The sarcoma ring trial: a case-based analysis of inter-center agreement across 21 German-speaking sarcoma centers

Siyer Roohani; Jolina Handtke; Kamal Hummedah; Markus Albertsmeier; Dimosthenis Andreou; Leonidas Apostolidis; Marinela Augustin; Sebastian Bauer; Moritz Billner; Florian Bösch; Christoph K W Deinzer; Niklas Deventer; Anna Duprée; Franziska Eckert; Lars Engel; Katja Fechner; Hagen Fritzsche; Verena Gaidzik; Saeed Ghani; Robert Grützmann; Wiebke K Guder; Rainer Hamacher; Judith S Hecker; Anne Hendricks; Axel Hillmann; Philipp Houben; Georg Hübner; Philipp Ivanyi; Christina Jentsch; Maren Jordan; Peter Kappl; Moritz Kaths; Torsten Kessler; Johanna Kirchberg; Carolin Knebel; Robert Krempien; Burkhard Lehner; Ulrich Lenze; Lars H Lindner; Alisa Martina Lörsch; Nadia Maguire; Sophie Müller; Pompiliu Piso; Vlatko Potkrajcic; Peter Reichardt; Stephan Richter; Simone Schewe; Lars M Schiffmann; Felicitas Scholten; Jana Käthe Striefler; Matthias Schwarzbach; Katharina Seidensaal; Sabine Semrau; Joanna Szkandera; Christoph J Szuszies; Beate Timmermann; Armin Tuscherer; Armin Wiegering; Moritz T Winkelmann; David Kaul; Jens Jakob

doi:10.1007/s00432-024-06063-z

The sarcoma ring trial: a case-based analysis of inter-center agreement across 21 German-speaking sarcoma centers

J Cancer Res Clin Oncol. 2025 Jan 4;151(1):30. doi: 10.1007/s00432-024-06063-z.

Authors

Siyer Roohani^{1

2

3}, Jolina Handtke¹, Kamal Hummedah^{4

5}, Markus Albertsmeier⁶, Dimosthenis Andreou^{7

8}, Leonidas Apostolidis⁹, Marinela Augustin¹⁰, Sebastian Bauer^{11

12}, Moritz Billner¹³, Florian Bösch¹⁴, Christoph K W Deinzer¹⁵, Niklas Deventer¹⁶, Anna Duprée¹⁷, Franziska Eckert^{18

19}, Lars Engel²⁰, Katja Fechner²¹, Hagen Fritzsche²², Verena Gaidzik²³, Saeed Ghani²⁴, Robert Grützmann²⁵, Wiebke K Guder^{8

12}, Rainer Hamacher^{11

12}, Judith S Hecker²⁶, Anne Hendricks²⁷, Axel Hillmann²⁸, Philipp Houben²⁹, Georg Hübner³⁰, Philipp Ivanyi³¹, Christina Jentsch^{32

33

34}, Maren Jordan³⁵, Peter Kappl³⁶, Moritz Kaths^{12

37}, Torsten Kessler³⁸, Johanna Kirchberg^{34

39}, Carolin Knebel⁴⁰, Robert Krempien^{41

42}, Burkhard Lehner⁴³, Ulrich Lenze⁴⁰, Lars H Lindner^{44

45}, Alisa Martina Lörsch²⁶, Nadia Maguire⁴⁶, Sophie Müller²⁷, Pompiliu Piso⁴⁷, Vlatko Potkrajcic¹⁸, Peter Reichardt^{24

42}, Stephan Richter^{34

48}, Simone Schewe¹⁷, Lars M Schiffmann⁴⁹, Felicitas Scholten³⁵, Jana Käthe Striefler⁵⁰, Matthias Schwarzbach³⁵, Katharina Seidensaal^{51

52

53}, Sabine Semrau⁵⁴, Joanna Szkandera⁵⁵, Christoph J Szuszies⁵⁶, Beate Timmermann^{12

57}, Armin Tuscherer^{58

59}, Armin Wiegering^{27

60}, Moritz T Winkelmann⁶¹, David Kaul^{1

3

62}, Jens Jakob^{63

64}

Affiliations

¹ Department of Radiation Oncology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
² Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité (Junior) Clinician Scientist Program, Berlin, Germany.
³ German Cancer Consortium (DKTK), Partner Site Berlin, a Partnership Between DKFZ and Charité-Universitätsmedizin Berlin, Berlin, Germany.
⁴ Sarcoma Unit, Department of Surgery, University Medical Center and Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
⁵ DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany.
⁶ Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-Universität (LMU) Munich, LMU University Hospital, Munich, Germany.
⁷ Department of Orthopedics and Trauma, Medical University of Graz, Graz, Austria.
⁸ Department of Orthopedic Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
⁹ Department of Medical Oncology, Heidelberg University Hospital, National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany.
¹⁰ Department of Hematology and Oncology, Paracelsus Medical University, Nuremberg, Germany.
¹¹ Department of Medical Oncology and Sarcoma Center, West German Cancer Center, University Duisburg-Essen, Medical School, Essen, Germany.
¹² DKTK Partner Site Essen, German Cancer Consortium (DKTK), Heidelberg, Germany.
¹³ Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Paracelsus Medical University, Klinikum Nürnberg, Nuremberg, Germany.
¹⁴ Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany.
¹⁵ Department of Internal Medicine VIII-Medical Oncology and Pneumology, University Hospital Tübingen, Tübingen, Germany.
¹⁶ Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Muenster, Germany.
¹⁷ Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
¹⁸ Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany.
¹⁹ Department of Radiation Oncology, AKH, Comprehensive Cancer Center Vienna, Medical University Vienna, Vienna, Austria.
²⁰ Department of Visceral-Thoracic and General Surgery, Paracelsus Medical University, Nuremberg, Germany.
²¹ Department of Surgery, University Hospital, Erlangen, Germany.
²² University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD, Dresden University of Technology, Dresden, Germany.
²³ Clinic for Internal Medicine III, University Hospital Ulm, Ulm, Germany.
²⁴ Helios Klinikum Berlin Buch, Sarkomzentrum, Berlin, Germany.
²⁵ Department of General and Visceral Surgery, Friedrich-Alexander-University, Erlangen, Germany.
²⁶ Department of Medicine III, School of Medicine and Health, Technical University of Munich (TUM), Munich, Germany.
²⁷ Department of General, Visceral, Transplantation, Vascular, and Pediatric Surgery and Comprehensive Cancer Center Mainfranken Würzburg, University Hospital Würzburg, Würzburg, Germany.
²⁸ Department of Orthopedic and Trauma Surgery, Barmherzige Brüder Regensburg Medical Center, Regensburg, Germany.
²⁹ Department for General-, Visceral- and Transplant Surgery, University Hospital Muenster, Muenster, Germany.
³⁰ Department of Radiation Oncology, Barmherzige Brüder Regensburg Medical Center, Regensburg, Germany.
³¹ Clinic for Hematology, Hemostaseology, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
³² Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD, Dresden University of Technology, Dresden, Germany.
³³ OncoRay-National Center for Radiation Research in Oncology, Dresden, Germany.
³⁴ Nationales Centrum Für Tumorerkrankungen Dresden (NCT/UCC): Deutsches Krebsforschungszentrum (DKFZ), Universitätsklinikum Carl Gustav Carus Dresden, Medizinische Fakultät der Technischen Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany.
³⁵ Varisano Klinikum Frankfurt Höchst, Frankfurt, Germany.
³⁶ Department of Radiology, Neuroradiology, and Nuclear Medicine, Barmherzige Brüder Regensburg Medical Center, Regensburg, Germany.
³⁷ Department of General, Visceral and Transplantation Surgery, Sarcoma Center, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
³⁸ Department of Hematology and Oncology, University Hospital Muenster, Muenster, Germany.
³⁹ Department of General, Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany.
⁴⁰ Department of Orthopaedics and Sports Orthopaedic, Klinikum Rechts Der Isar, Technical University of Munich (TUM), Munich, Germany.
⁴¹ Clinic for Radiotherapy, HELIOS Klinikum Berlin-Buch, Schwanebecker, Berlin, Germany.
⁴² MSB Medical School Berlin, Fakultät für Medizin, Berlin, Germany.
⁴³ Department of Orthopaedics, Heidelberg University Hospital, Heidelberg, Germany.
⁴⁴ SarKUM, Center of Bone and Soft Tissue Tumors, LMU University Hospital, LMU Munich, 81377, Munich, Germany.
⁴⁵ Department of Medicine III, LMU University Hospital, LMU Munich, 81377, Munich, Germany.
⁴⁶ Department of Oncology and Hematology, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany.
⁴⁷ Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany.
⁴⁸ Department of Medicine 1, National Center for Tumor Diseases Dresden (NCT/UCC), Sarcoma Center, University Hospital Carl Gustav Carus Dresden, Dresden University of Technology, Dresden, Germany.
⁴⁹ Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.
⁵⁰ Department of Internal Medicine II, Oncology/Hematology/BMT/Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
⁵¹ Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.
⁵² Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.
⁵³ National Center for Tumor Diseases (NCT), Heidelberg, Germany.
⁵⁴ Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany.
⁵⁵ Division of Clinical Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
⁵⁶ Department of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany.
⁵⁷ Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), Essen, Germany.
⁵⁸ Department I of Internal Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.
⁵⁹ Faculty of Medicine and University Hospital, University of Cologne, Center for Integrated Oncology Cologne Aachen Bonn Cologne Duesseldorf (ABCD), Cologne, Germany.
⁶⁰ Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany.
⁶¹ Department for Diagnostic and Interventional Radiology, University Hospital Tübingen, Tübingen, Germany.
⁶² Health and Medical University Potsdam, Potsdam, Germany.
⁶³ Sarcoma Unit, Department of Surgery, University Medical Center and Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany. [email protected].
⁶⁴ DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany. [email protected].

Abstract

Purpose: The management of soft tissue sarcoma (STS) at reference centers with specialized multidisciplinary tumor boards (MTB) improves patient survival. The German Cancer Society (DKG) certifies sarcoma centers in German-speaking countries, promoting high standards of care. This study investigated the variability in treatment recommendations for localized STS across different German-speaking tertiary sarcoma centers.

Methods: In this cross-sectional case-based survey study, 5 anonymized patient cases with imaging data of localized STS were presented to MTBs of 21 German-speaking tertiary referral hospitals. Centers provided recommendations on treatment sequence and modalities, along with the consensus level within their MTB. Agreement percentages were calculated, and consensus levels were rated on a scale of 1 to 10.

Results: Five patient cases were discussed resulting in 105 recommendations. Agreement percentages for case 1 to 5 were 14.3%, 61.9%, 33.3%, 52.4% and 9.3%, with a median agreement percentage of 33.3%. Grouping pre- and postoperative therapies as "perioperative" and including recommendations with and without regional hyperthermia raised the median agreement to 47.6%. The mean consensus level within each center across all 5 cases was 9.5.

Conclusion: This first case-based analysis of inter-center agreement for STS management in German-speaking countries reveals low inter-center agreement but high intra-center consensus. Our study includes nearly all tertiary sarcoma centers in German-speaking countries, affirming its strong external validity. These findings suggest potential and clinically very relevant differences in treatment standards among sarcoma centers. Enhanced case-based exchanges and collaborative efforts are needed to reduce discrepancies and standardize the management of STS patients.

Keywords: German Cancer Society; Guidelines; Inter-center agreement; Reference center; Ring trial; Soft tissue sarcoma.

Publication types

Multicenter Study

MeSH terms

Adult
Aged
Cross-Sectional Studies
Female
Germany
Humans
Male
Middle Aged
Sarcoma* / pathology
Sarcoma* / therapy
Tertiary Care Centers