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Principles of Oncologic Imaging and Reporting
Reporting
D.M.
D.M. Panicek, New York/USA
OIC 2012 Oncologic Imaging Course | June 28-30, 2012 | Dubrovnik, Croatia
David M. Panicek, MD, FACR
Department of Radiology
Memorial Sloan-Kettering Cancer Center
New York, NY 10065 USA
Learning Objectives
• Review some general principles of oncologic imaging
• Illustrate importance of clinical context during interpretation of oncologic exams
• Discuss ways to ensure that reports
– provide added value to referring physicians
– reflect the radiologist’s role as consultant
–
Oncologic imaging examinations are often complex, and specialized knowledge is
required to interpret them in a clinically relevant manner. The radiologist needs to be
aware of the details of the staging system and pattern of spread for a given tumor type;
the strengths and limitations of available imaging modalities in specific oncologic
applications, especially in assessing tumor response to different conventional and
newer therapies; and various pitfalls in the overall approach to interpretation and
reporting of oncologic imaging examinations.
General Principles of Oncologic Imaging
1. Radiologic staging requires knowledge of specific staging elements for a given
tumor type.
2. Scrutinize the areas most likely to harbor that specific disease.
3. Compare to more remote studies to avoid the "No change, no change, no change
— OOPS!" scenario.
4. Search for worsening disease before declaring "improvement."
5. A test may not be equally valuable for both diagnosis and post-treatment followup. For example, CT and MRI show different tissues in bone: CT shows
destruction or sclerosis of trabecula caused by tumor deposits in the marrow,
whereas MRI directly shows tumor deposits replacing the marrow.
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6. An imaging modality may have widely different abilities to demonstrate various
types of metastases. For example, PET is quite sensitive for lytic bone
metastases but rather insensitive to blastic bone metastases of breast cancer
(particularly lobular carcinoma).
7. Biopsy results (especially negative ones) are not a perfect reference standard,
and should not automatically negate the results of imaging tests.
8. Patients with cancer often have other, benign lesions that can mimic cancer at
staging or follow-up.
Clinical Context in Oncologic Imaging
The medical history of a patient with cancer is often complex. Yet a radiologic exam
is only a "snapshot" taken during a brief moment of that history. Meaningful
interpretation of an exam (the radiologist’s "added value") requires integration of current
findings with results of various other, previous radiologic studies and pertinent clinical
information. In that manner, the radiologist serves as a true consultant, rather than
being merely a "film reader." Reports otherwise may be technically accurate, but
clinically unhelpful (or even misleading).
Optimizing Oncologic Imaging Reports
• Distill the myriad imaging findings into a focused, clinically relevant report
– Emphasize the issues related to the patient's tumor
– Minimize extraneous findings not relevant to patient care
• Tiny renal lesions (too small to characterize, "ditzels")
• Degenerative changes
• Small lipomas
– Synthesize findings in the Impression
• Poor: "Enhancing soft tissue mass in renal bed."
• Good: "Recurrent renal cancer in surgical bed."
• Poor: "Enlarging mass in left adrenal."
• Good: "Probable metastasis in left adrenal."
•
Focus the report toward its audience
– Surgeon
• Is it resectable; If so, what structures are involved?
– Medical oncologist
• Is patient doing better, worse, or unchanged?
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– Radiation oncologist
• What region(s) to treat?
– Patient
• Avoid alarming or pejorative words
•
Standardized report templates
Standardized report templates convey the maximal amount of clinically
relevant information, using a minimal number of words, in a consistent,
organized format.
•
Integrated Imaging Summary
When patients undergo both a PET/CT scan and a contemporaneous
diagnostic CT or MRI within four weeks of each other, issuing an Integrated
Imaging Summary provides a single, cohesive interpretation of the findings
from both studies — rather than leaving this essential integration step for the
referring physician to accomplish.
Example: "The small pulmonary nodules present on CT may
be malignant despite being PET negative (they are below the resolution
of PET)."
•
Standardized lexicon for degree of diagnostic certainty
Some diagnoses are simply stated without an accompanying qualifier in the
radiology report (such as "displaced fracture of femoral shaft"), indicating that
the radiologist is certain of the stated diagnosis. In situations in which the
diagnosis is less clear, the words used to convey an individual radiologist's
assessment of the likelihood of a diagnosis have been shown to have widely
different meanings — both to other radiologists and to referring physicians.
To decrease this variability and improve communication, the following
smaller, well-defined lexicon of certainty terms was developed in consensus
and is used by radiologists at MSKCC.
Consistent with
Suspicious for/Probable
Possible
Less likely
Unlikely
>90%
~75%
~50%
~25%
<10%
© MSKCC 2010
The percentage associated with each term indicates the radiologist's best
estimate of the probability of that diagnosis, based on experience and
judgment. Although such estimates have always been in each radiologist's
mind, this lexicon makes them more uniform and explicit in the report. This
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table is printed at the bottom of every radiology report (except for breast
imaging studies, to avoid confusion with the BI-RADS system) at our
institution.
References
AJCC Cancer Staging Manual. 7th edition. Springer, 2009.
Khorasani R, Bates DW, Teeger S, Rothschild JM, Adams DF, Seltzer SE. Is
terminology used effectively to convey diagnostic certainty in radiology reports? Acad
Radiol 2003; 10:685-688.
Schwartz LH, Panicek DM, Berk AR, Li Y, Hricak H. Improving communication of
diagnostic radiology findings through structured reporting. Radiology 2011; 260:174181.
Uematsu T, Yuen S, Yukisawa S, Aramaki T, Morimoto N, Endo M, Furukawa H, Uchida
Y, Watanabe J. Comparison of FDG PET and SPECT for detection of bone metastases
in breast cancer. Am J Roentgenol 2005; 184:1266-1273.