Review/Cancer imaging
Soft-tissue sarcoma in adults: Imaging appearances, pitfalls and diagnostic algorithms

https://doi.org/10.1016/j.diii.2022.12.001Get rights and content

Highlights

  • The radiologist has a pivotal role in the management of patients with suspected soft-tissue sarcoma.

  • Patients with suspected soft-tissue sarcoma must be referred to sarcoma reference center to avoid delayed diagnosis and inadequate surgery with positive margins.

  • Conventional and quantitative MRI helps plan biopsy, anticipate histologic grade, and decide on therapeutic strategy in patients with soft-tissue sarcoma.

  • Distinct practical radiological algorithms are used for the diagnostic management of homogeneous adipocytic tumors and intra-truncal soft-tissue sarcomas.

Abstract

This article provides an overview of the current knowledge regarding diagnostic imaging of patients with soft-tissue sarcomas, which is a heterogeneous group of rare mesenchymal malignancies. After an initial contextualization, diagnostic flow-chart based on initial radiological findings of soft-tissue masses (with specific focus on adipocytic soft-tissue tumors [STTs], hemorragic STTs and retroperitoneal STTs) are provided considering relevant results from novel researches, guidelines, and experts’ viewpoints, with the aim to help radiologists and clinicians in their practice. Particularly, the central place of sarcoma reference centers in the diagnostic and therapeutic management is highlighted, as well as the pivotal role that radiologists should play to correctly identify patients with soft-tissue sarcoma at the initial stage of the disease. Indications and methods for performing imaging-guided biopsies are also discussed, as well as clues to improve soft-tissue sarcoma grading with conventional and quantitative imaging.

Introduction

Sarcomas are rare malignant mesenchymal tumors divided into bone sarcomas, visceral sarcomas, and soft-tissue sarcomas (STS) [1]. Regarding STS, their rarity, ubiquity, and the diversity of their initial clinical and radiological presentations make them challenging to diagnose. Hence, 32 to 70% of patients with STS are not treated in agreement with international guidelines [2]. Yet, correctly orienting patients with a suspicion of STS towards sarcoma reference centers is crucial for their appropriate diagnostic and therapeutic management and to maximize the chance of favourable outcomes. Indeed, Blay et al. have shown in two large cohorts of 12,528 and 35,784 patients that patients managed inside sarcoma reference centers and with the expertise of multidisciplinary tumor board (MDTB) had significantly better compliance to clinical practice guidelines, better quality of the initial surgery with less reoperations, and lower rates of local and metastatic relapses compared to other patients [3,4]. In parallel, the organizations of care for patients with STS, such as the sarcoma network (NETSARC+) in France, have enabled active and collaborative clinical researches and data sharing and, consequently, a considerable amount of knowledge in the epidemiology, treatment, biology, and imaging of STS. The last guidelines published in 2021 by the European Society of Medical Oncology summarize the practical aspects of this knowledge for clinicians but with a limited overview of the improvements of imaging [5].

The purpose of this review was to summarize the current state of good practices for the imaging of patients with STS with an emphasis of the pivotal role of radiologists in the patients’ diagnostic management.

Section snippets

Epidemiology and presentation of STS

STS accounts for 1% of all adult malignancies, with 11 lineages and more than 80 different histologic and molecular subtypes [1,6,7]. Annual records have shown a progressive increase in the incidence of STS over the last decade with 13,100 new patients in the USA in 2020 compared to 11,280 in 2012 [7,8]. The incidence of STS grows with age, with a median age of approximately 60 years [9]. However, some STSs are more frequent in young patients, such as rhabdomyosarcoma and alveolar soft-part

First-line imaging: ultrasonography and conventional radiographs

The initial assessment of soft-tissue lumps usually begins with ultrasonography. Conventional radiography remains suggested by the American College of Radiology Appropriateness Committee, even for superficial masses, to look for the mineralization and bone erosion [42,43]. Conventional radiography can also help orienting towards primary bone origin with secondary extension to soft tissue. According to the European Society for musculoskeletal Radiology [44], ultrasonography should: (i), confirm

Local staging

Once the diagnosis of STS is proven and its grade estimated on biopsy, the local staging relies on MRI. The aim is to help the MDTB of the sarcoma reference centers select the best therapeutic approach. Thus, in addition to tumor size and depth, it is crucial to evaluate the operability by the surgeon, and to identify features associated with a higher grade than the ‘biopsy-grade’, as neoadjuvant treatments may be subsequently indicated.

Conclusion

Imaging has a central place in each phase of the management of STS patients, and both non-specialized and specialized radiologists can have a strong impact in the appropriate management of STS patients [3,4]. Indeed, during the diagnostic interval, knowing when continuing the radiological investigations, how to perform a good quality MRI able to provide the relevant information, and when addressing the patients rapidly to a sarcoma reference center can strongly impact the patients’ quality of

Human rights

The authors declare that the work described has been performed in accordance with the Declaration of Helsinki of the World Medical Association revised in 2013 for experiments involving humans.

Informed consent and patient details

The authors declare that this report does not contain any personal information that could lead to the identification of the patients.

Author contributions

All authors attest that they meet the current International Committee of Medical Journal Editors (ICMJE) criteria for Authorship.

CRediT authorship contribution statement

Amandine Crombé: Conceptualization, Methodology, Project administration, Supervision, Writing – original draft, Validation, Writing – review & editing, Resources. Michèle Kind: Conceptualization, Methodology, Writing – original draft, Validation, Writing – review & editing, Resources. David Fadli: Visualization, Writing – original draft, Validation, Writing – review & editing. Marco Miceli: Resources, Validation, Writing – review & editing. Pierre-Antoine Linck: Resources, Visualization,

Declaration of Competing Interest

The authors declare that they have no competing interest in relation with this article.

Funding

This article did not receive specific funding.

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