Chondrosarcoma of the chest wall: primary diagnostics is decisive for outcome Björn 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 Surgery 2009 Mar;137(3):610-4

Methods: All chondrosarcoma of the chest wall in Sweden ( ) 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 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: widemarginalintralesional Sarcoma center Non-specialty hospital

Surgical margins and survival

Local recurrence Sarcoma center16 % (9/55) Non-specialty center57 % (24/42)

Better outcome at sarcoma centers

Survival after recurrence

Prognostic factors for local recurrence (Hazard ratio) Surgical margin4 Histologic grade2 Prognostic factors for metastases (Hazard ratio) Histologic grade4 Local recurrence4 Tumor size 1.01 (per cm increment)

The 10-year survival rate 0.75 for patients treated at sarcoma centers 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 mass71 % (39/59)57 % (27/47)

The diagnosis at the first medical visit n Tumor88 (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 ( ) 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 Malignant11 Benign 5 Uncertain24

Fine needle aspiration biopsy at sarcoma center (30 patients) n Malignant29 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!