Revised 15 June 2010

The broad ranging types of musculoskeletal tumours and sarcomas prohibit a rigid recommendation with respect to follow-up.

• A follow-up program for the individual patient (frequency of examination and types of evaluation) would depend on the expected biological behavior of the tumor, an assessment of the treatment accomplished (whether it might result in cure or not)and the site of the primary lesion (tissue and anatomical).
• In all cases, the follow-up visit should be a clinical examination of the patient with emphasis on the local site and the common foci of metastases. In most sarcomas, metastatic disease will involve the lungs so that periodic chest X-rays would be indicated.
• For superficial and distal tumours, clinical examination is more reliable than imaging. For deeper, proximal and axial tumours, periodic CT scans or MR scans are preferable.
• Bone scans are unreliable as an indicator of early local recurrence. In areas where bone has been surgically interfered with the scan will remain "hot" for two to three years after.

See 4) Summary of standard recommendations below.

1) Rationale for follow-up for patients whose disease has been treated for cure and for whom further interventions for cure may be possible

Follow-up is generally indicated where early detection of an abnormality may result in cure.

Areas of concern:

a) Curable recurrence at the site of the primary:

if a second wide excision is possible it may achieve a cure providing there is no sign of metastasis. Therefore intensive follow-up with examination of the primary site is recommended every 3 months and if superficial this may be sufficient. If the primary was deep the examination should be supplemented by scans (CT or MR) every 6 months.

if further surgery is not possible or can not achieve a cure follow to assess symptoms from treatment or disease at 6 monthly intervals. No imaging tests are indicated unless symptoms arise.

b) Development of curable lung metastases:

In those with osteosarcoma, wedge excisions of the metastases can achieve long term survival. Quasi adjuvant chemotherapy may also be recommended. CXR of the lungs every 3 months for 2 years then every 6 months till 5 yrs of follow-up completed – then yearly.

For patients with soft tissue sarcomas, the role of metastasectomy is controversial as there has not been routine benefit noted at meta-analysis. Patients who would be fit enough to undergo thoracotomy and felt to be going to benefit from resection of metastases if detected are generally followed with routine CXR as above.

c) Complex treatment programs resulting in late complications

For example, complications from combined resection and radiotherapy of a limb, radiotherapy to abdominal organs compromising function of the bowel or kidneys.

• Follow with special attention to the function of the relevant organ at routine visits 3 – 6 monthly.
• Once blood counts have returned to normal following adjuvant chemotherapy, it is generally not necessary to follow these routinely.
• Once serum biochemistry has recovered or stabilized, it is generally not necessary to follow these routinely.
• Adriamycin cardiotoxicity may develop years after adjuvant therapy.

2) In those patients when any future recurrence, local or distant, is not amenable to curative therapy

Rigorous follow-up is less important for this small minority of patients. They should be followed as for other patients with incurable disease.

3) Those patients who were not curable at presentation (and 2 above)

• Less rigorous follow up is indicated. No routine tests should be done. The patients are often be followed in their local community at 6 to 12 monthly intervals.
• If there is recurrence in the future and symptoms arise then palliative measures specifically to control those symptoms can be instituted.
• There is no evidence that finding such incurable recurrence earlier by testing asymptomatic patients allows any better or more effective treatment.

4) Summary of standard recommendations: