Gina Brown
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Transcript of Gina Brown
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Radiology Cancer Staging
Dr Gina Brown
Radiologist
Royal Marsden Hospital
UK
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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
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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.
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T1 sm2/Sm1
Local excision?
T1/T2
Primary TME
surgery
T2/T3aPrimary
TME surgery
T3b
Primary TME
surgery
T3c /T3d
Preop
Rx
surgery
T4/CRM
Preop
Rx
Radical
surgery
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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
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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 radiologists opinion of tumour appearance and extent.
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Histopathology model
The RCPath introduced minimum dataset reporting in 1997.
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Histopathological AssessmentPathology Reporting Form Patients Initials . Date of Birth /./.. Sex M F
Pathologist Surgeon Operation date /./200..
Macroscopic Assessment - Mesorectum Has the patient received pre-op RT/CRT Yes No
Specimen Grade Complete Moderate Incomplete
Photograph Surfaces Anterior Posterior
Tumour is above at below the peritoneal reflection.
Maximum tumour diameter ..mms
Presence of tumour / wall perforation (pT4) Yes No
Position of tumour (Please mark on diagram)
Ant. quadrant Left lateral quadrant
Post quadrant Right lateral quadrant
Circumferential
Distance to distal margin ..mms
Photograph of Sequential Slices Yes No
Involvement of proximal/distal margin Yes No
Histology Type: Adenocarcinoma Yes No
Differentiation: (By predominate type) Poor Well/Mod
Other tumour type (Please State) .
Local Invasion:
Submucosa (pT1) Muscularis propria (pT2) Beyond Muscularis propria (pT3)
Local invasion/peritoneal breach (pT4) Tumour perforation (pT4)
Maximum extramural spread of tumour ..mm
Minimum distance of tumour to CRM from outer edge of tumour ..mm
Is the resection histologically complete (i.e. >1mm) ? Yes No
Metastatic Spread
No of Nodes examined .. No. of positive nodes ..
Apical Node positive Yes No
Code No:
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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 high-risk patients to benefit from postoperative adjuvant therapy.
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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.
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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
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Slice 1Slice 2
Slice 4Slice 3
Slice 5Slice 6
Slice 1 Slice 2
Slice 3
Slice 6
Slice 4
Slice 5
MRI high resolution
Mesorectal fascia
vessels
Lymph
nodes
Distance to CRM
Depth of spread/mm
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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
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MEASURES
The freeform non-proforma and proforma reports for each patient
were independently analysed
noting the explicit mention of
minimum dataset prognostic
factors.
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MEASURES
We measured the completeness of staging information by the
same radiologist before and after
introduction of proforma reporting
in 100 patients
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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.
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Proforma reporting
Using proforma reporting, staging data was missing in 4/121 radiology
reports (3.0%, p
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Proforma reporting vs non-proforma reporting by the same specialist
GI MDT review (CT staged tumours, N=45)
0
10
20
30
40
50
60
70
80
90
100
Prognostic Factor
Pe
rce
nta
ge
(%
) o
f p
ati
en
ts
Non-proforma Post-proforma
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Proforma reporting vs non-proforma reporting by the same specialist GI
MDT review (MRI staged tumours, N=55)
EMVI T stage N stage M stage CRM
0
10
20
30
40
50
60
70
80
90
100
Prognostic factor
Pe
rce
nta
ge
(%
) o
f p
ati
en
ts
Pre-proforma Post-proforma
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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 proforma-based reporting for the radiologist as a tool to generate a more comprehensive report.
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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.
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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.
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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
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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.
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RCR/NCIN Working Party
for Cancer Reporting
Radiology Working Group for
Standards in Cancer Reporting
Commission proforma
reporting templates from
Expert authors (RCR/NCIN)
Special interest
group
(SIGS)
Evidence base for standards eg:
MBUR7, NICE,
CRAC Audit Approve and circulate the draft through the
working group
STAKEHOLDERS:
- Multi disciplinary sub speciality
- NCRI CSGs
NCIN / connecting
For health
subspecialty experts
eg: surgeons, pathologists
and oncologists
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RCR standard for cross
sectional imaging in
cancer management
Radiology Working Group for
Standards in Cancer Reporting
Commission proforma
reporting templates from
Expert authors (RCR/NCIN)
Special interest
group
(SIGS)
Evidence base for standards eg:
MBUR7, NICE,
CRAC Audit
working group
STAKEHOLDERS:
- Multi disciplinary sub speciality
- NCRI CSGs
NCIN / connecting
For health
RCR standard for cross
sectional imaging in
cancer management
RCR Pilot
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RCR led Pilot
A pilot of implementation of proforma reporting for cancers in
Colorectal
Prostate
Lung
Gynae malignancies
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Aim of pilot
Test feasibility and effectiveness of implementation of proforma
reporting for cancers lung,
gynaecological, colorectal, and
prostate cancers
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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
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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.
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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
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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)