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Local staging of early rectal cancer: correlation of MRI and EUS T staging with pathological staging
Abstract / Clinical Radiology 72 (2017) S1eS13
S3
(PET-CT) imaging demonstrated lymphadenopathy in the mediastinum and pulmonary hila confirmed to be due to sarcoidosis by endobronchial ultrasound (EBUS) guided tissue sampling. One patient was commenced on steroid treatment which improved the sarcoidosis, repeat imaging showing resolution of the lymphadenopathy. All patients remained asymptomatic from a respiratory point of view. Conclusion: These cases highlight the importance of recognising potential autoimmune toxicities of PD-1 inhibitors. Each of our three patients developed thoracic lymphadenopathy while on Pembrolizumab and in the setting of metastatic melanoma, such imaging findings could potentially be misinterpreted as disease progression and therefore negatively impact on further management decisions. Radiologists should be aware of the association between Pembrolizumab therapy and the development of sarcoidosis, to avoid inaccurately ascribing imaging findings. Such cases mandate biopsy proof to confirm the diagnosis and direct ongoing management.
(25/37) of patients had small FOV images through the axial and coronal planes of the tumour. The accuracy of the CRM was only concordant with the histological report in 77% (23/30) and did not meet the national standard. Conclusion: We are not meeting national standards for image quality of rectal MRI. This may be a contributing factor to the unsatisfactory CRM involvement reporting accuracy and ultimately may affect patient management decisions. We need to encourage closer working relationships between radiologists and radiographers to raise image quality in order to improve overall patient care.
Osteophyte related fibrosis: an under-appreciated but common finding on high-resolution computed tomography (HRCT)
Purpose: Local excision techniques can offer reduced morbidity to patients with early rectal lesions, including cancer. Accurate T staging is essential in identifying lesions suitable for local excision and allowing selection of appropriate technique. Our early rectal cancer multidisciplinary team (MDT) utilises magnetic resonance imaging (MRI) and endorectal ultrasound (EUS) for T staging of tumours and this study correlates the findings of these examinations with pathological T staging. Published data from other centres were used as a standard to assess local performance. Methods and materials: Patients who underwent transanal endoscopic microsurgery (TEMS) in the four-year period to August 2016 were reviewed. Where available the MRI, EUS and pathology T stage were recorded. For cancers, comparison was made between the imaging and pathological T stage, and positive predictive value (PPV) was calculated. Results: 94 patients underwent TEMS and 31 of these were found to be cancers. 24 were pT1, 6 pT2 and one was pT3a. All patients underwent MRI, however, only 11 of the cancer patients had mrT stage reported. mrT stage correlated with pathology in seven patients (PPV 64%). EUS T staging was available in 15 patients and correlated with pathology in eight (PPV 62%). Conclusion: The role and accuracy of EUS and MRI in early rectal cancer remain unclear. Our findings compare favourably with published data from other centres, however, our case numbers are small, as are the numbers in published series. A larger study is needed to clarify the role of these modalities in local staging and surgical decision making. Training in interpretation of MRI in early rectal cancer, improved MR technique and pro forma reporting may improve accuracy of local staging.
Authors: Derek A.J. Smith, Alberto Nania, Nik Hirani, Gillian Ritchie, Mark Jones, John T. Murchison Purpose: To determine the prevalence and degree of osteophyte related fibrosis in a typical HRCT population. Methods and materials: We retrospectively reviewed 100 consecutive HRCTs performed at the Royal Infirmary of Edinburgh, UK. We recorded patient age, osteophyte presence and size on multiplanar reconstruction (MPR) reformats, and assessed any parenchymal changes. The spectrum of adjacent lung findings were defined as ground-glass opacification, interstitial thickening, traction bronchiectasis or honeycombing. Results: 79% had thoracic osteophytes, mostly right sided, and 42% demonstrated focal changes in the adjacent lung (98% in the medial right lower lobe). The majority (74%) demonstrated milder changes, with seven traction bronchiectasis and four focal honeycombing. 6% had osteophytes, but diffuse lung disease which excluded analysis of lung changes. Osteophyte size and age were statistically significant factors (p¼0.04 and p¼0.02 respectively) for the presence of lung changes, and older age was associated with more severe changes (p¼0.004). Conclusion: Parenchymal changes adjacent to thoracic vertebral osteophytes are common. These have previously been suggested to be consistent with a fibrotic or aging lung process, but the prevalence had not previously been well quantified in this population. We have demonstrated spectrum of changes correlating both with patient age and osteophyte size, clinically discrete from interstitial lung disease, and have termed this benign process ‘osteophyte related fibrosis. Audit of rectal MRI quality and accuracy circumferential resection margin involvement
of
reporting
the
Authors: Tarryn Carlsson, Andrew Macallister, Hedwig Karteszi Purpose: To assess quality of our magnetic resonance imaging (MRI) rectum studies against national guidelines and accuracy of reporting the circumferential resection margin (CRM) when compared with postoperative histological reports in patients who had a primary resection. Methods and materials: We retrospectively reviewed 50 consecutive patients with rectal carcinoma and a primary resection between 1 January 2015 and 1 February 2017. 13 patients were excluded in the image quality arm (n¼37) and seven were excluded from the reporting accuracy arm (n¼30). Standards: - 100% of studies should include the mesorectum up to L5/S1 on the large field of view (FOV) axial and sagittal planes (national) - 100% of studies should include small FOV sequences in axial and coronal planes to the tumour (national) - Reporting accuracy should be >90% predicting involvement of the CRM (national). Results: We did not meet any of the scan quality standards; only 76% (28/ 37) included the mesorectum up to L5/S1 on the large FOV and only 68%
Local staging of early rectal cancer: correlation of MRI and EUS T staging with pathological staging Authors: Nada Bashar, Farhat Bano, Joanne O’Connor, Catriona Farrell
Interobserver agreement of C and E coding in CT colonography Authors: Vincent Leung, Nicola Cook, Stephen Sammut, Paul Clarke, Ingrid Britton Purpose: In our institution, a computed tomography colonography (CTC) report coding system is used that classifies reports by C and E code. The C coding refers to the intra-colonic findings on a scale from 1e5, where one is ‘no size significant polyps’ and five is ‘malignant-looking lesion. The E coding provides similar classification of the extra-colonic findings. The purpose of this study is to validate the coding system by assessing the interobserver agreement. Methods and materials: A retrospective study was performed of all CTCs in our trust between 1 July 2016 and 30 September 2016 across two hospital sites. Our standard practice is for each study to be read initially by an advanced practitioner radiographer with a final report issued by a consultant radiologist. Basic demographic information and report coding by the advanced practitioner and consultant radiologist were collected. Results: 683 CTCs (266 female, 197 male, mean age 68.6 years) were performed. For C coding, 57 were excluded either as they were not coded, not read by a radiographer prior to consultant report or rated as an inadequate study by either reader. The percentage agreement between radiographer findings and radiologist report was 92.3% for C coding and 50.6% for E coding. Interobserver agreement Kappa statistic was calculated to be 0.77 (95% CI 0.703e0.830) for C coding and 0.27 (95% CI 0.206e0.324) for E coding.
S3
(PET-CT) imaging demonstrated lymphadenopathy in the mediastinum and pulmonary hila confirmed to be due to sarcoidosis by endobronchial ultrasound (EBUS) guided tissue sampling. One patient was commenced on steroid treatment which improved the sarcoidosis, repeat imaging showing resolution of the lymphadenopathy. All patients remained asymptomatic from a respiratory point of view. Conclusion: These cases highlight the importance of recognising potential autoimmune toxicities of PD-1 inhibitors. Each of our three patients developed thoracic lymphadenopathy while on Pembrolizumab and in the setting of metastatic melanoma, such imaging findings could potentially be misinterpreted as disease progression and therefore negatively impact on further management decisions. Radiologists should be aware of the association between Pembrolizumab therapy and the development of sarcoidosis, to avoid inaccurately ascribing imaging findings. Such cases mandate biopsy proof to confirm the diagnosis and direct ongoing management.
(25/37) of patients had small FOV images through the axial and coronal planes of the tumour. The accuracy of the CRM was only concordant with the histological report in 77% (23/30) and did not meet the national standard. Conclusion: We are not meeting national standards for image quality of rectal MRI. This may be a contributing factor to the unsatisfactory CRM involvement reporting accuracy and ultimately may affect patient management decisions. We need to encourage closer working relationships between radiologists and radiographers to raise image quality in order to improve overall patient care.
Osteophyte related fibrosis: an under-appreciated but common finding on high-resolution computed tomography (HRCT)
Purpose: Local excision techniques can offer reduced morbidity to patients with early rectal lesions, including cancer. Accurate T staging is essential in identifying lesions suitable for local excision and allowing selection of appropriate technique. Our early rectal cancer multidisciplinary team (MDT) utilises magnetic resonance imaging (MRI) and endorectal ultrasound (EUS) for T staging of tumours and this study correlates the findings of these examinations with pathological T staging. Published data from other centres were used as a standard to assess local performance. Methods and materials: Patients who underwent transanal endoscopic microsurgery (TEMS) in the four-year period to August 2016 were reviewed. Where available the MRI, EUS and pathology T stage were recorded. For cancers, comparison was made between the imaging and pathological T stage, and positive predictive value (PPV) was calculated. Results: 94 patients underwent TEMS and 31 of these were found to be cancers. 24 were pT1, 6 pT2 and one was pT3a. All patients underwent MRI, however, only 11 of the cancer patients had mrT stage reported. mrT stage correlated with pathology in seven patients (PPV 64%). EUS T staging was available in 15 patients and correlated with pathology in eight (PPV 62%). Conclusion: The role and accuracy of EUS and MRI in early rectal cancer remain unclear. Our findings compare favourably with published data from other centres, however, our case numbers are small, as are the numbers in published series. A larger study is needed to clarify the role of these modalities in local staging and surgical decision making. Training in interpretation of MRI in early rectal cancer, improved MR technique and pro forma reporting may improve accuracy of local staging.
Authors: Derek A.J. Smith, Alberto Nania, Nik Hirani, Gillian Ritchie, Mark Jones, John T. Murchison Purpose: To determine the prevalence and degree of osteophyte related fibrosis in a typical HRCT population. Methods and materials: We retrospectively reviewed 100 consecutive HRCTs performed at the Royal Infirmary of Edinburgh, UK. We recorded patient age, osteophyte presence and size on multiplanar reconstruction (MPR) reformats, and assessed any parenchymal changes. The spectrum of adjacent lung findings were defined as ground-glass opacification, interstitial thickening, traction bronchiectasis or honeycombing. Results: 79% had thoracic osteophytes, mostly right sided, and 42% demonstrated focal changes in the adjacent lung (98% in the medial right lower lobe). The majority (74%) demonstrated milder changes, with seven traction bronchiectasis and four focal honeycombing. 6% had osteophytes, but diffuse lung disease which excluded analysis of lung changes. Osteophyte size and age were statistically significant factors (p¼0.04 and p¼0.02 respectively) for the presence of lung changes, and older age was associated with more severe changes (p¼0.004). Conclusion: Parenchymal changes adjacent to thoracic vertebral osteophytes are common. These have previously been suggested to be consistent with a fibrotic or aging lung process, but the prevalence had not previously been well quantified in this population. We have demonstrated spectrum of changes correlating both with patient age and osteophyte size, clinically discrete from interstitial lung disease, and have termed this benign process ‘osteophyte related fibrosis. Audit of rectal MRI quality and accuracy circumferential resection margin involvement
of
reporting
the
Authors: Tarryn Carlsson, Andrew Macallister, Hedwig Karteszi Purpose: To assess quality of our magnetic resonance imaging (MRI) rectum studies against national guidelines and accuracy of reporting the circumferential resection margin (CRM) when compared with postoperative histological reports in patients who had a primary resection. Methods and materials: We retrospectively reviewed 50 consecutive patients with rectal carcinoma and a primary resection between 1 January 2015 and 1 February 2017. 13 patients were excluded in the image quality arm (n¼37) and seven were excluded from the reporting accuracy arm (n¼30). Standards: - 100% of studies should include the mesorectum up to L5/S1 on the large field of view (FOV) axial and sagittal planes (national) - 100% of studies should include small FOV sequences in axial and coronal planes to the tumour (national) - Reporting accuracy should be >90% predicting involvement of the CRM (national). Results: We did not meet any of the scan quality standards; only 76% (28/ 37) included the mesorectum up to L5/S1 on the large FOV and only 68%
Local staging of early rectal cancer: correlation of MRI and EUS T staging with pathological staging Authors: Nada Bashar, Farhat Bano, Joanne O’Connor, Catriona Farrell
Interobserver agreement of C and E coding in CT colonography Authors: Vincent Leung, Nicola Cook, Stephen Sammut, Paul Clarke, Ingrid Britton Purpose: In our institution, a computed tomography colonography (CTC) report coding system is used that classifies reports by C and E code. The C coding refers to the intra-colonic findings on a scale from 1e5, where one is ‘no size significant polyps’ and five is ‘malignant-looking lesion. The E coding provides similar classification of the extra-colonic findings. The purpose of this study is to validate the coding system by assessing the interobserver agreement. Methods and materials: A retrospective study was performed of all CTCs in our trust between 1 July 2016 and 30 September 2016 across two hospital sites. Our standard practice is for each study to be read initially by an advanced practitioner radiographer with a final report issued by a consultant radiologist. Basic demographic information and report coding by the advanced practitioner and consultant radiologist were collected. Results: 683 CTCs (266 female, 197 male, mean age 68.6 years) were performed. For C coding, 57 were excluded either as they were not coded, not read by a radiographer prior to consultant report or rated as an inadequate study by either reader. The percentage agreement between radiographer findings and radiologist report was 92.3% for C coding and 50.6% for E coding. Interobserver agreement Kappa statistic was calculated to be 0.77 (95% CI 0.703e0.830) for C coding and 0.27 (95% CI 0.206e0.324) for E coding.