11. Quality indicators – Soft Tissue Sarcoma
Quality indicators are measured variables whose collection serves to assess the quality of the underlying structures, processes or results. Quality indicators are an important management tool. The aim of their use is the continuous improvement of care by presenting outcomes, critically reflecting on them and, if necessary, improving them. The present selection of quality indicators was defined according to the methodology of the guideline program oncology [791]. For the definition process, a „working group Quality Indicators“ (AG QI) was constituted. This created the final set of quality indicators based on the strong recommendations („should“) of the newly developed guideline and the results of the search for existing national and international quality indicators. The exact procedure and composition of the WG QI are presented in the guideline report.
After two online meetings of this WG, the final set of 14 quality indicators was adopted.
In addition, the WG makes as a recommendation that local disease-free survival (DFS), metastasis-free survival, and overall survival (OS) are provided by cancer registries, both for the guideline group updating the S3 guideline Adult Soft Tissue Sarcomas and for the individual certified sarcoma center.
Pre-therapeutic presentation in the tumor board (initial diagnosis of soft tissue sarcoma)
Numerator
Patients of the denominator presented in the pre-therapeutic tumor board.
Denominator
All patients with initial diagnosis of soft tissue sarcoma. Participants Tumor Board: surgical discipline with treatment focus on soft tissue sarcomas, hematol-ogy/oncology, pathology, radiology and radiation oncology.
Quality target / reference range
EC
Quality objective: Pretherapeutic presentation of pa-tients with first diagnosis soft tissue sarcoma in the interdisciplinary tumor board as often as possible
Reference recommendations
The planning of sarcoma treatment shall take place pre-therapeutically in the interdisciplinary tumor board. At least one surgical discipline with a focus on soft tissue sarcomas, as well as hematology/oncology, pathology, radiology, and radiation oncology shall be represented. Location-specific expertise should be consulted on a case-by-case basis.
- Consensus
- Strong consensus
Treatment in the certified sarcoma center
Numerator
Patients of the denominator with care in certified sarcoma center
Denominator
All patients with soft tissue sarcoma
Quality target / reference range
EC
Quality objective: Treatment of as many patients with soft tissue sarcoma as possible in certified sarcoma centers
Reference recommendations
The diagnosis and therapy of soft tissue sarcoma shall be performed by or in coordination with a certified sarcoma center or associated cooperation partner.
- Consensus
- Strong consensus
Complete report of findings after resection of soft tissue sarcoma
Numerator
Patients of the denominator with report of findings indicating: Grading according to FNCLCC; Minimum distances to relevant resection margins and critical structures; WHO classification; Dignity group-ICD-O
Denominator
All patients with initial diagnosis of soft tissue sarcoma and resection. Dignity groups: benign, intermediate (locally aggressive), intermediate (rarely metastatic) or malignant. FNCLCC: see in chapter 4.1.4.3, table "FNCLCC Grading System: Definition of Parameters" and table "FNCLCC Grading System: Tumor Differentiation Score According to Histologic Type".
Quality target / reference range
4.19: EK; 4.20: EK; 4.24: EK
Quality objective: Complete report of findings after resection of a soft tissue sarcoma as often as possible.
Notes
Reference recommendations
The minimum distances to relevant resection margins and critical structures shall be specified in the histopathological findings. R0 status is defined as „no tumor on ink“.
- Consensus
- Strong consensus
Histopathological subtyping shall be performed according to the currently valid WHO classification.
The tumor shall be classified into the diagnostic groups benign, intermediate (locally aggressive), intermediate (rarely metastatic) or malignant.
The ICD-O coding (if available) shall be added as additional information.
- Consensus
- Strong consensus
Risk assessment GIST
Numerator
Patients of the denominator with risk assessment of GIST.
Denominator
All patients with initial diagnosis of localized GIST, M0 and resection.
Quality target / reference range
EC
Quality objective: To assess the risk of recurrence after resection of a GIST, M0, as frequently as possible.
Reference recommendations
An assessment of individual recurrence risk shall be performed on the resected primary localized GIST without evidence of distant metastases (cM0) to assess the indication for adjuvant imatinib therapy.
- Consensus
- Strong consensus
Mutation analysis GIST
Numerator
Patients of the denominator with mutation analysis of the genes KIT (exon 9, 11) and PDGFRA (exon 18).
Denominator
All patients with initial diagnosis of intermediate/high risk GIST and/or M1. Risk classification GIST: see chapter 10.1.1.3 of the guideline.
Quality target / reference range
EC
Quality Objective: To perform mutation analysis as frequently as possible in intermediate/high risk GIST and/or M1.
Reference recommendations
For every intermediate/high risk GIST as well as for every metastatic GIST, a mutation analysis of at least the KIT (exon 9, 11) and PDGFRA (exon 18) genes shall be performed.
If no mutation can be detected in these three loci, further hot spot regions shall be investigated by molecular pathology or the case should be sent to a reference laboratory.
- Consensus
- Strong consensus
Primary histological confirmation of soft tissue sarcomas
Numerator
Patients of the denominator with pre-therapeutic histologic backup.
Denominator
All patients with soft tissue sarcoma and therapy, except superficial soft tissue sarcomas ≤3cm. Therapy: surgery, radiation, chemotherapy, hyperthermia, isolated limb perfusion.
Quality target / reference range
5.1: EK; 5.3: EK
Quality objective: Histological confirmation of soft tissue sarcomas, except for superficial soft tissue sarcomas ≤3cm, as often as possible before therapy.
Reference recommendations
When there is clinical suspicion and/or imaging suspicion of soft tissue sarcoma, this shall be confirmed on histology.
- Consensus
- Strong consensus
In cases of clinical suspicion and/or imaging suspicion of soft tissue sarcoma that is smaller than 3 cm in diameter and superficially located, primary R0 resection may be performed.
- Consensus
- Strong consensus
R0 resection for soft tissue sarcoma
Numerator
Patients of the denominator with R0 resection
Denominator
All patients with initial diagnosis of soft tissue sarcoma and resection.
Quality target / reference range
GRADE: moderate-high
Quality objective: R0 resection of primary soft tissue sarcomas as often as possible (except planned R1 resections).
Reference recommendations
Resection of primary soft tissue sarcoma of the extremities shall be performed as a wide resection. The goal is an R0 resection.
Hysterectomy without morcellement for sarcoma confined to the uterus.
Numerator
Patients of the denominator with hysterectomy without morcellation.
Denominator
All patients with sarcoma confined to the uterus (ICD-O T C54, C55 iVm morphology codes chapter 13.1), M0 with hysterectomy.
Quality target / reference range
5.44: EK; 5.48: EK
Quality objective: Hysterectomy without morcellation for sarcoma confined to the uterus as frequently as possible.
Reference recommendations
In leiomyosarcoma confined to the uterus, complete removal of the uterus shall be performed without morcellement or uterine injury.
- Consensus
- Consent
In high-grade endometrial stromal sarcoma confined to the uterus, complete removal of the uterus shall be performed without morcellation or uterine injury.
- Consensus
- Strong consensus
Pre/postoperative radiotherapy for soft tissue sarcoma.
Numerator
Patients of the denominator with preoperative or postoperative radiotherapy.
Denominator
All patients with initial diagnosis of soft tissue sarcoma of extremities or trunk (excluding cutaneous sarcomas ICD-0 T C44), G2 or G3, M0 and resection. ICD-O topography extremities or trunk: C47.1 - C47.8, C48.0, C49.1 – C49.8
Quality target / reference range
GoR: A; GRADE: low-moderate
Quality objective: To provide pre-operative or post-operative radiotherapy as frequently as possible for soft tissue sarcomas of the extremities or trunk (G2 or G3, M0).
Reference recommendations
For G2 and G3 soft tissue sarcomas, preoperative or postoperative radiotherapy shall be given.
- Recommendation grade
- A: Starke Empfehlung für oder gegen ein Maßnahme - verwendete Ausdrucksweise = soll/soll nicht
- Level of evidence
- ⊕⊕⊕⊝
Overall survival (follow-up: 16 months)
⊕⊕⊕⊝Disease-specific survival (follow-up: 76 months).
⊕⊕⊕⊝Overall survival low-grade STS (follow-up: 67 months).
⊕⊕⊕⊝Local recurrence (follow-up: 76 months)
⊕⊕⊕⊝Free of distant metastases (follow-up: 76 months)
⊕⊕⊝⊝Overall survival (follow-up: 240 months)
⊕⊕⊕⊝Local recurrence (follow-up: 232.7 months)
- Consensus
- Strong consensus
- References
- [315] [316] [317] [318]
Pre-therapeutic presentation in the tumor board (recurrence and/or secondary distant metastasis of a soft tissue sarcoma).
Numerator
Patients of the denominator with pre-therapeutic presentation in the tumor board
Denominator
All patients with local recurrence and/or newly diagnosed secondary distant metastases of soft tissue sarcoma. Participants Tumor Board: surgical discipline with treatment focus on soft tissue sarcomas, hematology/oncology, pathology, radiology and radiation oncology.
Quality target / reference range
6.4: EK; 7.10: EK
Quality objective: Pretherapeutic presentation of recurrences and/or secondary distant metastasis of soft tissue sarcomas in the interdisciplinary tumor board as often as possible.
Reference recommendations
In local recurrences of soft tissue sarcomas not pretreated with neoadjuvant or adjuvant therapy, a multimodal therapy concept shall be defined in an interdisciplinary sarcoma board.
- Consensus
- Strong consensus
The indication for local therapy of metastases shall be multidisciplinary.
- Consensus
- Strong consensus
Post-operative presentation to the tumor board (local recurrence and R1/R2 resection of soft tissue sarcoma).
Numerator
Patients of the denominator who presented postoperatively to the tumor board
Denominator
All patients with local recurrence soft tissue sarcoma and R1/R2 resection. Participants Tumor Board: surgical discipline with treatment focus on soft tissue sarcomas, hematology/oncology, pathology, radiology and radiation oncology.
Quality target / reference range
EC
Quality objective: Post-operative presentation of R1-/R2-resected local recurrences of soft tissue sarcomas in the interdisciplinary tumor board as often as possible.
Reference recommendations
After incomplete resection of an isolated local recurrence, whether pretreated with chemotherapy according to guidelines or not, a multidisciplinary therapeutic decision shall be made.
- Consensus
- Strong consensus
First-line chemotherapy for soft tissue sarcoma
Numerator
Patients of the denominator with doxorubicin monotherapy or anthracycline-containing combination therapy.
Denominator
All patients with soft tissue sarcoma and first-line chemotherapy.
Quality target / reference range
EC
Quality objective: To use doxorubicin monotherapy or anthracycline-containing combination therapy as frequently as possible in first-line chemotherapy.
Reference recommendations
The choice of systemic therapy shall be doxorubicin monotherapy or anthracycline-containing combination therapy, taking into account toxicity and goals.
- Consensus
- Strong consensus
Complete report of findings after resection GIST
Numerator
Patients of the denominator with reports of findings indicating: R status Primary location Number of mitoses per 5mm² Tumor rupture
Denominator
All patients with initial diagnosis of GIST and resection.
Quality target / reference range
EC
Quality objective: Complete report of findings after resection of a GIST as often as possible.
Reference recommendations
When diagnosing GIST on a resected tumor, R status, primary location, tumor size (largest longitudinal diameter), number of mitoses per 5 mm², and a determination of whether tumor rupture is present shall be included in the pathology report.
- Consensus
- Strong consensus
Postoperative mortality in retroperitoneal sarcoma.
Numerator
Patients of the denominator who died within 30d post-operatively.
Denominator
All patients with initial diagnosis of retroperitoneal sarcoma (RPS) (ICD-10 C48.0 or C48.8) and tumor resection.
Quality target / reference range
As a result of the discussion of the international QI, the LL defines as a specific objective that post-operative mortality should be collected for patients with retroperitoneal sarcoma (RPS). Since the basis is the existing international QI, its population is also adopted.
Source wording:
QPI 11a - 30 Day Mortality Following Curative Oncological Treatment.
30-day mortality following curative treatment for extremity and retroperitoneal sarcoma.
Numerator: Number of patients with extremity or retroperitoneal sarcoma who receive oncological treatment with curative intent who die within 30 days of treatment.
Denominator: All patients with extremity or retroperitoneal sarcoma who receive curative oncological treatment.
Exclusions: No exclusions.
Source: Sarcoma National Managed Clinical Network, N., South East and West of Scotland Cancer Networks Audit Report Sarcoma Quality Performance Indicators. Clinical Audit Data: 01 April 2014 to 31 March 2015. 2016.
Reference recommendations
References
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