Home Gadolinium Contrast Enhancement Improves Confidence in Diagnosing Recurrent Soft Tissue Sarcoma by MRI
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Gadolinium Contrast Enhancement Improves Confidence in Diagnosing Recurrent Soft Tissue Sarcoma by MRI

Posted Apr 30, 2017 Updated Apr 10, 2023
By Shinn-Huey S. Chou MD , Daniel S. Hippe MS , Amie Y. Lee MD , Kurt Scherer MD , Jack A. Porrino MD , Darin J. Davidson MD , Felix S. Chew MD , Alice S. Ha MD
11 min read

Rationale and Objectives

To determine how utilization of postgadolinium magnetic resonance imaging (MRI) influenced reader accuracy and confidence at identifying postoperative soft tissue sarcoma (STS) recurrence among readers with various levels of expertise.

Materials and Methods

This retrospective study was institutional review board approved and Health Insurance Portability and Accountability Act compliant. Postoperative MRI from 26 patients with prior STS resection (13 patients with confirmed recurrence, 13 without recurrence) was reviewed. Four blinded readers of varying expertise (radiology resident, fellow, attending, and orthopedic oncologist) initially evaluated only the precontrast images and rated each MRI for recurrence on a 5-point confidence scale. Assessment was repeated with the addition of contrast-enhanced sequences. Diagnostic accuracy based on confidence ratings was evaluated using the area under the receiver operating characteristic curve (AUC). Changes in confidence ratings were calculated using Wilcoxon signed-rank test.

Results

All readers demonstrated good diagnostic accuracy both with and without contrast-enhanced images (AUC >0.98 for each reader). When contrast-enhanced images were made available, the resident recorded improved confidence with both assigning ( P = 0.031) and excluding recurrence ( P = 0.006); the fellow showed improved confidence only with assigning recurrence ( P = 0.015); and the surgeon showed improved confidence in excluding recurrence ( P = 0.003). The addition of contrast-enhanced images did not significantly influence the diagnostic confidence of the attending radiologist.

Conclusions

Diagnostic accuracy of MRI was excellent in evaluating postoperative STS recurrence, and reader confidence improved depending on expertise when postgadolinium imaging was included in the assessment.

Introduction

Soft tissue sarcomas (STS) are a heterogeneous group of mesenchymal neoplasms that constitute less than 1% of all adult malignancies . Primary treatment of STS typically consists of limb-sparing surgical resection with or without radiation therapy and/or chemotherapy . The role of chemotherapy and radiation preoperatively and postoperatively can vary depending on specific diagnosis, adequacy of margin, tumor grade, and lesion location. Although the reported rates of local recurrence ranged from 6.5% to near 50% and averaging around 20% , there is no established optimal surveillance strategy given the lack of prospective data . In addition to periodic clinical assessments posttreatment, magnetic resonance imaging (MRI) is often performed to survey for local recurrence . It is the most appropriate radiologic procedure for local recurrence surveillance of malignant or aggressive musculoskeletal soft tissue tumors based on the American College of Radiology Appropriateness Criteria guideline . However, its utility in detecting asymptomatic recurrence has been disputed, with prior studies showing inconsistent results, and several recent studies suggesting doubtful benefits . Advanced imaging tools such as positron emission tomography hybrid imaging and functional MRI employing dynamic contrast enhancement (DCE) and diffusion-weighted imaging with apparent diffusion coefficient have shown promising results in supplementing standard MRI protocols, such as improved specificity by DCE, in identifying recurrence .

Intravenous gadolinium-based contrast agents are commonly used in MRI follow-up of STS after treatment . The American College of Radiology Appropriateness Criteria express only a mild preference for MRI with and without contrast over MRI without contrast in STS surveillance . To our knowledge, there is no study in the literature evaluating a reader’s ability to detect STS recurrence on postoperative MRI, which also explores the impact of contrast-enhanced pulse sequences, controlled for patients, readers, and techniques.

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Materials and Methods

Patient Selection and MRI Examinations

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Image Analysis

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Statistical Analysis

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Results

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TABLE 1

Patient Demographics and Resected Tumor Characteristics ( n = 26 Patients)

Variable No. (%) or Median (Range)P Value With Recurrence ( n = 13) Without Recurrence ( n = 13) Sex Male 8(62) 4(31) 0.24 Female 5(38) 9(69) Age, years 60(26–75) 53(27–85) 0.64 Tumor location Lower extremity 5(38) 9(69) 0.27 Pelvis 3(23) 3(23) Thorax 1(8) 0(0) Upper extremity 4(31) 1(8) Tumor depth Deep 10(77) 9(69) >0.99 In relation to superficial fascia Superficial 3(23) 4(31) Largest tumor dimension, cm Before surgery \* 7.2(3.0–17.0) 5.0(2.5–23.0) 0.51 Recurrence 5.0(1.0–23.0) — — Tumor margin † Positive 6(46) 4(31) 0.69 Negative 7(54) 8(62) Tumor grade ‡ Low 3(23) 2(15) 0.67 Intermediate 3(23) 5(38) High 7(54) 5(38) Tumor histopathology Myxoid type 8(62) 4(31) 0.24 Other 5(38) 9(69)

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Figure 1, A 63-year-old woman with left gluteal undifferentiated pleomorphic sarcoma status post resection at an outside institution. Patient denied any symptoms and physical examination revealed a well-healed transverse incision without palpable soft tissue mass. Precontrast axial T1 (a) and T2 fat-suppressed (b) images showed a T1-isointense, T2-hyperintense nodule (white arrows) adjacent to a seroma. Postcontrast axial (c) T1 fat-suppressed images demonstrated corresponding solid enhancement of the nodule (white arrows). Incorrect diagnoses were made by all four readers with confidence levels of 2 (most likely no recurrence) and 3 (equivocal) based on precontrast images. The resident and attending radiologists made the correct diagnoses with assessments of 4 (most likely recurrence) and 5 (definitely recurrence), respectively, after the addition of contrast-enhanced images. The fellow radiologist moved toward the correct diagnosis from 2 (most likely no recurrence) to 3 (equivocal). The orthopedic oncologist moved farther away from the correct diagnosis from 3 (equivocal) to 2 (most likely no recurrence). MRI, magnetic resonance imaging.

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TABLE 2

Diagnostic Accuracy of Confidence Score for Recurrence with or without Postcontrast Images Available

Reader AUC Sensitivity † Specificity † With Contrast Without Contrast_P_ Value \* With Contrast Without Contrast_P_ Value \* With Contrast Without Contrast_P_ Value \* R1: Resident radiologist 1.000 1.000 >0.99 13(100.0) 8(61.5) 0.0625 13(100.0) 13(100.0) >0.99 R2: Fellow radiologist 1.000 0.985 0.060 12(92.3) 11(84.6) >0.99 13(100.0) 12(92.3) >0.99 R3: Attending radiologist 1.000 0.994 0.25 11(84.6) 10(76.9) >0.99 13(100.0) 13(100.0) >0.99 R4: Orthopedic oncologist 0.997 0.982 0.52 11(84.6) 7(53.9) 0.125 13(100.0) 12(92.3) >0.99 All readers(R1–R4) ‡ 0.999 0.990 0.19 47(90.4) 36(69.2) 0.027 52(100.0) 50(96.2) 0.50 Radiologists(R1–R3) ‡ 1.000 0.993 0.016 36(92.3) 29(74.4) 0.065 39(100.0) 38(97.4) >0.99

AUC, area under the ROC curve; ROC, receiver operating characteristic.

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Figure 2, Numbers of cases (count) with the assigned confidence ratings for recurrence (top row) and nonrecurrence (bottom row) when interpreting MRI without contrast-enhanced sequences (left column) and MRI with contrast-enhanced sequences (right column) for all four individual readers. Confidence ratings: 1 = definitely no recurrence; 2 = most likely no recurrence; 3 = equivocal; 4 = most likely recurrence; 5 = definitely recurrence. MRI, magnetic resonance imaging.

TABLE 3

Confidence in Recurrence Diagnosis

Reader With Recurrence Without Recurrence With Contrast Without Contrast_P_ Value \* With Contrast Without Contrast_P_ Value \* R1: Resident radiologist 4.7 ± 0.5 4.1 ± 1.0 0.031 1.2 ± 0.4 1.8 ± 0.4 0.006 R2: Fellow radiologist 4.8 ± 0.6 4.2 ± 0.9 0.015 1.1 ± 0.3 1.3 ± 0.6 0.15 R3: Attending radiologist 4.7 ± 0.8 4.0 ± 1.1 0.065 1.0 ± 0.0 1.1 ± 0.3 >0.99 R4: Orthopedic oncologist 4.1 ± 0.9 3.8 ± 0.8 0.13 1.1 ± 0.3 1.9 ± 0.5 0.003 R1–R4 combined 4.6 ± 0.7 4.0 ± 0.9 <0.001 1.1 ± 0.3 1.5 ± 0.6 <0.001 R1–R3 combined 4.7 ± 0.6 4.1 ± 1.0 <0.001 1.1 ± 0.3 1.4 ± 0.5 0.008

Values are mean ± standard deviation of the confidence scale (5-point scale with 1 = definitely absent and 5 = definitely present).

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Figure 3, A 75-year-old woman with extraskeletal myxoid chondrosarcoma recurrence in the left thigh. Precontrast images showed hyperintense nodules surrounding the superficial femoral vessels in the medial thigh on the axial T2 fat-suppressed image (a) . Nodules were isointense to muscle on the axial T1 (b) and axial T1 fat-suppressed images (c) . Postcontrast axial T1 fat-suppressed image (d) demonstrated corresponding solid enhancement of the nodules. All four readers made the correct diagnosis. Confidence levels were improved from 3 (equivocal) based on precontrast images to 4 (most likely) and 5 (definitely recurrence) after the addition of postcontrast images in the orthopedic oncologist, resident radiologist, and fellow radiologist. Confidence levels of the attending radiologist remained the same at 5 (definitely recurrence).

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Discussion

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Academic Radiology, Volume 24, Issue 5
Journals General Radiology
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