chondrosarcoma of the chest wall:
TRANSCRIPT
Chondrosarcoma of the chest wall:primary diagnostics is decisive for outcomeBjörn 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 Surgery2009 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 marginalintralesional
Sarcoma center 25 26
Non-specialty hospital 18 22
4
2
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
male female
Thoracic pain 12 % (7/59) 11 % (5/47)
Palpable mass 71 % (39/59) 57 % (27/47)
The diagnosis at the first medical visit
n
Tumor 88 (85 % of patients)
Pleurisy 4
Rib fracture/ 9
Muscle strain 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)
n
Malignant 11
Benign 5
Uncertain 24
Fine needle aspiration biopsy at sarcoma center (30 patients)
n
Malignant 29
Benign 0
Uncertain 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!