Download Rectal MRI Synoptic Reporting

Rectal MRI Synoptic Reporting
Conjoint recommendations from the NZ branch of the RANZCR and the
National Bowel Cancer Working Group (NBCWG)
General Background
Synoptic reporting has been gaining increasing traction over the last few years - especially
for oncology staging and screening studies. This is secondary to both internal pressures
from within radiology, as well as external pressures from other clinicians and government
initiatives.
The government established the National Tumour Standards as part of the Faster Cancer
Treatment programme in 2013 - ten standards in all, covering the majority of cancers.
Almost all of these national tumor standards mandate that patient treatment plans should
be discussed at an MDT meeting; and within these meetings the staging of the cancer
often determines the course of treatment (eg. straight to surgery vs. adjuvant
chemotherapy vs. palliative care). Radiological staging is now the mainstay of overall
staging. Of note, these tumour standards do mandate synoptic reporting of pathology, and
radiology might therefore not be far behind.
Within the MDT there is emphasis on standardized staging of cancers based on the
American Joint Committee on Cancer (AJCC) manual (now up to edition 7). Often the lead
radiologist at the MDT will be reviewing complex cases they haven't formally reported
themselves, as well as cases from outside their own DHB - accordingly standardized
reports facilitate a more straight forward review process, as well as minimizing and
clarifying discordant results.
Outside of the MDT setting standardized reports are easier for referring surgeons and
physicians to review and extract the necessary staging information, and plan any proposed
surgery.
Overall, one can conclude from all this that synoptic reporting for oncology cases is
preferred by clinicians, may be mandated by the government (via the FCT programme) in
the future, and most importantly makes the job of an MDT lead radiologist easier.
Rectal MRI background
For bowel cancer there are 23 standards set up by the NBCWG under the auspices of the
Ministry of Health - of these, standard #10 mandates rectal MRI for all non-metastatic
rectal cancer patients. Currently there is no timeframe stipulation on this (although it is
clearly integral to the other time focused standards), nor is there any stipulation for
synoptic reporting. The NBCWG is composed about approximately 20 experts in the field
of bowel cancer including surgeons, oncologists, radiation oncologists, radiologists,
pathologists, support staff and MOH representatives.
The standards and issues around them are routinely reviewed; and at the most recent
meeting of the NBCWG in March 2015, several of the clinical oncologists, radiation
oncologists, and surgeons independently expressed frustration with the variability in both
quality and reporting style of rectal MRI. This was of great concern given how crucial the
rectal MRI report is for staging and determining treatment pathways. The consensus view
of the clinicians was that standardization of reports was desirable.
From the clinicians point of view there were three main areas where standardization would
be beneficial: MDTs, data collection, and surgical planning.
From the radiologists perspective it is hard to argue against the concerns raised; and in
fact at many NZ hospitals and radiology practices, synoptic reporting is already standard.
This is not uniform however by any measure, and the template of synoptic reports used do
still vary somewhat.
The NBCWG were therefore of the opinion that distribution of a communique to all NZ
radiologists, under the joint banner of the group and the RANZCR (NZ branch), would best
bring this issue to the attention of radiologists in NZ; and hopefully encourage our
members to adopt synoptic reporting of rectal MRI within their hospitals and radiology
clinics.
Minimum requirements for a Synoptic MRI Rectum report
Whilst a synoptic report of a rectal MRI might vary in format and depth, there is a fairly well
established list of key findings that should be included in any report, to enable accurate
staging and allow clinicians to choose the best treatment plan.
These fall under the broad TNM headings, but with additional findings that have a major
impact on both planned surgery and the need for neo-adjuvant therapy.
This list covers the essential findings for complete staging and treatment planning, but
there are a number of additional features included in templates used at various hospitals whether these are useful or not is best established locally. Two examples are included in
the appendix (and there are many more available) from both Auckland DHB and the
Ontario health service. The well researched background explanatory pdf from Ontario is
also included, or can be accessed via:
https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=133269
TUMOUR
Location - low/mid/upper and distance from anal verge
Size
- length and degree of circumferential involvement
T stage - T2, T2/3, T3, or T4
EMVI - is there any extra mural venous invasion?
MRF
- distance from tumour/EMVI to closest mesorectal fascia in any plane
Peritoneal reflection - does the tumour extend above the anterior reflection
- if yes, is there any T3 disease above the reflection
NODES
Peri-rectal nodes? - if yes, how many at least moderately suspicious for involvement
- distance from MRF to closest involved node
Other regional nodes? - if yes, how many
N stage - based on total number of involved regional lymph nodes (N0, N1, or N2)
METASTASES
Metastatic non-regional nodes? - external or common iliac nodes considered metastatic
Other metastatic sites? - bone and peritoneum
M stage - noting that staging CT scan will be required to fully stage for metastatic disease
Conclusion:
The issue of whether to adopt synoptic reporting is a complex one, and will undoubtedly
attract much debate for some time yet. However the use of synoptic reporting for rectal
MRI is clearly advantageous to the patient, the clinical team, and the radiologists involved.
The National Bowel Cancer Working Group would like to bring this to the attention of all
NZ radiologists, with the support of the RANZCR, to recommend the use of standardized
synoptic reporting for rectal MRI.