns of failure and prognostic factors. Int J Radiat Oncol Biol Phys 1995;33:585–93.[CrossRef][Medline]
- Mandard AM, Petiot JF, Marnay J, Mandard JC, Chasle J, de Ranieri E, et al. Prognostic factors in soft tissue sarcoma; a multivariate analysis of 109 cases. Cancer 1989;63:1437–51.[CrossRef][Medline]
- Heise HW, Myers MH, Russel WO, Suit HD, Enzinger FM, Edmonson JH, et al. Recurrence free survival time for surgically treated soft tissue sarcoma patients. Cancer 1986;57:172–7.[CrossRef][Medline]
- Kane JM. Surveillance strategies for patients following surgical resection of soft tissue sarcomas. Curr Opin Oncol 2004;16:238–321.
- Chang AE, Schaner EG, Conkle DM, Flye MW, Doppman JL, Rosenberg SA. Evaluation of computed tomography in the detection of pulmonary metastases: a prospective study. Cancer 1979;43:913–6.[CrossRef][Medline]
- Sakata K, Johnson FE, Beitler AL, Kraybill WG, Virgo KS. Extremity soft tissue sarcoma patient follow up; tumour grade and size affect surveillance strategies after potentially curative surgery. Int J Oncol 2003;22:1335–43.[Medline]
This article has been cited by other articles:
|
|
|
|
 
A. C. Watts, K. Teoh, T. Evans, I. Beggs, J. Robb, and D. Porter
MRI surveillance after resection for primary musculoskeletal sarcoma
J Bone Joint Surg Br,
April 1, 2008;
90-B(4):
484 - 487.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
BJR review of the year - 2006
Br. J. Radiol.,
March 1, 2007;
80(951):
147 - 151.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
