Chest CT Imaging Patterns Contradict ACR Guidelines for Extremity Sarcoma Staging and Surveillance

R. Lor Randall, MD, FACS

Gauging the concordance between institutional practice patterns and professional clinical management guidelines may be a necessary part of ensuring optimal patient care, according to R. Lor Randall, MD, FACS. He explained that institutional practice patterns may not always reflect the recommendations that are endorsed by professional guideline committees, highlighting a potential gap in education and awareness.

According to findings from a retrospective review published in the Journal of Surgical Oncology¹ investigators at the University of California (UC) Davis in Sacramento evaluated their own compliance with the American College of Radiology (ACR) guidelines for sarcoma staging and surveillance. The guidelines, which have been published since 2015, recommend pulmonary staging and surveillance with chest CT without contrast for patients with extremity sarcoma.²

As part of the analysis, investigators collected 1,916 CT studies from patients with extremity sarcoma who underwent CT imaging at UC Davis between 2005 and 2023. The results showed that more patients received CT with contrast both before and after the publication of the guidelines. Moreover, 79.2% of patients’ final surveillance CT scans after 2015 were performed with contrast, adding $297,704 worth of additional patient and institutional expenses.

“[It’s] surprising to us that we weren’t as compliant as we wanted. This paper has really changed the practices immediately at our own institution,” said Randall, who is the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at UC Davis Comprehensive Cancer Center.

In an interview with OncLive^®, Randall discussed the importance of taking a temperature check of individual institutional practice patterns and explained the next steps in ensuring adherence to clinical care guidelines in extremity sarcoma.

OncLive: What is the importance of evaluating institutional compliance regarding clinical care guidelines?

Randall: Like everything we do in sarcoma medical and surgical oncology, we want to be very reflective of the value equation, if you will, on care delivery, meaning the [result of] outcomes and safety divided by costs. One of the things we looked at [in our study] arose out of one of our tumor boards where we were routinely trying to order chest CTs without contrast for surveillance of our patients with soft tissue sarcomas. We found that many of the radiologists were converting those [orders] into [CT] with contrast. We went back and realized that in 2015 the ACR put out recommendations that for lung metastases being surveyed by chest CT that no contrast was necessary. We brought this forward to our radiologists. It was interesting because the opinions were divergent.

We decided to look back at our own experience with this. We looked at our cohort of patients retrospectively from 2005 to 2023 in which we had almost 2000 CT scans done for sarcoma and sarcoma surveillance for [patients with] soft tissue sarcomas. We were shocked to find that most cases were still ordered with IV contrast. Almost 80% of the patients, before or after [the publication of the guidelines] still had contrast. We realized that, despite us requesting that they don’t get IV contrast, these [orders] were somehow being switched to that. We don’t have the exact reasons as to why. We realized that from an institutional standpoint, this was an additional cost of about $300,000 to the health system for [ordering CTs] with contrast when the ACR declared that it was not advantageous for these patients.

We wanted to get this out there that we struggle with this even as an NCI-designated Comprehensive Cancer Center that prides itself on a transregional sarcoma program where we try to be fully compliant with guidelines such as those by the ACR. We hope this will [inspire] other institutions of our caliber to do the same so we can get this laid to rest that we should not be [ordering CTs with] IV contrast for surveillance of patients with sarcoma.

What is the clinical significance of this retrospective review?

Despite sarcoma specialists being aware that there’s really no need for IV contrast for surveillance of patients with sarcoma, they should look at their own institutional practices, because they may be getting contrast more than they need to. For the medical oncology community which is going to be ordering most of these scans, they really need to emphasize in their ordering practices that [a CT without contrast] should not be reversed. I suspect that most medical oncologists are ordering [CTs] without contrast, but for some reason, they’re still getting this switch by some provider downstream.

What are the next steps for this research?

The purpose of this [research] is to shine a light on the issue. We now want to take this information to the organizations that are thought leaders in this [area] such as ASCO, Connective Tissue Oncology Society, the Musculoskeletal Tumor Society, and other allied sarcoma specialty groups, and make sure best practices are being adhered to, so that patients aren’t undergoing the unnecessary use of IV contrast.

What is the take-home message for your surgical oncology and medical oncology colleagues?

They need to be aware of the guidelines that have been out since 2015 and they need to be in line with those guidelines and make sure that they talk about their importance to their radiologists and other allied providers so that they don’t put a patient through the additional cost and very small risk of IV contrast for sarcoma surveillance.

The other take-home message is that we need to mind our own chops. I encourage all of us to look at our own practices downstream from our tumor boards to look at what our institutions are doing and make sure that we’re compliant with the latest guidelines from subspecialty or specialty societies.

References

1. Priester J, Simister SK, Sario M, et al. Scrutinizing the use of contrasted chest CTs in extremity sarcoma staging and surveillance. J Surg Oncol. 2024;129(3):523-530. doi:10.1002/jso.27510
2. American College of Radiology ACR Appropriateness Criteria Soft Tissue Masses. Updated 2022. Accessed February 9, 2024. https://acsearch.acr.org/docs/69434/Narrative/