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/T3aPrimary

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 radiologists opinion of tumour appearance and extent.

Histopathology model

The RCPath introduced minimum dataset reporting in 1997.

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:

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.

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

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

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

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

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

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.

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

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

-

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

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)