Abstract
PurposeTo analyze how the MRI reporting of rectal cancer has evolved (following guideline updates) in The Netherlands.MethodsRetrospective analysis of 712 patients (2011–2018) from 8 teaching hospitals in The Netherlands with available original radiological staging reports that were re-evaluated by a dedicated MR expert using updated guideline criteria. Original reports were classified as “free-text,” “semi-structured,” or “template” and completeness of reporting was documented. Patients were categorized as low versus high risk, first based on the original reports (high risk = cT3-4, cN+, and/or cMRF+) and then based on the expert re-evaluations (high risk = cT3cd-4, cN+, MRF+, and/or EMVI+). Evolutions over time were studied by splitting the inclusion period in 3 equal time periods.ResultsA significant increase in template reporting was observed (from 1.6 to 17.6–29.6%; p < 0.001), along with a significant increase in the reporting of cT-substage, number of N+ and extramesorectal nodes, MRF invasion and tumor-MRF distance, EMVI, anal sphincter involvement, and tumor morphology and circumference. Expert re-evaluation changed the risk classification from high to low risk in 18.0% of cases and from low to high risk in 1.7% (total 19.7%). In the majority (17.9%) of these cases, the changed risk classification was likely (at least in part) related to use of updated guideline criteria, which mainly led to a reduction in high-risk cT-stage and nodal downstaging.ConclusionUpdated concepts of risk stratification have increasingly been adopted, accompanied by an increase in template reporting and improved completeness of reporting. Use of updated guideline criteria resulted in considerable downstaging (of mainly high-risk cT-stage and nodal stage).Graphic abstract
Highlights
MRI is routinely used to stratify rectal cancer patients for differentiated treatments based on the presence of known high-risk features
Due to the retrospective nature of the study, informed consent was waived. As part of this multicenter project the primary staging of MRIs including radiological staging reports, treatment specifics, and clinical outcome data of 1426 patients with biopsy-proven rectal adenocarcinoma were previously collected, originating from 10 Dutch medical centers (1 university hospital, 8 large teaching hospitals, and 1 comprehensive cancer center). As part of this previous study project, the MRI examinations of a subset of the collected study patients were re-evaluated by a single dedicated MRI expert (DMJL with > 10 years of experience in reading rectal MRI) from the principal investigating (PI) center according to the staging template published in the most recent European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus guidelines on rectal MRI from 2018 [14]
From the initial cohort of 1426, n = 712 patient cases could be included (63.6% male, median age 66, range 26–94 years), for whom both the original primary staging reports and re-evaluation reports were available. These patients included 95 (13.3%) patients who were treated with direct surgery, 61 (8.6%) patients who underwent short-course radiotherapy (5 × 5 Gy) followed by surgery, and 556 (78.1%) patients who underwent a long course of neoadjuvant treatment
Summary
MRI is routinely used to stratify rectal cancer patients for differentiated treatments based on the presence (or absence) of known high-risk features. The Mercury study group showed that high-resolution MRI can accurately determine the depth of extramural invasion [12] and a report by Taylor et al showed that, by doing so, MRI can accurately identify tumors with a low-risk cT-stage (cT1-2 and cT3 with < 5 mm perirectal invasion) that can safely be managed by surgery only [13]. This subdivision of cT-stage according to the depth of invasion has been adopted for risk stratification in several guidelines [1, 3, 14]
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