Download Radiology Cancer Staging

Radiology Cancer Staging
Dr Gina Brown
Radiologist
Royal Marsden Hospital
UK
Cancers fulfilling criteria for
standardised reporting
• preoperative therapy and radical surgery is
determined according to staging risk for selected high
risk patients.
• Radiological staging prevents unnecessary and
potentially harmful preoperative over treatment in
patients with good prognosis tumours
• accuracy of detailed pre operative identification of
key prognostic information by CT and/or MR has
been validated against the histopathology gold
standard
• Documentation of baseline characteristics of tumour
essential – esp if preoperative therapy is given
• Reliable staging information can be provided to the
clinical team at diagnosis
Relevance of Cancer imaging
• Individualise treatment according to
both risk of local and distant failure
• Weekly MDT meeting to review the
imaging and clinical status of patients
before making decisions about
treatment.
• Decisions made often take into account
baseline staging features.
T1
sm2/Sm1
Local
excision?
T1/T2
Primary
TME
surgery
T2/T3a
Primary
TME
surgery
T3b
Primary
TME
surgery
T3c /T3d
Preop
Rx
surgery
T4/CRM
Preop
Rx
Radical
surgery
Examples
• Treatments offered based on preoperative imaging
include



primary surgery for tumours with absent poor prognostic
factors
pre operative chemoradiotherapy for patients with locally
advanced tumours
neoadjuvant chemotherapy followed by potentially curative
surgery for patients presenting with synchronous but
resectable metastatic disease
• wide implications for pre operative treatment it is
crucial that this radiological staging information is
clearly provided and documented
Current practice
• describe CT and MRI scan
appearances of tumour providing
what they consider the pertinent
staging information in the form of a
“freeform” text report which,
although not standardised,
represents the radiologist’s opinion
of tumour appearance and extent.
Histopathology model
• The RCPath introduced minimum
dataset reporting in 1997.
Histopathological Assessment
Code No:
Pathology Reporting Form
Patient’s Initials
….……
Pathologist…………………
…/…./..…
Date of Birth
Surgeon…………………………
Sex
M
Operation date
F
…/…./200..
Macroscopic Assessment - Mesorectum
Has the patient received pre-op RT/CRT
Yes
No
Specimen Grade
Moderate
Incomplete
Anterior
Posterior
below
…………the peritoneal reflection.
Yes
No
 Photograph of Sequential Slices
Yes
No
Involvement of proximal/distal margin
Yes
No
Histology
Type:
Yes
No
Differentiation:
(By predominate type)
Poor
Well/Mod
Complete
 Photograph Surfaces
Tumour is
above
at
Maximum tumour diameter
…..mms
Presence of tumour / wall perforation
(pT4)
Position of tumour (Please mark on diagram)
Ant. quadrant
Left lateral quadrant
Post quadrant
Right lateral quadrant
Circumferential
Distance to distal margin
…..mms
Adenocarcinoma
…………………………………………….
Other tumour type (Please State)
Local Invasion:
Submucosa (pT1)
Muscularis propria (pT2)
Local invasion/peritoneal breach (pT4)
Beyond Muscularis propria (pT3)
Tumour perforation (pT4)
…..mm
Maximum extramural spread of tumour
Minimum distance of tumour to CRM from outer edge of tumour
.….mm
Is the resection histologically complete (i.e. >1mm) ?
No
Yes
Metastatic Spread
No of Nodes examined
Apical Node positive
……..
No. of positive nodes
Yes
No
……..
Histopathology proforma
reporting
• led to an improvement in the reporting of key
prognostic factors by pathologists
• circumferential resection margin reporting
improved from 31% to 100%
• minimum data set reporting of prognostic
histopathological data in colorectal cancer is
now the standard of care that enables highrisk patients to benefit from postoperative
adjuvant therapy.
Preoperative proforma?
• Histopathology assessment of the resected
specimen is clearly too late to influence
preoperative treatment choices.
• As with many solid tumours there is strong
evidence that preoperative therapy benefits
selected patients with colorectal cancer and
selection is based on preoperative staging .
• We hypothesise that a proforma based
reporting system for radiology staging would
be of value in enabling efficient identification
of patients with pertinent risk factors.
What should we expect to see on
a staging report
•
•
•
•
Assessment of tumour resectability
Extent of tumour spread (using TNM)
Metastatic spread
Tumor specific prognostic factors e.g. extramural
venous invasion and peritoneal disease.
• The local staging and prognostic characteristics
• Distant metastatic disease staging evaluated by
imaging
MRI high resolution
Mesorectal fascia
Slice 1
Slice 2
Distance to CRM
vessels
Slice 3
Slice 5
Depth of spread/mm
Slice 4
Slice 6
Slice 1
Slice 2
Lymph
nodes
Slice 3
Slice 5
Slice 4
Slice 6
AUDIT
•
•
We compared the documentation of
staging information from the non
proforma “freeform” report with the
proforma reporting by radiologist
121 patients in total with 66 colon
cancer patients evaluated by CT
alone and 55 patients with rectal
cancer evaluated by both CT and MRI
MEASURES
• The “freeform” non-proforma and
proforma reports for each patient
were independently analysed
noting the explicit mention of
minimum dataset prognostic
factors.
MEASURES
•
We measured the completeness
of staging information by the
same radiologist before and after
introduction of proforma reporting
in 100 patients
Results of freeform reporting
• This showed missing staging data in
118/121 (97.5%) of reports.
• Information regarding the presence or
absence of metastatic disease was
missing in 90/121 (74.3%) of CT
reports.
• Rectal cancer margin status, which
governs resectability, was missing in
40/55 (73%) of reports.
Proforma reporting
• Using proforma reporting, staging
data was missing in 4/121 radiology
reports (3.0%, p<0.001).
• Rectal cancer margin status was
missing in 2/55 (4%, p<0.001).
Proforma reporting vs non-proforma reporting by the same specialist
GI MDT review (CT staged tumours, N=45)
Non-proforma
Post-proforma
100
Percentage (%) of patients
90
80
70
60
50
40
30
20
10
0
Prognostic Factor
Proforma reporting vs non-proforma reporting by the same specialist GI
MDT review (MRI staged tumours, N=55)
Pre-proforma
Post-proforma
100
Percentage (%) of patients
90
80
70
60
50
40
30
20
10
0
EMVI
T stage
N stage
Prognostic factor
M stage
CRM
Results
• at best, only up to 20% of non proforma
reports were complete;
• improving to 98.2% complete when
proforma reporting was introduced
• highlights the benefit of proformabased reporting for the radiologist as a
tool to generate a more comprehensive
report.
Summary
• This lack of clear documentation could result
in under treatment of the patient
preoperatively
• highlights the importance of explicitly stating
validated prognostic factors
• a simple proforma can achieve this and
provides clear and consistent documentation
for treatment rationales.
• false negative assumptions would be
minimised preventing understaging and
therefore under treatment of patients.
Advantages
• Proforma reporting has further benefits for the
MDT process.
• Individual items are more clearly identified,
focusing the attention of the MDM discussion
and promoting more efficient meetings and
decision making.
• The process of proforma reporting may also
highlight areas that radiologists find difficult to
accurately detect, prompting the radiologist to
seek training and support as well as feedback
from histopathology colleagues.
challenges
• proforma reporting may be
considered by some to be too
restrictive
• however, the radiologist always
has the option of free text and
can always recommend further
MDT discussion – for
clarification
To improve quality of cancer care
• Morris et al demonstrated an “unacceptable”
variation in stoma rates between NHS trusts ranging
from 8.5% to 52.6% but could not identify the reasons
- proper documentation of height and stage of the
tumours from pre-operative imaging would have
made comparison of these APE rates more
meaningful.
• Universal adoption of proforma reporting would
provide standardised comparisons to help in future
national audits for objective comparisons between
centres and treatment policies.
RCR/NCIN Working Party
for Cancer Reporting
Radiology Working Group for
Standards in Cancer Reporting
RCR standard for cross
sectional imaging in
cancer management
Special interest
group
(SIGS)
STAKEHOLDERS:
- Multi disciplinary sub– speciality
Commission proforma
reporting templates from
Expert authors (RCR/NCIN)
- NCRI CSG’s
NCIN / connecting
For health
Evidence base for standards eg:
MBUR7, NICE,
CRAC Audit
Approve and circulate the draft through the
working group
RCR Pilot
-
subspecialty experts
eg: surgeons, pathologists
and oncologists
RCR led Pilot
• A pilot of implementation of
proforma reporting for cancers in
• Colorectal
• Prostate
• Lung
• Gynae malignancies
Aim of pilot
• Test feasibility and effectiveness of
implementation of proforma
reporting for cancers lung,
gynaecological, colorectal, and
prostate cancers
Multicentre pilot of MDT
Proforma Introduction
• 10-15 UK centres – RCR call for
pilot centres



Data collection support
Cancer reporting workshops
RCR pilot centre status
Objectives
1. Can standardised proforma reporting for cancer staging in the
MDT setting can be achieved in multiple centres?
2. areas of difficulty in implementation - how are they overcome by
the different centres?
3. Minimum data staging before and after proforma adoption
4. Impact/usefulness of support workshops and proforma
completion notes
5. To receive feedback of the proformas from the MDT end users
and adjustments from their use.
6. Appropriateness of detail in the proforma: clinical
impacts/decision pathways
7. Compare our experience with the Ontario Cancer Care initiative
and comparison of the equivalent evaluation forms for the
participating centres in Ontario.
Conclusion
• gains from proforma based
comprehensive radiology reporting will
prevent inappropriate patient
management, ineffective surgery and
suboptimal patient outcomes.
• proforma-based reporting should be
universally adopted in the MDT setting,
since it will enable the consistent and
systematic identification of high risk
patients for pre-operative therapies
Working group:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Tony Nicholson: RCR Dean
Dr Andrea Rockall (NCIN subspecialty lead for Gynae Oncology Radiology and
RCR co-lead for Cancer Standards in Oncology Imaging)
Dr Julie Olliff (RCR co-lead for Cancer Standards in Oncology Imaging)
Dr Anwar Padhani (NCIN subspecialty lead for Prostate cancer radiology reports
and RCR co-lead for Cancer Standards in Oncology Imaging)
Dr Fergus Gleeson/Dr Sujal Desai (NCIN subspecialty leads for Lung cancer)
Dr Ashley Guthrie (NCIN co-lead for Colorectal cancer)
Dr Mick Peake (NCIN chair, National Lead for Lung Cancer, and Royal College
of Physicians)
Professor Paul Finan (National Lead for Colorectal Cancer, and Royal College of
Surgeons),
Dr Jem Rashbass (Royal College of Pathologists),
Miss Hazel Beckett (Head of Professional Practice, RCR)
Ms Gillian Dollamore (Executive Officer, Professional Standards Team, RCR)
Mrs Nan Parkinson, (Faculties Administrator, RCR)
Collaborators from Ontario Cancer Care, synoptic reporting project
Dr Erin Kennedy (Project lead, Department of Surgery, Mount Sinai Hospital,
Toronto, ON, Canada)
Mark Fruitman (Radiologist, Department of Radiology, St. Joseph's Health
Centre, Toronto, ON, Canada)
Laurent Milot (Radiologist, Department of Radiology, Sunnybrook Health
Sciences Centre, Toronto, ON, Canada)