Practice Guideline

. 2025 Jun;35(6):3324-3335.

doi: 10.1007/s00330-024-11242-0. Epub 2024 Dec 18.

Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2024: imaging immediately after neoadjuvant therapy in soft tissue sarcoma, soft tissue tumor surveillance, and the role of interventional radiology

Iris-Melanie Noebauer-Huhmann¹, Joan C Vilanova², Olympia Papakonstantinou³, Marc-André Weber⁴, Radhesh K Lalam⁵, Violeta Vasilevska Nikodinovska^{6

7}, Hatice T Sanal⁸, Frédéric E Lecouvet⁹, Ana Navas¹⁰, José Martel-Villagrán¹¹, Jacky W J de Rooy¹², Jan Fritz^{13

14}, Koenraad Verstraete¹⁵, Thomas Grieser¹⁶, Pavol Szomolanyi^{17

18}, Snehansh Chaudhary¹⁹, Luca Maria Sconfienza^{20

21}, Alberto S Tagliafico^{22

23}, P Diana Afonso²⁴, Omar M Albtoush²⁵, Giacomo Aringhieri²⁶, Remide Arkun^{27

28}, Gunnar Aström²⁹, Alberto Bazzocchi³⁰, Rajesh Botchu³¹, Martin Breitenseher³², Danoob Dalili³³, Mark Davies³¹, Milko C de Jonge³⁴, Berna D Mete³⁵, Jan L M A Gielen³⁶, Geoff Hide³⁷, Amanda Isaac³⁸, Slavcho Ivanoski³⁹, Ramy M Mansour⁴⁰, Catherine Mccarthy⁴¹, Lorenzo Muntaner-Gimbernat⁴², Paul O'Donnell⁴³, Şebnem Örgüç⁴⁴, Winston J Rennie⁴⁵, Santiago Resano⁴⁶, Philip Robinson^{47

48}, Simone A J Ter Horst^{49

50}, Kirsten van Langevelde¹⁰, Klaus Wörtler⁵¹, Marita Koelz⁵², Joannis Panotopoulos⁵³, Reinhard Windhager⁵³, Barbara J Fueger⁵⁴, Maximilian Schmid⁵⁵, Filip M Vanhoenacker^{56

57}

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, Clínica Girona, Institute of Diagnostic Imaging (IDI) Girona, University of Girona, Girona, Spain.
³ 2nd Department of Radiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece.
⁴ Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany.
⁵ Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK.
⁶ Medical Faculty, University "Ss. Cyril and Methodius", Skopje, North Macedonia.
⁷ Department of Diagnostic and Interventional Radiology, University Surgical Clinic "St. Naum Ohridski", Skopje, North Macedonia.
⁸ Radiology Department, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Türkiye.
⁹ 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.
¹⁰ Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
¹¹ Radiology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain.
¹² Department of Imaging, Radiology, Radboud University Medical Center, Nijmegen, The Netherlands.
¹³ Department of Radiology, NYU Grossman School of Medicine, New York, USA.
¹⁴ Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Tübingen, Germany.
¹⁵ Department of Radiology, Ghent University Hospital, Ghent, Belgium.
¹⁶ Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany.
¹⁷ High Field MR Center, Department of Biomedical Imaging and Image‑Guided Therapy, Medical University Vienna, Vienna, Austria.
¹⁸ Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia.
¹⁹ Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
²⁰ IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
²¹ Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Milan, Italy.
²² Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
²³ Department of Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
²⁴ Hospital Particular da Madeira, and Hospital da Luz Lisboa, Lisbon, Portugal.
²⁵ Department of Radiology, University of Jordan, Ammam, Jordan.
²⁶ Academic Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
²⁷ Ege University Medical School (Emeritus), Izmir, Türkiye.
²⁸ Star Imaging Center, Izmir, Türkiye.
²⁹ Department of Immunology, Genetics and Pathology (including Oncology), Uppsala University, Uppsala, Sweden.
³⁰ Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
³¹ Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK.
³² Sigmund Freud Privatuniversität, Vienna, Austria.
³³ Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), London, UK.
³⁴ Department of Radiology, St. Antonius Hospital, Utrecht, The Netherlands.
³⁵ Department of Radiology School of Medicine, Izmir Demokrasi University, Izmir, Türkiye.
³⁶ Department of Radiology, Jessa Ziekenhuis, Campus Virga Jesse, Hasselt, Belgium.
³⁷ Department of Radiology, Freeman Hospital, Newcastle Upon Tyne, UK.
³⁸ School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
³⁹ St. Erasmo Hospital for Orthopaedic Surgery and Traumatology Ohrid, Ohrid, North Macedonia.
⁴⁰ Oxford University Hospitals, Oxford, UK.
⁴¹ Oxford Musculoskeletal Radiology and Oxford University Hospitals, Oxford, UK.
⁴² Hospital Univeritario Son Espases Balearic Islands University, Palma, Spain.
⁴³ Royal National Orthopaedic Hospital NHS Trust | RNOH · Department of Radiology, London, UK.
⁴⁴ Manisa Celal Bayar University, Manisa, Türkiye.
⁴⁵ Clinical MSK Radiology, Loughborough University, Leicester Royal Infirmary, Leicester, UK.
⁴⁶ Hospital Universitario Ramón y Cajal, Madrid, Spain.
⁴⁷ Musculoskeletal Radiology Department Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
⁴⁸ NIHR Leeds Biomedical Research Centre, Leeds, UK.
⁴⁹ Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
⁵⁰ Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands.
⁵¹ Musculoskeletal Radiology Section, Klinikum Rechts der Isar, Technical University of Munich ‑ TUM School of Medicine, Munich, Germany.
⁵² Department of Pathology, Medical University of Vienna, Vienna, Austria.
⁵³ Department of Orthopaedics and Traumatology, Medical University of Vienna, Vienna, Austria.
⁵⁴ Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria.
⁵⁵ Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria.
⁵⁶ Department of Radiology AZ Sint Maarten Mechelen, University (Hospital) Antwerp, Antwerp, Belgium.
⁵⁷ Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.

PMID: 39694887
PMCID: PMC12081562
DOI: 10.1007/s00330-024-11242-0

Practice Guideline

Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2024: imaging immediately after neoadjuvant therapy in soft tissue sarcoma, soft tissue tumor surveillance, and the role of interventional radiology

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

. 2025 Jun;35(6):3324-3335.

doi: 10.1007/s00330-024-11242-0. Epub 2024 Dec 18.

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, Clínica Girona, Institute of Diagnostic Imaging (IDI) Girona, University of Girona, Girona, Spain.
³ 2nd Department of Radiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece.
⁴ Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany.
⁵ Department of Radiology, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK.
⁶ Medical Faculty, University "Ss. Cyril and Methodius", Skopje, North Macedonia.
⁷ Department of Diagnostic and Interventional Radiology, University Surgical Clinic "St. Naum Ohridski", Skopje, North Macedonia.
⁸ Radiology Department, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Türkiye.
⁹ 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.
¹⁰ Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
¹¹ Radiology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain.
¹² Department of Imaging, Radiology, Radboud University Medical Center, Nijmegen, The Netherlands.
¹³ Department of Radiology, NYU Grossman School of Medicine, New York, USA.
¹⁴ Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Tübingen, Germany.
¹⁵ Department of Radiology, Ghent University Hospital, Ghent, Belgium.
¹⁶ Department for Diagnostic and Interventional Radiology, University Hospital Augsburg, Augsburg, Germany.
¹⁷ High Field MR Center, Department of Biomedical Imaging and Image‑Guided Therapy, Medical University Vienna, Vienna, Austria.
¹⁸ Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia.
¹⁹ Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
²⁰ IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
²¹ Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Milan, Italy.
²² Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
²³ Department of Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
²⁴ Hospital Particular da Madeira, and Hospital da Luz Lisboa, Lisbon, Portugal.
²⁵ Department of Radiology, University of Jordan, Ammam, Jordan.
²⁶ Academic Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.
²⁷ Ege University Medical School (Emeritus), Izmir, Türkiye.
²⁸ Star Imaging Center, Izmir, Türkiye.
²⁹ Department of Immunology, Genetics and Pathology (including Oncology), Uppsala University, Uppsala, Sweden.
³⁰ Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
³¹ Department of Musculoskeletal Radiology, Royal Orthopedic Hospital, Birmingham, UK.
³² Sigmund Freud Privatuniversität, Vienna, Austria.
³³ Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), London, UK.
³⁴ Department of Radiology, St. Antonius Hospital, Utrecht, The Netherlands.
³⁵ Department of Radiology School of Medicine, Izmir Demokrasi University, Izmir, Türkiye.
³⁶ Department of Radiology, Jessa Ziekenhuis, Campus Virga Jesse, Hasselt, Belgium.
³⁷ Department of Radiology, Freeman Hospital, Newcastle Upon Tyne, UK.
³⁸ School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
³⁹ St. Erasmo Hospital for Orthopaedic Surgery and Traumatology Ohrid, Ohrid, North Macedonia.
⁴⁰ Oxford University Hospitals, Oxford, UK.
⁴¹ Oxford Musculoskeletal Radiology and Oxford University Hospitals, Oxford, UK.
⁴² Hospital Univeritario Son Espases Balearic Islands University, Palma, Spain.
⁴³ Royal National Orthopaedic Hospital NHS Trust | RNOH · Department of Radiology, London, UK.
⁴⁴ Manisa Celal Bayar University, Manisa, Türkiye.
⁴⁵ Clinical MSK Radiology, Loughborough University, Leicester Royal Infirmary, Leicester, UK.
⁴⁶ Hospital Universitario Ramón y Cajal, Madrid, Spain.
⁴⁷ Musculoskeletal Radiology Department Chapel Allerton Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
⁴⁸ NIHR Leeds Biomedical Research Centre, Leeds, UK.
⁴⁹ Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
⁵⁰ Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands.
⁵¹ Musculoskeletal Radiology Section, Klinikum Rechts der Isar, Technical University of Munich ‑ TUM School of Medicine, Munich, Germany.
⁵² Department of Pathology, Medical University of Vienna, Vienna, Austria.
⁵³ Department of Orthopaedics and Traumatology, Medical University of Vienna, Vienna, Austria.
⁵⁴ Department of Biomedical Imaging and Image Guided Therapy, Medical University of Vienna, Vienna, Austria.
⁵⁵ Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria.
⁵⁶ Department of Radiology AZ Sint Maarten Mechelen, University (Hospital) Antwerp, Antwerp, Belgium.
⁵⁷ Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium.

PMID: 39694887
PMCID: PMC12081562
DOI: 10.1007/s00330-024-11242-0

Abstract

Objectives: An update of the first European Society of Musculoskeletal Radiology (ESSR) consensus on soft tissue tumor imaging in 2015 became necessary due to technical advancements, further insights into specific entities, and the revised WHO classification (2020) and AJCC staging system (2017). The third part of the revised guidelines covers algorithms and techniques beyond initial imaging: (1) Imaging after neoadjuvant therapy in soft tissue sarcoma, (2) sarcoma surveillance, and (3) special aspects, including surveillance of non-malignant entities and the role of interventional radiology.

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 level of agreement (0 to 10) during two iterative rounds that could result in either 'group consensus,' 'group agreement,' or 'lack of agreement.'

Results: The three sections contain 47 statements with comments. Group consensus was reached in 91.5%, group agreement in 6.4%, lack of agreement in 2.1%. In sarcoma, imaging immediately after neoadjuvant therapy is pivotal for determining the therapy effects and for resection-planning; surveillance should include imaging at fixed grade- and type-dependent intervals. In general, MRI is the method of choice for loco-regional surveillance of soft tissue sarcomas, and chest CT to assess metastatic disease. Interventional radiology has a role, especially in oligometastatic disease, palliative tumor control and local recurrences.

Conclusion: Strategies for standardized soft tissue tumor imaging regarding therapy control, surveillance, and useful interventional procedures are provided.

Key points: Question An ESSR consensus update on soft tissue tumor imaging regarding surveillance became necessary due to technical advancements, further entity-specific insights, and revised WHO- and AJCC-classifications. Findings Imaging immediately after neoadjuvant therapy in soft tissue sarcoma is pivotal. Post-therapeutic surveillance should include imaging at regular intervals, stratified for tumor grade and type. Clinical relevance The updated ESSR soft tissue tumor imaging guidelines aim to provide best practice expert consensus for standardized imaging, to support radiologists in their decision-making, and to improve examination comparability, both in individual patients and in future studies on individualized strategies.

Keywords: Consensus; Diagnostic imaging; Practice guideline; Sarcoma (Soft tissue); Soft tissue neoplasms.

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Conflict of interest statement

Compliance with ethical standards. Guarantor: The scientific guarantor of this publication is Univ.-Prof. Priv.-Doz. Dr. Iris-Melanie Noebauer-Huhmann. Conflict of interest: A.B. is a member of the Advisory Editorial Board for European Radiology (European Society of Musculoskeletal Radiology). 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 performed by a Delphi process

References

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. 10.1055/s-0035-1569251 - PubMed
1. WHO (2020) WHO classification of tumours of soft tissue and bone, 5th edn. Available via https://publications.iarc.fr/Book-And-Report-Series/Who-Classification-O.... Accessed 14 Jun 2023
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. 10.3322/caac.21388 - PubMed
1. Euro Health Observatory (2023) Improving healthcare quality in Europe: chapter 9: clinical practice guidelines as a quality strategy. 233–263. Available from https://iris.who.int/bitstream/handle/10665/327356/9789289051750-eng.pdf.... Accessed 14 Jun 2023
1. Khodyakov D (2023) Generating evidence using the Delphi method. Available from https://i2insights.org/2023/10/17/delphi-method/. Accessed 17 Oct 2023

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Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2024: imaging immediately after neoadjuvant therapy in soft tissue sarcoma, soft tissue tumor surveillance, and the role of interventional radiology

Affiliations

Soft tissue tumor imaging in adults: European Society of Musculoskeletal Radiology-Guidelines 2024: imaging immediately after neoadjuvant therapy in soft tissue sarcoma, soft tissue tumor surveillance, and the role of interventional radiology

Authors

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Abstract

Conflict of interest statement

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