Ultrasound screening of soft tissue masses in the trunk ...



Ultrasound screening of soft tissue masses in the trunk and extremity - a BSG guide for ultrasonographers and primary care.Mike BradleyPhilip RobinsonCraig GerrandAndrew HayesIntroductionSoft tissue masses in the trunk and extremity are common and most are benign. However, it is very important to rapidly identify malignant tumours, including soft tissue sarcomas. Ultrasound examination is a useful screening test which quickly identifies masses with concerning features and provides rapid reassurance about benign tumours (often lipomas), avoiding the distress and service demands of an unnecessary urgent cancer referral ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1155/2012/781723", "ISSN" : "1357-714X", "PMID" : "22792037", "abstract" : "<p> <italic>Purpose</italic> . To prospectively evaluate regional referrals into a soft tissue sarcoma service from outside the tertiary centre with local hospital imaging. <italic>Materials and Methods</italic> . Consecutive referrals were prospectively assessed for: patient demographics, source, referral date, date received by Multidisciplinary Team (MDT), lesion size, local radiology, MDT radiology and final diagnoses. Radiology diagnosis was categorised benign, indeterminate or malignant by consensus. Delays were defined as &gt;10 days. <italic>Results</italic> . 112 patients were included with high correlation between local and MDT radiology categrorisation and histology ( <math> <mi>P</mi> <mo>=</mo> <mn>0.54</mn> </math> and <math> <mi>P</mi> <mo>=</mo> <mn>0.49</mn> </math> , resp.). There was only a trend for MDT radiology diagnosis to downgrade local imaging diagnosis ( <math> <mi>n</mi> <mo>=</mo> <mn>15</mn> </math> , <math> <mi>P</mi> <mo>&gt;</mo> <mn>0.05</mn> </math> ). 48 cases (43%) had ultrasound and MRI at referral and 20 (18%) ultrasound only. 85% of cases were benign (lipoma most common), 15% malignant (sarcoma most common). Delay occurred in 34% of cases. <italic>Discussion</italic> . In comparison to previous series these results show a reduction in benign lesions, increased biopsy and malignancy rate for lesions referred to a tertiary centre when imaging is performed and reviewed by local radiologists. <italic>Advances in Knowledge</italic> . Imaging triage of soft tissue masses can decrease benign referral rates and increase the proportion of indeterminate and malignant lesions referred to specialist centres. </p>", "author" : [ { "dropping-particle" : "", "family" : "Rowbotham", "given" : "Emma", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bhuva", "given" : "Shaheel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gupta", "given" : "Harun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "Philip", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Sarcoma", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "1-5", "title" : "Assessment of Referrals into the Soft Tissue Sarcoma Service: Evaluation of Imaging Early in the Pathway Process", "type" : "article-journal", "volume" : "2012" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.crad.2009.01.012", "ISSN" : "1365-229X", "PMID" : "19414084", "abstract" : "AIM To evaluate the efficacy of ultrasound as a first-line investigation in patients with a clinical soft-tissue mass. METHODS Three hundred and fifty-eight consecutive patients (155 male, 203 female, mean age 48 years) referred from primary and secondary care with soft-tissue masses underwent ultrasound evaluation. Five radiologists performed ultrasound using a 10-15 MHz linear transducer and recorded the referrer diagnosis, history, lesion size, anatomical location and depth, internal echogenicity, external margins (well-defined rim or infiltrative), and vascularity on power Doppler (absent or present, if present the pattern was listed as either linear or disorganized). A provisional ultrasound diagnosis was made using one of eight categories. Benign categories (categories 1-5) were referred back to a non-sarcoma specialist or original referrer for observation. Indeterminate or possible sarcomas (categories 6-8) were referred for magnetic resonance imaging (MRI) within 14 days. Additionally category 8 lesions were referred to the regional sarcoma service. Institutional and regional database follow-up was performed. RESULTS Two hundred and eighty-four of the 358 (79%) lesions were classified as benign (categories 1-5). On follow-up 15 of the 284 patients were re-referred but none (284/284) had a malignancy on follow-up (24-30 months). Overall at ultrasound 33 lesions were larger than 5 cm, 42 lesions were deep to deep fascia with 20 showing both features. In this subgroup of 95 patients there were six malignant tumours with the rest benign. Seventy-three of the 358 patients underwent MRI; the results of which indicated that there were 60 benign or non-tumours, 10 possible sarcomas, and three indeterminate lesions. Overall six of 12 (6/358, 1.68% of total patients) lesions deemed to represent possible sarcomas on imaging were sarcomas. CONCLUSION Ultrasound is an effective diagnostic triage tool for the evaluation of soft-tissue masses referred from primary care.", "author" : [ { "dropping-particle" : "", "family" : "Lakkaraju", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sinha", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Garikipati", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Edward", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical radiology", "id" : "ITEM-2", "issue" : "6", "issued" : { "date-parts" : [ [ "2009", "6" ] ] }, "page" : "615-21", "title" : "Ultrasound for initial evaluation and triage of clinically suspicious soft-tissue masses.", "type" : "article-journal", "volume" : "64" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[4, 5]", "plainTextFormattedCitation" : "[4, 5]", "previouslyFormattedCitation" : "[4, 5]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[4, 5].Referral guidelines recommend that masses which have any of the following features should be referred urgently to a sarcoma multi-disciplinary team (MDT) for investigation and further management:Increasing in sizeSize more than 5 cm (except subcutaneous lipomas)PainfulMasses which are deep or recur after previous excision are also more likely to be sarcomas ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1186/s13569-016-0060-4", "ISSN" : "2045-3329", "PMID" : "27891213", "author" : [ { "dropping-particle" : "", "family" : "Dangoor", "given" : "Adam", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seddon", "given" : "Beatrice", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gerrand", "given" : "Craig", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grimer", "given" : "Robert", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Whelan", "given" : "Jeremy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Judson", "given" : "Ian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical Sarcoma Research", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2016" ] ] }, "page" : "20", "publisher" : "BioMed Central", "title" : "UK guidelines for the management of soft tissue sarcomas", "type" : "article-journal", "volume" : "6" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[2]", "plainTextFormattedCitation" : "[2]", "previouslyFormattedCitation" : "[2]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[2]. Lipomatous tumours are common in the trunk and extremity and the vast majority, particularly in the subcutaneous tissues, are simple lipomas or benign variants such as angiolipomas or fibrolipomas. Deep lipomatous tumours (under the deep fascia) are most often inter- or intramuscular lipomas or atypical lipomatous tumours (ALTs). ALTs are indolent tumours with no capacity for metastatic spread in the absence of de-differentiation (a rare event), and can be large (considerably greater than 5cm) at presentation. The term “well differentiated liposarcoma” is now only used to describe tumours in the abdomen where the risk of de-differentiation is higher. 5% of patients have multiple lipomas. Angiolipomas are also typically multiple ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "978-92-832-2434-1", "abstract" : "\"WHO Classification of Soft Tissue and Bone\" is the fifth volume of the 4th Edition of the WHO series on histological and genetic typing of human tumors. This authoritative, concise reference book provides an international standard for oncologists and pathologists and will serve as an indispensable guide for use in the design of studies monitoring response to therapy and clinical outcome. Diagnostic criteria, pathological features, and associated genetic alterations are described in a strictly disease-oriented manner. Sections on all recognized neoplasms and their variants include new ICD-O codes, epidemiology, clinical features, macroscopy, pathology, genetics, and prognosis and predictive factors.This book is in the series commonly referred to as the \"Blue Book\" series.", "edition" : "Fourth", "editor" : [ { "dropping-particle" : "", "family" : "Fletcher", "given" : "Christopher D M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bridge", "given" : "Julia A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hogendoorn", "given" : "Pancras C W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mertens", "given" : "Fredrik", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013" ] ] }, "publisher" : "World Health Organization", "publisher-place" : "Lyon, France", "title" : "Who Classification of Tumours of Soft Tissue and Bone", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[3]", "plainTextFormattedCitation" : "[3]", "previouslyFormattedCitation" : "[3]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[3] .Tumours which are confirmed on ultrasound to be lipomatous and located above the deep fascia are rarely malignant or ALTs, even if there are some atypical features on ultrasound (eg vascularity or thickened septae)ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/PAS.0000000000000468", "ISSN" : "1532-0979", "PMID" : "26146760", "abstract" : "To discriminate lipomas from atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDL) we perform fluorescence in situ hybridization (FISH) for MDM2 amplification in several problematic situations: \"lipomas\" >10 cm, lesions with equivocal atypia, recurrent \"lipomas,\" all retroperitoneal/pelvic/abdominal \"lipomas\", and in cases not fitting the above criteria but having worrisome clinical or radiologic features. To ascertain the validity of these criteria, we have reviewed our experience with 301 consecutive differentiated lipomatous tumors in which the diagnosis of ALT could not be established on the basis of histologic sections and in which FISH was performed on the basis of the above criteria. The final diagnosis was based on MDM2 amplification status. Given the nature of this study to evaluate difficult lesions, most cases included (74%) were received in consultation. This enhanced our study series for borderline cases, and the data presented may not be generalizable to adipocytic tumors seen outside a subspecialty setting. Of 301 cases, 108 proved to be ALT/WDL (36%). The most common test indication was size >10 cm (n=187), followed by equivocal atypia (n=145), retroperitoneal/pelvic/abdominal location (n=86), recurrence (n=33), and clinical concern (n=12). Of the tumors >10 cm, 68 (36%) proved to be ALT/WDL, whereas the remainder were interpreted as lipoma or its variants (eg, spindle cell or pleomorphic lipoma). The 2 groups did not differ statistically in size, although ALTs consistently occurred in patients above 50 years of age. Of the cases with equivocal atypia, 72 (50%) proved to be ALT/WDL. Those in the retroperitoneum/abdomen/pelvis were ALT/WDL in 30 cases (35%), and those that had recurred were ALT in 18 cases (55%). Recurrence, atypia, and having multiple indications for testing were more common in ALT than in benign lesions (P=0.02, 0.0001, 0.0012, respectively). No ALT/WDL occurred in the hands and feet, and only a single ALT/WDL was superficial (1 ALT/WDL vs. 60 lipoma/spindle cell or pleomorphic lipoma). Small (<10 cm) retroperitoneal tumors without additional features were always benign (n=9). On the basis of our results, FISH testing is recommended for: (1) recurrent lesions; (2) deep extremity lesions that are >10 cm in patients over 50 years of age; (3) in cases with equivocal atypia; (4) in lesions of the retroperitoneum/pelvis/abdomen, and in special clinical situations as directed by treating clinicians. Testing is l\u2026", "author" : [ { "dropping-particle" : "", "family" : "Clay", "given" : "Michael R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Martinez", "given" : "Anthony P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Weiss", "given" : "Sharon W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Edgar", "given" : "Mark A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The American journal of surgical pathology", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "2015", "10" ] ] }, "page" : "1433-9", "title" : "MDM2 Amplification in Problematic Lipomatous Tumors: Analysis of FISH Testing Criteria.", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[1]", "plainTextFormattedCitation" : "[1]", "previouslyFormattedCitation" : "[1]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[1]. Patients can be reassured accordingly and given advice to observe the mass for changes. Furthermore, if necessary, these can be excised by a non-specialist surgical team. In the unlikely event that such a tumour is malignant on histological examination, re-excision including the deep fascia is usually possible, without detriment to long term outcomes. The aim of this document is therefore to clarify how to screen trunk and extremity soft tissue tumours using ultrasound and triage them appropriately. This document is a companion to the BSG guidance on the management of soft tissue sarcomas ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1186/s13569-016-0060-4", "ISSN" : "2045-3329", "PMID" : "27891213", "author" : [ { "dropping-particle" : "", "family" : "Dangoor", "given" : "Adam", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seddon", "given" : "Beatrice", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gerrand", "given" : "Craig", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grimer", "given" : "Robert", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Whelan", "given" : "Jeremy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Judson", "given" : "Ian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical Sarcoma Research", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2016" ] ] }, "page" : "20", "publisher" : "BioMed Central", "title" : "UK guidelines for the management of soft tissue sarcomas", "type" : "article-journal", "volume" : "6" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[2]", "plainTextFormattedCitation" : "[2]", "previouslyFormattedCitation" : "[2]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[2] .Ultrasound technique for evaluation of soft tissue massesScans should be performed or supervised by a clinician who is FRCR or RCR accredited to perform and report ultrasound (preferably musculoskeletal ultrasound).A clinical history should be taken, including details of size, duration, precipitants, growth, and associated symptoms, particularly pain. A clinical examination of the mass for position and local changes should be performed.The ultrasound machine used must be of diagnostic/medical standard with at least 6 monthly quality assurance of electrical safety, transducer, machine and monitor quality.Ultrasound should be performed on a high resolution scanner with a linear high frequency probe, typically up to 15/18 mHz, depending on the anatomical location.Ultrasound examination should evaluate mass size, mass location (relationship to fascia), echotexture, whether cystic, solid or mixed, and Doppler characteristics (at low flow settings).Recommendations for action after ultrasound scanScans diagnostic of a benign non –tumour diagnosis (such as a ganglion) should be reported to the requesting clinician and GP to manage as appropriate.Patients with scans diagnostic of a benign lipoma with typical* or atypical** ultrasound features and which are subcutaneous, painless and not growing can be referred back to primary care for further management. This could include excision by a non-specialist team, observation with advice to patients, or interval scan (for example after 6 months). It is reasonable, if there are ongoing concerns, to refer larger tumours in this category (>7cm) for non-urgent assessment by a Sarcoma Service, although the risk of malignancy is very low.Patients with scans diagnostic of a benign lipoma with typical* or atypical** ultrasound features and which are deep to fascia, painful or enlarging should be further investigated with an MRI scan first if possible, and then should be referred to a Sarcoma Service for advice on a non-urgent basis (non-cancer referral). This may include review of the imaging and/or the patient.In the less common situation that the scan indicates a lipoma with significantly concerning ultrasound features, or a non-lipoma with indeterminate or concerning ultrasound features, raising the possibility of malignancy, then an urgent 2-week wait, suspected cancer, referral to a sarcoma service is appropriate, ideally with an urgent MRI if available.Scans which are diagnostic or suspicious of a malignant non-sarcomatous mass (such as a lymph node mass) should be reported to the requesting clinician and GP for urgent referral to the appropriate oncology service (Figure 1).GUIDE FOR ULTRASOUND IMAGING OF LIPOMATOUS TUMOURSBenign lipoma with typical ultrasound features*Homogeneous massNo or septal linear power Doppler flowNo or thin (<2mm) septaBenign lipoma with atypical ultrasound features**Lipoma but very thick septa (>2mm) Nodular area(s) of oedema or fat necrosis in predominantly fatty lesionDisorganised power Doppler flow in predominantly fatty lesion Lipoma with concerning ultrasound features*** Nodular area of non-fat signal in a deep lipomatous massNon-lipoma with indeterminate or concerning ultrasound features****Solid non lipomatous mass Heterogeneous massInvasive marginsDisorganised power Doppler flow in solid heterogeneous lesionFigure 1. Guide for Ultrasound Imaging of Trunk and Extremity TumoursReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1. Clay MR, Martinez AP, Weiss SW, Edgar MA. MDM2 Amplification in Problematic Lipomatous Tumors: Analysis of FISH Testing Criteria. Am. J. Surg. Pathol. 2015;39:1433–9. Available at: [Accessed May 12, 2018].2. Dangoor A, Seddon B, Gerrand C, Grimer R, Whelan J, Judson I. UK guidelines for the management of soft tissue sarcomas. Clin. Sarcoma Res. 2016;6:20. Available at: . Fletcher CDM, Bridge JA, Hogendoorn PCW, Mertens F eds. Who Classification of Tumours of Soft Tissue and Bone. Fourth. Lyon, France: World Health Organization; 2013.4. Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and triage of clinically suspicious soft-tissue masses. Clin. Radiol. 2009;64:615–21. Available at: [Accessed November 22, 2017].5. Rowbotham E, Bhuva S, Gupta H, Robinson P. Assessment of Referrals into the Soft Tissue Sarcoma Service: Evaluation of Imaging Early in the Pathway Process. Sarcoma. 2012;2012:1–5. Available at: [Accessed November 22, 2017]. ................
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