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Computed tomography (CT) staging in breast cancer
Abstract / Clinical Radiology 70 (2015) S10eS18
Results of 1st audit round: The audit identified 319 patients.17.5% (n¼55) patients had complications.16% (n¼50) were classified as minor and 6% (n¼18) major. 39% (n¼20) of minor complications were due to post procedural pain and 28%(n¼14) tube displacement. 0.9% (n¼3) suffered a colonic injury. Thirty-day procedure related mortality rate was 0.6% (n¼2). Our complications are just above our local target. As with other published series, minor complications are common and usually due to post-procedural pain or tube displacement. Only a small number of patients suffered a colonic injury, however, this is an avoidable complication. 1st action plan: Bupivicane for local anaesthesia and regular intra-venous (IV) paracetamol post-procedure to improve pain control. Cone beam computed tomography (CT) to be performed during RIG to confirm position of transverse colon. Re-audit in one-year. References 1. Power S, Kavanagh LN, Shields MC, et al. Insertion of balloon retained gastrostomy buttons: a 5-year retrospective review of 260 patients. Cardiovasc Intervent Radiol 2013;36(2):484e91. 2. Covarrubias DA, O’Connor OJ, McDermott S, et al. Radiologic percutaneous gastrostomy: review of potential complications and approach to managing the unexpected outcome. AJR 2013;200(4):921e31. 3. Grant DG, Bradley PT, Pothier DD, et al. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis. Clin Otolaryngol 2009;34(2):103e12. 4. Cardella JF, Kundu S, Miller DL, et al. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 2009;20(Suppl. 7): S189e91. Unprovoked venous investigating?
thromboembolism
(VTE)
e
are
we
over
Authors: Tahir Hussain, James A. Stephenson, Syed G. Naqvi, Ratan Verma, Daniel Barnes Background: National Institute for Health and Care Excellence (NICE) states we should consider abdomino-pelvic computed tomography (CT) scan (CABPEC) in all unprovoked VTE patients over 40 without signs of cancer on initial investigations.1 Our trust policy is all patients with unprovoked VTE have a CABPEC. We audited the adherence to the policy and diagnostic yield. Standard, indicator and target: From NICE guidelines and best evidence:1 1 Chest X-ray (CXR) in unprovoked DVT ¼100%. 2 Unprovoked VTE >40 years have CABPEC ¼100%. 3 Known VTE risk do not require CABPEC ¼0%. 4 CABPEC cancer diagnostic yield ¼10%. Methodology: 21 months retrospective data collection: Radiology reports. Electronic discharge summaries. MDT registries. Results of 1st audit round: Demographics: 305 unprovoked VTE ¼214 PE, 91 DVT. 152 males:153 females. Mean age ¼68. Standard 1: 16% Standard 2: 73% CABPEC e however, no subsequent cancer diagnosis identified in the cohort with no CABPEC. Standard 3: 3% imaged with known VTE risk. Standard 4: New cancer diagnosis on CABPEC ¼2.6% e all in patients with DVT, all PE related cancers identified on CT pulmonary angiogram (CTPA). All abdomino-pelvic cancers were disseminated, mean survival from VTE ¼4 months. 1st action plan: Diagnostic yield for new cancers on CABPEC is 2.6%, all were in patients with DVT. All PE related cancers were identified on CTPA. All intra-abdominal cancers were disseminated with a mean survival of four months. Our results do not support CABPEC for all unprovoked VTE, published evidence also supports this. A new imaging pathway is being written for investigation of unprovoked VTE, with subsequent repeat audit.
S13
References 1. National Institute for Health and Care Excellence. Pulmonary Embolism: clinical case scenarios. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. London: National Institute for Health and Care Excellence; 2012. Computed tomography (CT) staging in breast cancer Authors: Sin Yee Foo, Karen Gray Background: Despite advances in breast cancer detection and treatment, currently there are no consensus guidelines on staging newly diagnosed locally advanced breast cancer patients. Standard, indicator and target: The Royal College of Radiologists limits region of CT imaging for staging in symptomatic patients to neck, chest and liver.1 Methodology: Newly diagnosed locally advanced breast cancer patients between January 2012 and December 2013 were included and among these, the number of CT chest, abdomen and pelvis (CT CAP) examinations that were performed. Any significant pelvic abnormalities that would otherwise have been overlooked had the pelvis not been included were identified. Results of 1st audit round: This audit included 188 patients. Of these, 149 patients had a CT CAP as part of their staging. Only 31 of 149 patients had any pelvic findings at all and only two of these were subsequently deemed significant. These included a concurrent primary ovarian malignancy in a presumed gene carrier and a patient who had peritoneal and widespread metastatic disease at presentation. 50% of all pelvic findings required additional radiological investigations. Overall 98% of patients who had a CT pelvis +/- additional investigations had no/insignificant pelvic findings and therefore no change to their management plan. 1st action plan: To expand this audit to include other centres throughout Scotland to see if the number of pelvic findings are just as few to justify a change in the way breast cancer patients are staged. References 1. The Royal College of Radiologists. Recommendations for cross sectional imaging in cancer management e Breast cancer, 2nd edn. London: The Royal College of Radiologists; 2013. 2. National Institute of Health and Clinical Excellence. Early and locally advanced breast cancer: diagnosis and treatment. CG80. London: National Institute of Health and Clinical Excellence; 2009. Radiological investigation of renal/ureteric lithiasis with CTKUB Authors: Matthew J. Seager, Dominic Blunt, Kamran Zafar, Anu Mitra Background: Computed tomography kidneys, ureters and bladder (CTKUB) is recommended to investigate suspected renal/ureteric colic.1,2 Its radiation dose is equivalent to 370 chest X-rays with a larger effective dose in woman (internal position of the ovaries).1,3 CTKUB must therefore be used appropriately, with a significant diagnostic yield. Standard, indicator and target: As suggested by The Royal College of Radiologists:4 1 CTKUB should be used to investigate acute renal colic unless contraindicated e target 100% 2 CTKUB should be performed within 24 hours of presentation e target 100% 3 Calculi in 44% scans; alternate diagnoses in a further 6%. Methodology: A retrospective electronic search yielded a list of 75 consecutive patients with suspected renal/ureteric colic. Picture archiving and communication system (PACS) was reviewed to assess which imaging modalities were used and also to generate a list of 75 consecutive CTKUB scans requested by our emergency department (ED) team. Results of 1st audit round: 1. Total receiving CTKUB: 54 (72%) 2. 69 (92%) scans performed within 24 hours of request.
Results of 1st audit round: The audit identified 319 patients.17.5% (n¼55) patients had complications.16% (n¼50) were classified as minor and 6% (n¼18) major. 39% (n¼20) of minor complications were due to post procedural pain and 28%(n¼14) tube displacement. 0.9% (n¼3) suffered a colonic injury. Thirty-day procedure related mortality rate was 0.6% (n¼2). Our complications are just above our local target. As with other published series, minor complications are common and usually due to post-procedural pain or tube displacement. Only a small number of patients suffered a colonic injury, however, this is an avoidable complication. 1st action plan: Bupivicane for local anaesthesia and regular intra-venous (IV) paracetamol post-procedure to improve pain control. Cone beam computed tomography (CT) to be performed during RIG to confirm position of transverse colon. Re-audit in one-year. References 1. Power S, Kavanagh LN, Shields MC, et al. Insertion of balloon retained gastrostomy buttons: a 5-year retrospective review of 260 patients. Cardiovasc Intervent Radiol 2013;36(2):484e91. 2. Covarrubias DA, O’Connor OJ, McDermott S, et al. Radiologic percutaneous gastrostomy: review of potential complications and approach to managing the unexpected outcome. AJR 2013;200(4):921e31. 3. Grant DG, Bradley PT, Pothier DD, et al. Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis. Clin Otolaryngol 2009;34(2):103e12. 4. Cardella JF, Kundu S, Miller DL, et al. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 2009;20(Suppl. 7): S189e91. Unprovoked venous investigating?
thromboembolism
(VTE)
e
are
we
over
Authors: Tahir Hussain, James A. Stephenson, Syed G. Naqvi, Ratan Verma, Daniel Barnes Background: National Institute for Health and Care Excellence (NICE) states we should consider abdomino-pelvic computed tomography (CT) scan (CABPEC) in all unprovoked VTE patients over 40 without signs of cancer on initial investigations.1 Our trust policy is all patients with unprovoked VTE have a CABPEC. We audited the adherence to the policy and diagnostic yield. Standard, indicator and target: From NICE guidelines and best evidence:1 1 Chest X-ray (CXR) in unprovoked DVT ¼100%. 2 Unprovoked VTE >40 years have CABPEC ¼100%. 3 Known VTE risk do not require CABPEC ¼0%. 4 CABPEC cancer diagnostic yield ¼10%. Methodology: 21 months retrospective data collection: Radiology reports. Electronic discharge summaries. MDT registries. Results of 1st audit round: Demographics: 305 unprovoked VTE ¼214 PE, 91 DVT. 152 males:153 females. Mean age ¼68. Standard 1: 16% Standard 2: 73% CABPEC e however, no subsequent cancer diagnosis identified in the cohort with no CABPEC. Standard 3: 3% imaged with known VTE risk. Standard 4: New cancer diagnosis on CABPEC ¼2.6% e all in patients with DVT, all PE related cancers identified on CT pulmonary angiogram (CTPA). All abdomino-pelvic cancers were disseminated, mean survival from VTE ¼4 months. 1st action plan: Diagnostic yield for new cancers on CABPEC is 2.6%, all were in patients with DVT. All PE related cancers were identified on CTPA. All intra-abdominal cancers were disseminated with a mean survival of four months. Our results do not support CABPEC for all unprovoked VTE, published evidence also supports this. A new imaging pathway is being written for investigation of unprovoked VTE, with subsequent repeat audit.
S13
References 1. National Institute for Health and Care Excellence. Pulmonary Embolism: clinical case scenarios. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. London: National Institute for Health and Care Excellence; 2012. Computed tomography (CT) staging in breast cancer Authors: Sin Yee Foo, Karen Gray Background: Despite advances in breast cancer detection and treatment, currently there are no consensus guidelines on staging newly diagnosed locally advanced breast cancer patients. Standard, indicator and target: The Royal College of Radiologists limits region of CT imaging for staging in symptomatic patients to neck, chest and liver.1 Methodology: Newly diagnosed locally advanced breast cancer patients between January 2012 and December 2013 were included and among these, the number of CT chest, abdomen and pelvis (CT CAP) examinations that were performed. Any significant pelvic abnormalities that would otherwise have been overlooked had the pelvis not been included were identified. Results of 1st audit round: This audit included 188 patients. Of these, 149 patients had a CT CAP as part of their staging. Only 31 of 149 patients had any pelvic findings at all and only two of these were subsequently deemed significant. These included a concurrent primary ovarian malignancy in a presumed gene carrier and a patient who had peritoneal and widespread metastatic disease at presentation. 50% of all pelvic findings required additional radiological investigations. Overall 98% of patients who had a CT pelvis +/- additional investigations had no/insignificant pelvic findings and therefore no change to their management plan. 1st action plan: To expand this audit to include other centres throughout Scotland to see if the number of pelvic findings are just as few to justify a change in the way breast cancer patients are staged. References 1. The Royal College of Radiologists. Recommendations for cross sectional imaging in cancer management e Breast cancer, 2nd edn. London: The Royal College of Radiologists; 2013. 2. National Institute of Health and Clinical Excellence. Early and locally advanced breast cancer: diagnosis and treatment. CG80. London: National Institute of Health and Clinical Excellence; 2009. Radiological investigation of renal/ureteric lithiasis with CTKUB Authors: Matthew J. Seager, Dominic Blunt, Kamran Zafar, Anu Mitra Background: Computed tomography kidneys, ureters and bladder (CTKUB) is recommended to investigate suspected renal/ureteric colic.1,2 Its radiation dose is equivalent to 370 chest X-rays with a larger effective dose in woman (internal position of the ovaries).1,3 CTKUB must therefore be used appropriately, with a significant diagnostic yield. Standard, indicator and target: As suggested by The Royal College of Radiologists:4 1 CTKUB should be used to investigate acute renal colic unless contraindicated e target 100% 2 CTKUB should be performed within 24 hours of presentation e target 100% 3 Calculi in 44% scans; alternate diagnoses in a further 6%. Methodology: A retrospective electronic search yielded a list of 75 consecutive patients with suspected renal/ureteric colic. Picture archiving and communication system (PACS) was reviewed to assess which imaging modalities were used and also to generate a list of 75 consecutive CTKUB scans requested by our emergency department (ED) team. Results of 1st audit round: 1. Total receiving CTKUB: 54 (72%) 2. 69 (92%) scans performed within 24 hours of request.