Soft tissue tumor imaging in adults: whole-body staging in sarcoma, non-malignant entities requiring special algorithms, pitfalls and special imaging aspects. Guidelines 2024 from the European Society of Musculoskeletal Radiology (ESSR)

Iris-Melanie Noebauer-Huhmann¹, Filip M Vanhoenacker^{2

3}, Joan C Vilanova⁴, Alberto S Tagliafico^{5

6}, Marc-André Weber⁷, Radhesh K Lalam⁸, Thomas Grieser⁹, Violeta Vasilevska Nikodinovska^{10

11}, Jacky W J de Rooy¹², Olympia Papakonstantinou¹³, Catherine Mccarthy¹⁴, Luca Maria Sconfienza^{15

16}, Koenraad Verstraete¹⁷, José Martel-Villagrán¹⁸, Pavol Szomolanyi^{19

20}, Frédéric E Lecouvet²¹, Diana Afonso²², Omar M Albtoush²³, Giacomo Aringhieri²⁴, Remide Arkun^{25

26}, Gunnar Aström²⁷, Alberto Bazzocchi²⁸, Rajesh Botchu²⁹, Martin Breitenseher³⁰, Snehansh Chaudhary³¹, Danoob Dalili³², Mark Davies²⁹, Milko C de Jonge³³, Berna D Mete³⁴, Jan Fritz^{35

36}, Jan L M A Gielen³⁷, Geoff Hide³⁸, Amanda Isaac³⁹, Slavcho Ivanoski⁴⁰, Ramy M Mansour⁴¹, Lorenzo Muntaner-Gimbernat⁴², Ana Navas⁴³, Paul O Donnell⁴⁴, Şebnem Örgüç⁴⁵, Winston J Rennie⁴⁶, Santiago Resano⁴⁷, Philip Robinson^{48

49}, Hatice T Sanal⁵⁰, Simone A J Ter Horst^{51

52}, Kirsten van Langevelde⁴³, Klaus Wörtler⁵³, Marita Koelz⁵⁴, Joannis Panotopoulos⁵⁵, Reinhard Windhager⁵⁶, Johan L Bloem⁴³

Affiliations

¹ Department of Biomedical Imaging and Image Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria. iris.noebauer@meduniwien.ac.at.
² Department of Radiology, AZ Sint Maarten Mechelen University (Hospital) Antwerp, Antwerp, Belgium.
³ Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
⁴ Department of Radiology, Clínica Girona, Institute of Diagnostic Imaging (IDI) Girona, University of Girona, Girona, Spain.
⁵ Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
⁶ Department of Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
⁷ Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany.
⁸ Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK.
⁹ Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany.
¹⁰ Medical Faculty, Ss. Cyril and Methodius University, Skopje, Macedonia.
¹¹ Department of Radiology, University Surgical Clinic "St. Naum Ohridski", Skopje, Macedonia.
¹² Department of Imaging, Radiology, Radboud University Medical Center, Nijmegen, The Netherlands.
¹³ 2nd Department of Radiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece.
¹⁴ Oxford Musculoskeletal Radiology and Oxford University Hospitals, Oxford, UK.
¹⁵ IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
¹⁶ Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Milan, Italy.
¹⁷ Department of Radiology, Ghent University Hospital, Ghent, Belgium.
¹⁸ Radiology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain.
¹⁹ High Field MR Center, Department of Biomedical Imaging and Image‑Guided Therapy, Medical University Vienna, Vienna, Austria.
²⁰ Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia.
²¹ Department of Radiology and Medical Imaging, Cliniques Universitaires Saint Luc, Institut de Recherche Expérimentale et Clinique (IREC), Institut du Cancer Roi Albert II (IRA2), Université Catholique de Louvain (UCLouvain), Brussels, Belgium.
²² Hospital Particular da Madeira and Hospital da Luz Lisboa, Lisbon, Portugal.
²³ Department of Radiology, University of Jordan, Ammam, Jordan.
²⁴ Academic Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
²⁵ Ege University Medical School (Emeritus), Izmir, Türkiye.
²⁶ Star Imaging Center, Izmir, Türkiye.
²⁷ Department of Immunology, Genetics and Pathology (Oncology) and Department of Surgical Sciences (Radiology), Uppsala University, Uppsala, Sweden.
²⁸ Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
²⁹ Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK.
³⁰ Sigmund Freud Privatuniversität, Vienna, Austria.
³¹ Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
³² Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), London, UK.
³³ Department of Radiology, St. Antonius Hospital, Utrecht, The Netherlands.
³⁴ Department of Radiology School of Medicine, Izmir Demokrasi University, Izmir, Türkiye.
³⁵ Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA.
³⁶ Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Tübingen, Germany.
³⁷ Department of Radiology, Jessa Ziekenhuis, Campus Virga Jesse, Hasselt, Belgium.
³⁸ Department of Radiology, Freeman Hospital, Newcastle Upon Tyne, UK.
³⁹ School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
⁴⁰ St. Erasmo Hospital for Orthopaedic Surgery and Traumatology Ohrid, Ohrid, Macedonia.
⁴¹ Oxford University Hospitals, Oxford, UK.
⁴² Hospital Univeritario Son Espases Balearic Islands University, Palma, Spain.
⁴³ Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
⁴⁴ Royal National Orthopaedic Hospital, Stanmore, UK.
⁴⁵ Manisa Celal Bayar University, Manisa, Türkiye.
⁴⁶ Clinical MSK Radiology, Loughborough University, Leicester Royal Infirmary, Leicester, UK.
⁴⁷ Hospital Universitario Ramón y Cajal, Madrid, Spain.
⁴⁸ Musculoskeletal Radiology Department Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
⁴⁹ NIHR Leeds Biomedical Research Centre, Leeds, UK.
⁵⁰ Radiology Department, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Türkiye.
⁵¹ Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
⁵² Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands.
⁵³ Musculoskeletal Radiology Section, Klinikum Rechts der Isar, Technical University of Munich ‑ TUM School of Medicine, Munich, Germany.
⁵⁴ Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria.
⁵⁵ Departement of Orthopaedics and Traumatology, Division of Orthopaedics, Medical University of Vienna, Vienna, Austria.
⁵⁶ Departement of Orthopaedics and Traumatology, Medical University of Vienna, Vienna, Austria.

PMID: 39030374
PMCID: PMC11631817
DOI: 10.1007/s00330-024-10897-z

Review

Soft tissue tumor imaging in adults: whole-body staging in sarcoma, non-malignant entities requiring special algorithms, pitfalls and special imaging aspects. Guidelines 2024 from the European Society of Musculoskeletal Radiology (ESSR)

Iris-Melanie Noebauer-Huhmann et al. Eur Radiol. 2025 Jan.

. 2025 Jan;35(1):351-359.

doi: 10.1007/s00330-024-10897-z. Epub 2024 Jul 20.

Authors

Affiliations

¹ Department of Biomedical Imaging and Image Guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria. iris.noebauer@meduniwien.ac.at.
² Department of Radiology, AZ Sint Maarten Mechelen University (Hospital) Antwerp, Antwerp, Belgium.
³ Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.
⁴ Department of Radiology, Clínica Girona, Institute of Diagnostic Imaging (IDI) Girona, University of Girona, Girona, Spain.
⁵ Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
⁶ Department of Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
⁷ Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany.
⁸ Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK.
⁹ Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany.
¹⁰ Medical Faculty, Ss. Cyril and Methodius University, Skopje, Macedonia.
¹¹ Department of Radiology, University Surgical Clinic "St. Naum Ohridski", Skopje, Macedonia.
¹² Department of Imaging, Radiology, Radboud University Medical Center, Nijmegen, The Netherlands.
¹³ 2nd Department of Radiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece.
¹⁴ Oxford Musculoskeletal Radiology and Oxford University Hospitals, Oxford, UK.
¹⁵ IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
¹⁶ Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Milan, Italy.
¹⁷ Department of Radiology, Ghent University Hospital, Ghent, Belgium.
¹⁸ Radiology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain.
¹⁹ High Field MR Center, Department of Biomedical Imaging and Image‑Guided Therapy, Medical University Vienna, Vienna, Austria.
²⁰ Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia.
²¹ Department of Radiology and Medical Imaging, Cliniques Universitaires Saint Luc, Institut de Recherche Expérimentale et Clinique (IREC), Institut du Cancer Roi Albert II (IRA2), Université Catholique de Louvain (UCLouvain), Brussels, Belgium.
²² Hospital Particular da Madeira and Hospital da Luz Lisboa, Lisbon, Portugal.
²³ Department of Radiology, University of Jordan, Ammam, Jordan.
²⁴ Academic Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
²⁵ Ege University Medical School (Emeritus), Izmir, Türkiye.
²⁶ Star Imaging Center, Izmir, Türkiye.
²⁷ Department of Immunology, Genetics and Pathology (Oncology) and Department of Surgical Sciences (Radiology), Uppsala University, Uppsala, Sweden.
²⁸ Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
²⁹ Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK.
³⁰ Sigmund Freud Privatuniversität, Vienna, Austria.
³¹ Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
³² Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), London, UK.
³³ Department of Radiology, St. Antonius Hospital, Utrecht, The Netherlands.
³⁴ Department of Radiology School of Medicine, Izmir Demokrasi University, Izmir, Türkiye.
³⁵ Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA.
³⁶ Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Tübingen, Germany.
³⁷ Department of Radiology, Jessa Ziekenhuis, Campus Virga Jesse, Hasselt, Belgium.
³⁸ Department of Radiology, Freeman Hospital, Newcastle Upon Tyne, UK.
³⁹ School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
⁴⁰ St. Erasmo Hospital for Orthopaedic Surgery and Traumatology Ohrid, Ohrid, Macedonia.
⁴¹ Oxford University Hospitals, Oxford, UK.
⁴² Hospital Univeritario Son Espases Balearic Islands University, Palma, Spain.
⁴³ Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
⁴⁴ Royal National Orthopaedic Hospital, Stanmore, UK.
⁴⁵ Manisa Celal Bayar University, Manisa, Türkiye.
⁴⁶ Clinical MSK Radiology, Loughborough University, Leicester Royal Infirmary, Leicester, UK.
⁴⁷ Hospital Universitario Ramón y Cajal, Madrid, Spain.
⁴⁸ Musculoskeletal Radiology Department Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
⁴⁹ NIHR Leeds Biomedical Research Centre, Leeds, UK.
⁵⁰ Radiology Department, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Türkiye.
⁵¹ Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
⁵² Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands.
⁵³ Musculoskeletal Radiology Section, Klinikum Rechts der Isar, Technical University of Munich ‑ TUM School of Medicine, Munich, Germany.
⁵⁴ Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria.
⁵⁵ Departement of Orthopaedics and Traumatology, Division of Orthopaedics, Medical University of Vienna, Vienna, Austria.
⁵⁶ Departement of Orthopaedics and Traumatology, Medical University of Vienna, Vienna, Austria.

PMID: 39030374
PMCID: PMC11631817
DOI: 10.1007/s00330-024-10897-z

Abstract

Objectives: The revised European Society of Musculoskeletal Radiology (ESSR) consensus guidelines on soft tissue tumor imaging represent an update of 2015 after technical advancements, further insights into specific entities, and revised World Health Organization (2020) and AJCC (2017) classifications. This second of three papers covers algorithms once histology is confirmed: (1) standardized whole-body staging, (2) special algorithms for non-malignant entities, and (3) multiplicity, genetic tumor syndromes, and pitfalls.

Materials and methods: A validated Delphi method based on peer-reviewed literature was used to derive consensus among a panel of 46 specialized musculoskeletal radiologists from 12 European countries. Statements that had undergone interdisciplinary revision were scored online by the level of agreement (0 to 10) during two iterative rounds, that could result in 'group consensus', 'group agreement', or 'lack of agreement'.

Results: The three sections contain 24 statements with comments. Group consensus was reached in 95.8% and group agreement in 4.2%. For whole-body staging, pulmonary MDCT should be performed in all high-grade sarcomas. Whole-body MRI is preferred for staging bone metastasis, with [¹⁸F]FDG-PET/CT as an alternative modality in PET-avid tumors. Patients with alveolar soft part sarcoma, clear cell sarcoma, and angiosarcoma should be screened for brain metastases. Special algorithms are recommended for entities such as rhabdomyosarcoma, extraskeletal Ewing sarcoma, myxoid liposarcoma, and neurofibromatosis type 1 associated malignant peripheral nerve sheath tumors. Satisfaction of search should be avoided in potential multiplicity.

Conclusion: Standardized whole-body staging includes pulmonary MDCT in all high-grade sarcomas; entity-dependent modifications and specific algorithms are recommended for sarcomas and non-malignant soft tissue tumors.

Clinical relevance statement: These updated ESSR soft tissue tumor imaging guidelines aim to provide support in decision-making, helping to avoid common pitfalls, by providing general and entity-specific algorithms, techniques, and reporting recommendations for whole-body staging in sarcoma and non-malignant soft tissue tumors.

Key points: An early, accurate, diagnosis is crucial for the prognosis of patients with soft tissue tumors. These updated guidelines provide best practice expert consensus for standardized imaging algorithms, techniques, and reporting. Standardization can improve the comparability examinations and provide databases for large data analysis.

Keywords: Connective and soft tissue; Consensus; Diagnostic imaging; Neoplasms; Practice guideline.

PubMed Disclaimer

Conflict of interest statement

Compliance with ethical standards. Guarantor: The scientific guarantor of this publication is Univ.-Prof. Priv.-Doz. Dr. I.M.N.H. Conflict of interest: A.B. is a member of the European Radiology Editorial Board. He has not taken part in the review or selection process of this article. The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. Statistics and biometry: No complex statistical methods were necessary for this paper. Informed consent: Written informed consent was not required for this study because patients were not involved. Ethical approval: Institutional Review Board approval was not required because patients were not involved. Study subjects or cohorts overlap: Study subjects or cohorts have not been previously reported. Methodology: Expert consensus is performed by a Delphi process Perspective: not applicable Study design: not applicable Location: multicentre study

References

1. WHO classification of tumours of soft tissue and bone, 5th ed. 2020 [cited 2023 14JUN]. Available from: https://publications.iarc.fr/Book-And-Report-Series/Who-Classification-O...
1. Noebauer-Huhmann IM, Weber MA, Lalam RK et al (2015) Soft tissue tumors in adults: ESSR-approved guidelines for diagnostic imaging. Semin Musculoskelet Radiol 19:475–482 - PubMed
1. Amin MB, Greene FL, Edge SB et al (2017) The eighth edition AJCC cancer staging manual: continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin 67:93–99 - PubMed
1. Euro health observatory (2023) [cited 2023 14JUN]. Available from: https://eurohealthobservatory.who.int
1. Delphi method. [cited 2023 14JUN]. Available from: https://www.rand.org/topics/delphi-method.html

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Soft tissue tumor imaging in adults: whole-body staging in sarcoma, non-malignant entities requiring special algorithms, pitfalls and special imaging aspects. Guidelines 2024 from the European Society of Musculoskeletal Radiology (ESSR)

Affiliations

Soft tissue tumor imaging in adults: whole-body staging in sarcoma, non-malignant entities requiring special algorithms, pitfalls and special imaging aspects. Guidelines 2024 from the European Society of Musculoskeletal Radiology (ESSR)

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical

Research Materials