MRI Guideline Adherence Is Lacking in Soft Tissue Sarcoma

A significant percentage of patients with soft tissue sarcomas receive MRI examinations that do not meet recommended guidelines, according to a new analysis.¹

The report, which was published in BMC Cancer, is based on patients treated at a single cancer center in Germany, but the authors say the findings raise important questions about the real-world use of MRI imaging in STS cases.¹

Histological grading based on biopsies is considered the gold standard when assessing STS tumors, the authors explained. However, most cases have considerable heterogeneity and many patients have large-volume soft tissue masses. As a result, they said, there is a significant risk of under-grading based on non-representative biopsies.

Imaging data can help refine the accuracy of grading, they said, but only if comprehensive, high-quality imaging data is available. “Accordingly, the implementation of standardized imaging protocols is essential,” they wrote.

German guidelines, like those of other European countries and international guidelines, call for the use of contrast-enhanced MRI in cases of suspected sarcoma, though CT and PET/CT can be used to evaluate retroperitoneal sarcomas, the authors explained

“[MRI] enables detailed evaluation of tumor size, margin characteristics, intratumoral signal intensity and heterogeneity, peritumoral edema, and neurovascular or osseous involvement, both at initial diagnosis and during follow-up,” they said.

Germany’s guidelines also suggest T1- and T2-weighted sequences before and after contrast administration and diffusion-weighted imaging, the authors said.²

Despite such guidelines, though, the investigators said there is a lack of evidence-based or widely accepted consensus on standard MRI assessment. Thus, they said, patients often undergo non-standardized MRI prior to their referral to a sarcoma center.

The researchers wanted to find out how well the radiological guidelines are being applied in real-world practice. They decided to analyze a cohort of 64 patients of the University Medical Center Mannheim who had STS of the extremities and trunk and who received MRI examinations. In all but 2 cases, those MRI examinations occurred at external radiological centers. The other two examinations occurred at the university hospital.

The authors found that pre-treatment contrast-enhanced MRI images were available for 51 patients (79.7%). Forty of those referrals specifically indicated a soft tissue tumor, the authors said. They also found that the complete set of guideline-recommended imaging was available in just 2 out of the 64 cases.

“In both cases, the examinations were conducted under the suspicion of a tumor, and the diagnoses were confirmed as differentiated liposarcoma of the pelvis in one patient and dedifferentiated liposarcoma of the lower extremity in the other,” they explained.

In each of the other 62 cases, at least 2 of the required sequences were available. The most commonly unavailable sequence was the T1-weighted sequence without fat saturation before and after contrast administration using acquisition parameters. The second most commonly available sequence was diffusion-weighted imaging, they said.

The investigators posited a number of potential reasons for the lack of adherence to guidelines. They said the reasons may include inaccuracies in clinical referral questions, reimbursement constraints, diagnostic considerations, or perhaps simply a lack of awareness of the guidelines.

The analysis was based on a small number of patients and a single medical center, and factors such as regional variance in reimbursement policies might limit the generalizability of their findings.

In addition, they said that despite not completely following guidelines, the images that were available for the 64 patients were still sufficient to make surgical and therapeutic decisions.

“However, to enable precise tumor characterization, optimized surgical planning, improved prognostic accuracy, and enhanced multicenter research and artificial intelligence applications, standardized and guideline-conforming MRI protocols—including functional sequences such as DWI—are essential,” they concluded.

References

1. Hettler M, Kirschstein J, Ayx I, et al. Evaluation of magnetic resonance imaging parameters and compliance with guidelines in soft tissue sarcomas. BMC Cancer. Published online January 13, 2026. doi:10.1186/s12885-026-15569-3
2. Noebauer-Huhmann IM, Weber MA, Lalam RK, et al. Soft Tissue Tumors in Adults: ESSR-Approved Guidelines for Diagnostic Imaging. Semin Musculoskelet Radiol. 2015;19(5):e1. doi:10.1055/s-0036-1572350