Soft Tissue Tumour & Sarcoma Imaging Guidelines 2012
Version Control This is a controlled document please destroy all previous versions on receipt of a new version. Date Approved: March 2011 reissued April 2012 Review Date: April 2014 Version Date Issued Review Date Brief Summary of Change Owner s Name Draft December Original guideline MDT Network Imaging October 2010 1.0 2009 approved Group 1.0 October 2010 March 2011 Sarcoma Agreed by the Imaging & Implementation Sarcoma groups Group (SIG) 1.1 March 2011 April 2012 Reviewed SIG 1.2 April 2012 March 2014 / with the full guidelines Reviewed with guidelines no changes but rebranded for NEYHCA (Cancer) SIG For the latest version of these guidelines please see the NEYHCA (Cancer) website Please press control and click on the link below: www.hyccn.nhs.uk/networkguidelinesandpublications/networkimaginggroup.htm Signature Sheet Agreement of the NEYHCA (Cancer) Guidelines for the Care of Adult Patients with Soft Tissue Tumour & Sarcoma These guidelines have been agreed by: Title Name Date Agreed Chair of the Sarcoma Implementation Group, NEYHCA (Cancer) Medical Director LSTSMDT Lead Hull & East Yorkshire Hospitals NHS Trust Chair of the NEYHCA (Cancer) Imaging Clinical Expert Group Chair, NEYHCA Board / NEYHCA Cancer Management Group Professor Mike Lind 20/4/2012 Mr Alastair Platt 20/4/2012 Dr Ged Avery 20/4/2012 Mrs Allison Cooke 9/5/2012 The Sarcoma Implementation Group have agreed these guidelines 20/4/2012 Page 2 Soft Tissue Tumour & Sarcoma Imaging Guidelines Version 1.2 March 2011 reissued April 2012
Contents Version Control... 2 Signature Sheet... 2 Contents... 3 Soft Tissue Tumour & Sarcoma Imaging Guidelines... 4 1.1 Diagnosis... 4 1.2. Biopsy... 5 1.3. Staging... 5 1.4. Relapse... 5 1.5. Follow Up... 5 Appendices... 6 Appendix (i) Benign Diagnoses... 6 Appendix (ii) Lipoma Requiring Further Evaluation... 6 Appendix (iii) Indeterminate & Sarcoma... 6 Appendix (iv) MRI Protocol Guidelines... 7 Soft Tissue Tumour & Sarcoma Imaging Guidelines Version 1.2 March 2011 reissued April 2012 Page 3
Soft Tissue Tumour & Sarcoma Imaging Guidelines 1.1 Diagnosis 1. Patient attends GP Patients with suspicious lesions should be referred on a 2 week wait to the joint soft tissue tumour clinic. a. Same day USS b. MRI within 1 week Results reviewed at next available MDT US guided biopsy and CT chest are arranged to complete work up (or other test). Patients are then seen again in clinic with biopsy results the following week. Patients are either seen again in clinic to discuss the MRI findings or more usually are told by phone that they need further scans (having been warned to expect a call with their MDT outcome after the MDT. These calls are made by the Sarcoma CNSs. 2. Soft tissue Mass present and GP refers based on the sarcoma guidelines a. Ultrasound one stop clinic b. Consultant surgeon 3. Ultrasound a. Performed/supervised by clinician FRCR/ RCR accredited to perform/report ultrasound (preferably muscular skeletal, and preferably the one stop clinic service). b. History re-taken regarding duration, precipitants, growth, associated symptoms. Examined for position and local changes. c. Ultrasound machine used must be of diagnostic/medical standard with at least 6 monthly QA of electrical safety, transducer, machine and monitor quality. d. Ultrasound examination to assess mass size, mass location (relation to fascia), echotexture, cyst/solid/mixed, Doppler characteristics. e. If diagnostic for non sarcoma (benign) (appendix 1) report to GP. f. If diagnostic for non sarcoma (malignant) by history and appearances report to GP and copy sent to relevant MDT for discussion. g. If diagnostic for lipoma but concerning symptoms (appendix 2) report to GP & MRI (notify sarcoma service). h. If suspicious for sarcoma or indeterminate (appendix 3) report to GP& MRI (notify sarcoma service). 4. MRI performed within 2 weeks of Ultrasound (ideally <10 days) a. Recommended protocol appendix 4. b. If claustrophobic refer to sarcoma service with ultrasound. c. If diagnostic for non sarcoma (benign) (appendix 1) report to GP. d. If diagnostic for non sarcoma (malignant) (appendix 2) report to GP and copy sent to relevant MDT for discussion. e. If suspicious for sarcoma or indeterminate (appendix 4) report to GP& MRI (notify sarcoma service). 5. Sarcoma Service a. Review MR and US. b. Keep biopsy appointment or c. Postpone biopsy and advise LSMDT review first 6. Continue on diagnostic pathway. Page 4 Soft Tissue Tumour & Sarcoma Imaging Guidelines Version 1.2 March 2011 reissued April 2012
1.2. Biopsy 1. Performed by LSMDT member and send to sarcoma histopathologist. 2. Image guided dependant on anatomical location and expertise will be either ultrasound, fluoroscopically or CT guided. 3. Non-image guided (in clinic) - dependant on anatomical location and expertise, may be preferential for expediting management decisions if radiology shows no requirement for targeting focal areas of the mass. 4. Samples should be obtained using a core needle and as large as possible (typically greater than 16 gauge) but will ultimately depend on location, lesion type and patient comorbidity. 5. At least 2 samples should be sent preserved to histopathology and 1 sample fresh to cytogenetics if possible variations on the need for further fresh specimens will depend on level of suspicion for differing suspected tumour types. 1.3. Staging 1. Primary (local) staging will be typically addressed by the diagnostic ultrasound and/or MRI. 2. Staging CT thorax, abdomen and pelvis will be performed routinely to address metastases for highly suspicious lesions prior to known biopsy results or after positive biopsy results. Currently being audited 3. Routine CT/MRI liver, bone or PET scanning is unnecessary except for specific histological subtypes. 1.4. Relapse 1. Suspected early post treatment complications (< 4 weeks) can be initially assessed by ultrasound to detect abscess, seroma and haematoma. 2. Suspected tumour persistence or tumour recurrence will be typically best evaluated by MRI (may need contrast, see appendix 4). Alternative or additional use of ultrasound, CT, isotope bone scan and PET scanning will depend on the suspected tumour type or contraindications to MRI. 3. Biopsy may be necessary to clarify the diagnosis (same criteria as above). 1.5. Follow Up 1. CXR 6 monthly for 5 years for all high grade sarcomas. CT thorax only when clinically indicated. MRI 6 months post surgery for intermediate and high grade tumours of the limbs. 2. CT 6 months post surgery for intermediate and high grade tumours of the abdomen 3. PET scanning where clinically indicated Soft Tissue Tumour & Sarcoma Imaging Guidelines Version 1.2 March 2011 reissued April 2012 Page 5
Appendices Appendix (i) Benign Diagnoses Category Name Description 1 Normal 2 Benign cyst or Ganglion cyst 3 Benign vascular lesion 4 Benign Other 5 Lipoma No abnormality seen on ultrasound Oval lesion, hypo-echoic centrally with a well defined wall and posterior acoustic enhancement Solid or cystic structure with minor linear vascularity demonstrated on colour or power settings Any lesion with either inflammatory characteristics or benign soft tissue mass Homogenous hyper-echoic lesion within the dermis or deep fat planes, no flow within it on colour or power settings and causing no or minimal mass effect to the surrounding structures Appendix (ii) Lipoma Requiring Further Evaluation Category Name Description 6 Lipoma requiring further evaluation (i) Clinically painful, enlarging, greater than 5cm in size, deep to fascia or (ii) Lipoma but mild heterogenicity on ultrasound Appendix (iii) Indeterminate & Sarcoma Category Name Description 7 Indeterminate 8 Possible sarcoma (i) Clinically painful or (ii) Enlarging solid mass and no Doppler flow Solid, heterogeneous lesion with distortion of surrounding anatomy and disorganized vascularity on doppler flow Page 6 Soft Tissue Tumour & Sarcoma Imaging Guidelines Version 1.2 March 2011 reissued April 2012
Appendix (iv) MRI Protocol Guidelines 1. Mark mass with capsule(s). 2. MR imaging performed in 2 orthogonal planes, 5-6 mm slice thickness. a. Axial and Sagittal or Coronal b. T1 weighted (without fat suppression) c. T2 without weighted with fat suppression d. STIR or PD with fat saturation 3. Fast spin echo sequences can be used to reduce motion artefact. 4. Gadolinium useful a. To determine solid or cystic b. Identify necrotic tumour or haematoma c. Patients who have had previous surgery or radiotherapy 5. If gadolinium given T1 fat saturated sequences should be performed post injection. It is NOT necessary to perform T1 fat saturated sequences pre gadolinium injection. 6. Small field of view is ideal but if very focussed should perform localiser views so subsequent clinicians involved can determine exact body positioning. Soft Tissue Tumour & Sarcoma Imaging Guidelines Version 1.2 March 2011 reissued April 2012 Page 7