Transcript Document 7433728

Chondrosarcoma of the chest wall:
primary diagnostics is decisive for outcome
Björn Widhe and Henrik Bauer
Surgical treatment is decisive for outcome in
chondrosarcoma of the chest wall:
A population based Scandinavia Sarcoma Group
study of 106 patients
Journal of Thoracic and Cardiovascular Surgery
2009 Mar;137(3):610-4
Methods:
All chondrosarcoma of the chest wall in Sweden (1980-2002)
Clinical files, pathological specimens, radiographic interpretations,
Pathological specimens were reevaluated and graded blinded to
outcome by the SSG Pathology Board.
Surgical margins were classified into wide, marginal and
intralesional
Complete follow up median 9 (4-23) yrs
Sweden 1980-2002
114 chondrosarcoma patients
3 were excluded due to misclassification of tumor location
1 was excluded - radiation induced chondrosarcoma
4 were excluded as the diagnosis was not supported by the SSG
pathology group
106 patients remained for analysis
59 male and 47 female
Mean age 57 (13-85) year
106 patients
9 patients were not treated with a curative intent
97 patients were operated with a curative intent
55 operated at sarcoma center
42 operated at non specialty hospital
Surgical margins:
wide marginal
Sarcoma center
Non-specialty hospital
intralesional
25
26
4
2
18
22
Surgical margins and survival
Local recurrence
Sarcoma center
16 % (9/55)
Non-specialty center
57 % (24/42)
Better outcome at sarcoma centers
Survival after recurrence
Prognostic factors for local recurrence (Hazard ratio)
Surgical margin 4
Histologic grade 2
Prognostic factors for metastases (Hazard ratio)
Histologic grade 4
Local recurrence 4
Tumor size
1.01 (per cm increment)
The 10-year survival rate
0.75 for patients treated at sarcoma centers.
0.59 for those treated by thoracic or general surgeons.
Why are patients not referred?
Initial symptoms and diagnostics of chest wall
chondrosarcoma.
What happened at the first visit to a doctor?
Have inadequate preoperative diagnostics an impact
on survival ?
Symptoms and physical findings
Thoracic pain
Palpable mass
male
12 % (7/59)
71 % (39/59)
female
11 % (5/47)
57 % (27/47)
The diagnosis at the first medical visit
n
Tumor
Pleurisy
Rib fracture/
Muscle strain
88 (85 % of patients)
4
9
3
Doctors delay was defined as the period from the first
medical visit to the first day of treatment
Doctors delay was in median 4 months (0.1-120)
months
Doctor’s delay > 6 months in 40 % of patients
How come when a tumor was suspected in 85 % of
patients already at the first visit?
Results of the initial Chest radiograph
A tumor was suspected in only 54 % of the chest
radiographs.
Larger tumors were more often found at x-ray
(p<0.01)
Females had more often “normal” x-rays (p<0.01)
Fine needle aspiration biopsy at non-specialty hospitals
(40 patients)
Malignant
Benign
Uncertain
n
11
5
24
Fine needle aspiration biopsy at sarcoma center
(30 patients)
Malignant
Benign
Uncertain
n
29
0
1
Long doctor’s delay was due to several factors
– Normal initial x-ray
– Normal/inconclusive FNAB
– No biopsy at all – the patient was told to come back if
the tumor got bigger – doctor’s delay 18 months!!
“
The difference in accuracy of the Fine
needle aspiration biopsy might be the
most important factor why surgical
margins are worse at non-specialty
centers than at sarcoma centers”
Conclusions
– 10 year survival 16 % better at sarcoma center
– Thoracic surgeons can’t operate sarcomas (in Sweden)
– Normal chest x-ray leads to long doctor’s delay
– FNAB is great at sarcoma centers – but dangerous
outside – just like open biopsies!