Journal of Surgical Oncology 2014;109:593–596
MRI Surveillance Following Treatment of Extremity Soft Tissue Sarcoma MATTHEW D. CHENEY, MD, PhD,1* CHRISTINE GIRAUD, MA,2 SAVELI I. GOLDBERG, PhD,2 DANIEL I. ROSENTHAL, MD,3 FRANCIS J. HORNICEK, MD, PhD,4 EDWIN CHOY, MD, PhD,5 JOHN T. MULLEN, MD,6 YEN-LIN CHEN, MD,2 AND THOMAS F. DELANEY, MD2 1 Harvard Radiation Oncology Program, Boston, Massachusetts Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts 3 Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Massachusetts 4 Department of Orthopedic Oncology, Massachusetts General Hospital, Boston, Massachusetts 5 Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts 6 Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts 2
Background and Objectives: Local recurrence (LR) following limb‐sparing surgery and radiation therapy (RT) for extremity soft tissue sarcoma (STS) is rare. The current study investigates the utility of surveillance nuclear magnetic resonance imaging (MRI) for detection of asymptomatic LRs. Methods: The study cohort consisted of 168 adult patients with extremity STS treated with limb‐sparing surgery and RT with curative intent between October 2001 and January 2011. Follow‐up surveillance MRIs and history and physical examinations were performed per the NCCN guidelines with additional MRIs as clinically indicated. The method of LR detection and MRI number and indication were determined. Results: After a median follow‐up of 4.7 years (range: 0.6–10.5) 11 (6.5%; 11/168) patients developed LRs. Five hundred two MRIs were obtained, 429 (85.5%; 429/502) for surveillance and 73 (14.5%; 73/502) as clinically indicated. One hundred fourteen patients underwent 1 surveillance MRI. The median surveillance MRI interval was 6.4 months (range 1.4–68.9). Surveillance MRI detected an asymptomatic LR in 1 (0.9%; 1/114) patient with a complex reconstruction. Conclusions: Surveillance MRI infrequently detects asymptomatic LRs following limb‐sparing surgery and RT for extremity STS and should be limited to patients whose primary tumor sites are not easily assessed by history and physical examination.
J. Surg. Oncol. 2014;109:593–596. ß 2013 Wiley Periodicals, Inc.
KEY WORDS: magnetic resonance imaging; sarcoma; neoplasm recurrence; local; radiotherapy; limb salvage
INTRODUCTION Soft tissue sarcomas, the majority of which occur in extremities, are rare malignancies accounting for 10 cm, and prior recurrence also increase LR risk, some of which may be mitigated by the use of high‐dose RT [7–11]. The majority of LRs occur within 3 years, and while associated with worse outcomes, LRs are isolated in 2/3 of patients, and properly timed, aggressive local management of the recurrence can result in favorable long‐term local control rates [3,9,11–15]. The detection of LR is believed to be important, and in addition to regular history and physical examination, surveillance guidelines recommend prudent, periodic imaging of the primary site based on estimated LR risk and ease of examination, including nuclear magnetic resonance imaging (MRI) [16]. While the role of MRI in staging and treatment planning is well accepted, data informing the appropriate use of MRI in the surveillance setting are few and conflicting [17–22]. Therefore, the purpose of the current study was to evaluate the utility of surveillance MRI in the detection of asymptomatic LRs in extremity soft tissue sarcoma patients who were treated with RT and limb‐sparing surgery.
MATERIALS AND METHODS Patient Population and Treatment We utilized our institutional sarcoma database to identify all adult patients with extremity soft tissue sarcoma who were treated with limb‐
ß 2013 Wiley Periodicals, Inc.
sparing surgery and RT with curative intent between October 2001 and January 2011 at the Massachusetts General Hospital (Boston, MA). Chemotherapy, predominantly interdigitated mesna, adriamycin, ifosfamide, and dacarbazine (MAID) was allowed [23]. The study start date was chosen to match the 2001 adoption of the electronic medical record in the Sarcoma Clinic and thereby allow electronic data retrieval. The 2011 cutoff date allowed for >30 months of potential follow‐up, which would provide sufficient time to capture nearly all LRs. Inclusion required documentation of 6 months of follow‐up with a surgical, medical, or radiation oncologist after the completion of treatment. We chose to exclude patients with less than 6 months of documented follow‐up as these patients generally were followed locally. Patients with Ewing sarcoma, rhabdomyosarcoma, angiosarcoma, pre‐ disposing genetic disorders, node‐positive, recurrent, or metastatic
Abbreviations: CT, computed axial tomography; MAID, mesna, adriamycin, ifosfamide, and dacarbazine; MRI, nuclear magnetic resonance imaging; NCCN, National Comprehensive Cancer Network; RT, radiation therapy. Grant sponsor: Jennifer Hunter Yates Sarcoma Foundation.; Grant sponsor: Kenneth Stanton Fund.; Grant sponsor: The Cassandra Moseley‐Berry Fund and the Moseley Family. *Correspondence to: Matthew D. Cheney, MD, PhD, Harvard Radiation Oncology Program, Massachusetts General Hospital, Lunder Building/LL2, 55 Fruit Street, Boston, MA 02114. Fax: 857‐238‐6377. E‐mail: [email protected] Received 31 October 2013; Accepted 03 December 2013 DOI 10.1002/jso.23541 Published online 24 December 2013 in Wiley Online Library (wileyonlinelibrary.com).
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Cheney et al.
disease at presentation were excluded due to differing treatment and/or follow‐up paradigms. Clinical stage was assigned per the 2010 American Joint Committee on Cancer soft tissue sarcoma staging guidelines [24]. This study was approved by the Massachusetts General Hospital institutional review board.
Follow‐Up, Determination of MRI Indication, and Definition of MRI‐Detected Local Recurrence Patients were followed after treatment according to published guidelines from the National Comprehensive Cancer Network (NCCN) [16]. History and physical examinations were performed and MRIs were obtained at the discretion of the treating oncologist following the NCCN guidelines. Surveillance MRIs were defined as those ordered for the purpose of follow‐up, not motivated by patient symptoms or physical exam findings. All others were defined as clinically indicated. An MRI‐detected LR was asymptomatic, clinically undetectable, and identified on a surveillance MRI. For patients who underwent MRI, availability of reports was required. All LRs were confirmed by pathologic assessment. The date of last follow‐up was September 16, 2013.
RESULTS Patient Population and Treatment During the study period, 204 patients with extremity soft tissue sarcoma were treated with limb‐sparing surgery and RT with curative intent. One hundred sixty‐eight of these patients met the study eligibility criteria and 36 patients were excluded as shown in Table I. As shown in Table II, the median patient age was 52 years (range: 17–89). The median tumor size was 6.1 cm (range: 0.7–35.5 cm), including 45 (26.8%; 45/168) tumors 10 cm. The majority (74.4%; 125/168) of tumors arose in the lower extremity and most tumors were deep to or invading the superficial fascia (69.0%; 116/168). 88.1% (148/168; 86 grade 2, 62 grade 3) were high grade. Pre‐operative RT a post‐ operative boost was employed in 86.3% (145/168) of patients; the remainder underwent post‐operative RT. The mean RT dose was 52.7 Gy (standard deviation ¼ 8.4). Final negative surgical margins were achieved in 82.7% (139/168) of patients. 28.6% (48/168) of patients received a median of 6 cycles (range: 1–6) of chemotherapy with curative intent, predominantly MAID.
Treatment Outcomes 30.4% (51/168) of patients developed recurrent disease after a median follow‐up of 4.7 years (range: 0.6–10.5). 28.0% (47/168) of TABLE I. Indications for Exclusion of Extremity Soft Tissue Sarcoma Patients Treated With Radiation Therapy and Surgery With Curative Intent From the Study Population Patient characteristic Insufficient follow‐up Neurofibromatosis Recurrent disease at initial presentation Node‐positive disease Angiosarcoma Ewing sarcoma Metastatic disease Li–Fraumeni syndrome Rhabdomyosarcoma MRI reports unavailable Total excluded MRI, nuclear magnetic resonance imaging.
Journal of Surgical Oncology
Number of patients 13 6 5 4 2 2 1 1 1 1 36
TABLE II. Distribution of the Extremity Soft Tissue Sarcoma Patients’ Clinical Characteristics and Treatments Received Clinical characteristic Age (years) (%) Median [range]
MRI Surveillance Following Treatment of Extremity Soft Tissue Sarcoma MATTHEW D. CHENEY, MD, PhD,1* CHRISTINE GIRAUD, MA,2 SAVELI I. GOLDBERG, PhD,2 DANIEL I. ROSENTHAL, MD,3 FRANCIS J. HORNICEK, MD, PhD,4 EDWIN CHOY, MD, PhD,5 JOHN T. MULLEN, MD,6 YEN-LIN CHEN, MD,2 AND THOMAS F. DELANEY, MD2 1 Harvard Radiation Oncology Program, Boston, Massachusetts Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts 3 Department of Diagnostic Radiology, Massachusetts General Hospital, Boston, Massachusetts 4 Department of Orthopedic Oncology, Massachusetts General Hospital, Boston, Massachusetts 5 Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts 6 Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts 2
Background and Objectives: Local recurrence (LR) following limb‐sparing surgery and radiation therapy (RT) for extremity soft tissue sarcoma (STS) is rare. The current study investigates the utility of surveillance nuclear magnetic resonance imaging (MRI) for detection of asymptomatic LRs. Methods: The study cohort consisted of 168 adult patients with extremity STS treated with limb‐sparing surgery and RT with curative intent between October 2001 and January 2011. Follow‐up surveillance MRIs and history and physical examinations were performed per the NCCN guidelines with additional MRIs as clinically indicated. The method of LR detection and MRI number and indication were determined. Results: After a median follow‐up of 4.7 years (range: 0.6–10.5) 11 (6.5%; 11/168) patients developed LRs. Five hundred two MRIs were obtained, 429 (85.5%; 429/502) for surveillance and 73 (14.5%; 73/502) as clinically indicated. One hundred fourteen patients underwent 1 surveillance MRI. The median surveillance MRI interval was 6.4 months (range 1.4–68.9). Surveillance MRI detected an asymptomatic LR in 1 (0.9%; 1/114) patient with a complex reconstruction. Conclusions: Surveillance MRI infrequently detects asymptomatic LRs following limb‐sparing surgery and RT for extremity STS and should be limited to patients whose primary tumor sites are not easily assessed by history and physical examination.
J. Surg. Oncol. 2014;109:593–596. ß 2013 Wiley Periodicals, Inc.
KEY WORDS: magnetic resonance imaging; sarcoma; neoplasm recurrence; local; radiotherapy; limb salvage
INTRODUCTION Soft tissue sarcomas, the majority of which occur in extremities, are rare malignancies accounting for 10 cm, and prior recurrence also increase LR risk, some of which may be mitigated by the use of high‐dose RT [7–11]. The majority of LRs occur within 3 years, and while associated with worse outcomes, LRs are isolated in 2/3 of patients, and properly timed, aggressive local management of the recurrence can result in favorable long‐term local control rates [3,9,11–15]. The detection of LR is believed to be important, and in addition to regular history and physical examination, surveillance guidelines recommend prudent, periodic imaging of the primary site based on estimated LR risk and ease of examination, including nuclear magnetic resonance imaging (MRI) [16]. While the role of MRI in staging and treatment planning is well accepted, data informing the appropriate use of MRI in the surveillance setting are few and conflicting [17–22]. Therefore, the purpose of the current study was to evaluate the utility of surveillance MRI in the detection of asymptomatic LRs in extremity soft tissue sarcoma patients who were treated with RT and limb‐sparing surgery.
MATERIALS AND METHODS Patient Population and Treatment We utilized our institutional sarcoma database to identify all adult patients with extremity soft tissue sarcoma who were treated with limb‐
ß 2013 Wiley Periodicals, Inc.
sparing surgery and RT with curative intent between October 2001 and January 2011 at the Massachusetts General Hospital (Boston, MA). Chemotherapy, predominantly interdigitated mesna, adriamycin, ifosfamide, and dacarbazine (MAID) was allowed [23]. The study start date was chosen to match the 2001 adoption of the electronic medical record in the Sarcoma Clinic and thereby allow electronic data retrieval. The 2011 cutoff date allowed for >30 months of potential follow‐up, which would provide sufficient time to capture nearly all LRs. Inclusion required documentation of 6 months of follow‐up with a surgical, medical, or radiation oncologist after the completion of treatment. We chose to exclude patients with less than 6 months of documented follow‐up as these patients generally were followed locally. Patients with Ewing sarcoma, rhabdomyosarcoma, angiosarcoma, pre‐ disposing genetic disorders, node‐positive, recurrent, or metastatic
Abbreviations: CT, computed axial tomography; MAID, mesna, adriamycin, ifosfamide, and dacarbazine; MRI, nuclear magnetic resonance imaging; NCCN, National Comprehensive Cancer Network; RT, radiation therapy. Grant sponsor: Jennifer Hunter Yates Sarcoma Foundation.; Grant sponsor: Kenneth Stanton Fund.; Grant sponsor: The Cassandra Moseley‐Berry Fund and the Moseley Family. *Correspondence to: Matthew D. Cheney, MD, PhD, Harvard Radiation Oncology Program, Massachusetts General Hospital, Lunder Building/LL2, 55 Fruit Street, Boston, MA 02114. Fax: 857‐238‐6377. E‐mail: [email protected] Received 31 October 2013; Accepted 03 December 2013 DOI 10.1002/jso.23541 Published online 24 December 2013 in Wiley Online Library (wileyonlinelibrary.com).
594
Cheney et al.
disease at presentation were excluded due to differing treatment and/or follow‐up paradigms. Clinical stage was assigned per the 2010 American Joint Committee on Cancer soft tissue sarcoma staging guidelines [24]. This study was approved by the Massachusetts General Hospital institutional review board.
Follow‐Up, Determination of MRI Indication, and Definition of MRI‐Detected Local Recurrence Patients were followed after treatment according to published guidelines from the National Comprehensive Cancer Network (NCCN) [16]. History and physical examinations were performed and MRIs were obtained at the discretion of the treating oncologist following the NCCN guidelines. Surveillance MRIs were defined as those ordered for the purpose of follow‐up, not motivated by patient symptoms or physical exam findings. All others were defined as clinically indicated. An MRI‐detected LR was asymptomatic, clinically undetectable, and identified on a surveillance MRI. For patients who underwent MRI, availability of reports was required. All LRs were confirmed by pathologic assessment. The date of last follow‐up was September 16, 2013.
RESULTS Patient Population and Treatment During the study period, 204 patients with extremity soft tissue sarcoma were treated with limb‐sparing surgery and RT with curative intent. One hundred sixty‐eight of these patients met the study eligibility criteria and 36 patients were excluded as shown in Table I. As shown in Table II, the median patient age was 52 years (range: 17–89). The median tumor size was 6.1 cm (range: 0.7–35.5 cm), including 45 (26.8%; 45/168) tumors 10 cm. The majority (74.4%; 125/168) of tumors arose in the lower extremity and most tumors were deep to or invading the superficial fascia (69.0%; 116/168). 88.1% (148/168; 86 grade 2, 62 grade 3) were high grade. Pre‐operative RT a post‐ operative boost was employed in 86.3% (145/168) of patients; the remainder underwent post‐operative RT. The mean RT dose was 52.7 Gy (standard deviation ¼ 8.4). Final negative surgical margins were achieved in 82.7% (139/168) of patients. 28.6% (48/168) of patients received a median of 6 cycles (range: 1–6) of chemotherapy with curative intent, predominantly MAID.
Treatment Outcomes 30.4% (51/168) of patients developed recurrent disease after a median follow‐up of 4.7 years (range: 0.6–10.5). 28.0% (47/168) of TABLE I. Indications for Exclusion of Extremity Soft Tissue Sarcoma Patients Treated With Radiation Therapy and Surgery With Curative Intent From the Study Population Patient characteristic Insufficient follow‐up Neurofibromatosis Recurrent disease at initial presentation Node‐positive disease Angiosarcoma Ewing sarcoma Metastatic disease Li–Fraumeni syndrome Rhabdomyosarcoma MRI reports unavailable Total excluded MRI, nuclear magnetic resonance imaging.
Journal of Surgical Oncology
Number of patients 13 6 5 4 2 2 1 1 1 1 36
TABLE II. Distribution of the Extremity Soft Tissue Sarcoma Patients’ Clinical Characteristics and Treatments Received Clinical characteristic Age (years) (%) Median [range]
