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Study shows size of soft tissue lump may be linked to possible malignancy
Researchers found a link between a soft tissue lump that is bigger than a golf ball and its chance of being malignant.
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Patients who present with a new soft tissue lump that is bigger than a golf ball — or 4.3 cm diameter — that continues to grow should be referred to a tumor unit for additional testing, based results of a study presented at the 16th EFORT Congress in Prague.
Soft tissue sarcomas may present late and in advanced stages in most patients, so earlier diagnosis is one of the keys for successful treatment, according to Rajpal S. Nandra, MBBS, BSc, MRCS, MRCGP, one of the study investigators.
Nandra and colleagues identified several key factors for predicting the risk of malignancy when a suspicious soft tissue lump (STL) is assessed and, in the process, they were able to simplify referral criteria, Nandra told Orthopaedics Today Europe.
“The study generated a Bayesian belief network to estimate the likelihood of malignancy and the conditional relationships between variables. A large tumor allied with increasing size significantly increases risk, whilst pain was a poor diagnostic indicator. By reducing palpable size from 5 cm to that of a golf ball (red flag referral), we have created an ‘aide memoire’ for clinicians and also a visual analog to promote public awareness,” he said.
Factors associated with malignancy
The poster by Nandra and colleagues was one of 10 posters at the meeting recognized with the Jacques Duparc Award for best poster.
Nandra and colleagues included 3,018 patients with an STL who presented to The Royal Orthopaedic Hospital, in Birmingham, United Kingdom, for assessment between 1996 and 2007. Of those STLs, 1,563 (52%) were benign and 1,455 (48%) were malignant.
“Soft tissue sarcomas are known to present late with advanced stage at diagnosis. With earlier cancer diagnosis being a key health care initiative to improve patient outcomes, we wanted to identify key factors in predicting risk of malignancy when assessing suspicious STLs and simplify criteria,” Nandra said.
‘Golf ball’ rule aids referral process
The investigators analyzed data from the patients and found patient age, STL size and duration of symptoms correlated with malignancy. Patients with a malignant STL had a mean age of 56 years and patients with a benign STL had a mean age of 46 years (P < .001).
In patients with a STL that exceeded 4.3-cm diameter, there was a 59% chance it was malignant compared with a 30% chance of malignancy when the STL was smaller than 4.3 cm diameter.
Investigators found a large STL had the greatest positive predictive value (PPV) for malignancy at 70.6%, while pain was the least sensitive predictor of malignancy, with a PPV of 48%. With a large size STL that was still growing when the patient presented with it, Nandra and colleagues found the PPV value for malignancy was 78.5%.
Using data from the study, investigators found patients who were older than 69 years, had duration of symptoms between 8 weeks and 16 weeks, had a STL increasing in size and a STL greater than 10 cm had a 94.7% likelihood of malignancy.
Nandra and investigators concluded the “golf ball” rule will help regulate the referral process and hopefully make diagnosis more accurate. – by Robert Linnehan
- References:
- Nandra RS, et al. Eur J Surg Oncol. 2015;doi:10.1016/j.ejso.2015.05.017.
- Nandra RS, et al. Poster #1584. Presented at: 16th EFORT Congress; May 27-29, 2015; Prague.
- For more information:
- Rajpal S. Nandra, MBBS, BSc, MRCS, MRCGP, can be reached at West Midlands Deanery, The Royal Orthopaedic Hospital, Bone Tumour Service, Bristol Road South, Birmingham B31 2AP, United Kingdom; email: rajpalnandra1@nhs.net.
Disclosure: Nandra reports no relevant financial disclosures.
Perspective
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Pietro Ruggieri, MD, PhD
The authors of this interesting paper discuss the risk of malignancy in patients with soft tissue lumps.
With a theoretically very low risk of malignancy in primary care consultations, a correct diagnosis could be delayed.
From a review of more than 3,000 cases of soft tissue tumors, the authors were able to identify parameters for a correct diagnosis. A size larger than a golf ball and a growing pattern are crucial and easy to remember, and pain is not necessarily associated with sarcomas.
This paper gives precious information to both patients and medical practitioners. Still, today most soft tissue sarcomas are diagnosed late or inadequately excised. Therefore, these simple parameters will be of great help to reduce the number of wrong diagnoses made and treatments given.
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