Dr Randall on Incorporating Ultrasound STS Surveillance Into Clinical Practice

“For high-grade extremity STS, we’re getting baseline MRIs at 3 months post-operation and then following with ultrasounds. If we notice any changes on the ultrasound, we will move to an MRI.”

R. Lor Randall, MD, FACS, the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at the University of California (UC) Davis Comprehensive Cancer Center, discussed the potential role of a hybrid MRI and ultrasound approach to extremity soft tissue sarcoma (STS) surveillance.

The current standard practice for extremity STS surveillance is MRI, which is considered the gold standard due to its soft tissue contrast and ability to detect superficial and deep lesions. However, MRI is associated with high costs, limited accessibility, and potential contraindications for some patients. In contrast, ultrasound is less expensive, more accessible, and provides a quicker turnaround time with no contraindications. Randall described an implementation plan for high-grade extremity STS surveillance at UC Davis that reflects a shift toward leveraging the benefits of ultrasound.

This new algorithm begins with a baseline MRI at 3 months post-operation, followed by regular surveillance using ultrasounds, according to Randall. If suspicious changes are observed during the ultrasound evaluation, the patient is subsequently scheduled for an MRI, he explained. This strategy is supported by findings from a comprehensive scoping review, which revealed comparable diagnostic performance between ultrasound and MRI in STS surveillance.

This shift toward incorporating ultrasound is strongly motivated by economic considerations and emerging evidence supporting hybrid protocols, as outlined in the scoping review. Randall anticipated that insurance providers will favor this cost-effective, hybrid approach as further literature confirming the utility of ultrasound emerges.

Randall stressed that this new protocol is not all-encompassing; rather, it is reserved for the more straightforward cases where an R0 resection has been achieved, he said. High-risk cases, such as those involving positive margins or where local recurrence would result in a devastating outcome for the patient, will continue to use MRI for surveillance. The use of hybrid surveillance protocols is supported by findings showing their effectiveness in enhancing detection rates.