Staging Tool Research Articles

Sentinel Lymph Node Biopsy for Oral Cancer – When to use it?

Introduction: Sentinel lymph node biopsy (SLNB) for staging tool for oral squamous cell carcinoma (OSCC) was recommended in the 2016 NICE guidance for patients presenting with early (T1 and T2 N0) disease. However, when to deploy SLNB as opposed to elective selective lymphadenectomy (ELND) to detect occult regional metastases remains controversial and is the focus of this study. Methods: A retrospective analysis of 145 patients who had had sentinel lymph node biopsy for a previously untreated primary T1 or T2 oral cancer between 2010 and 2020 was performed. The primary outcome measures of interest were predictors of occult metastases, accuracy of SLNB, disease specific and overall survival. Results: This study reported97% NPV, 7.8% FNR, 2.7% FOR and 92% Sensitivity based on our 145-patient cohort. Depth of invasion (DOI) was a significant predictor of N status, overall survival and disease specific survival.There was a significant difference in the incidence of the neck node metastasis (17.5% vs 36.4%) in patients with DOI <5mm compared to those with DOI >5mm. Conclusions: The selection of SLNB as the preferred staging procedure over ELND requires discussion with patients and should include an estimate of the probability of requiring re-admission for a more complete lymphadenectomy procedure. Introduction: Sentinel lymph node biopsy (SLNB) for staging tool for oral squamous cell carcinoma (OSCC) was recommended in the 2016 NICE guidance for patients presenting with early (T1 and T2 N0) disease. However, when to deploy SLNB as opposed to elective selective lymphadenectomy (ELND) to detect occult regional metastases remains controversial and is the focus of this study. Methods: A retrospective analysis of 145 patients who had had sentinel lymph node biopsy for a previously untreated primary T1 or T2 oral cancer between 2010 and 2020 was performed. The primary outcome measures of interest were predictors of occult metastases, accuracy of SLNB, disease specific and overall survival. Results: This study reported97% NPV, 7.8% FNR, 2.7% FOR and 92% Sensitivity based on our 145-patient cohort. Depth of invasion (DOI) was a significant predictor of N status, overall survival and disease specific survival.There was a significant difference in the incidence of the neck node metastasis (17.5% vs 36.4%) in patients with DOI <5mm compared to those with DOI >5mm. Conclusions: The selection of SLNB as the preferred staging procedure over ELND requires discussion with patients and should include an estimate of the probability of requiring re-admission for a more complete lymphadenectomy procedure.

Chapter 11 - Prognostication in dementia

Dementia is a progressive, irreversible illness and leading global cause of death defined by cognitive and subsequent functional decline. Current treatments have limited impact on mortality. In this chapter, we discuss the trajectory of dementia and its variability, markers associated with poorer prognosis (such as poor nutrition, pneumonia, comorbid conditions), the impact of hospitalization on prognosis, and current models of end-of-life palliative care/hospice eligibility (with the use of the Functional Assessment Staging tool and other markers). We then discuss strategies to discuss prognosis with patients and their healthcare proxies using a mental model (Ask, Discover, Anticipate, Provide, Track: ADAPT) and specific skills. Because of progression of dementia variability, prognosis is better discussed in terms of function. For patients with dementia, initiating advance care planning earlier in their disease course allows for more patient involvement (such as to identify a surrogate decision maker).

Paradigm Shift in Prostate Cancer Diagnosis: Pre-Biopsy Prostate Magnetic Resonance Imaging and Targeted Biopsy.

With regard to the indolent clinical characteristics of prostate cancer (PCa), the more selective detection of clinically significant PCa (CSC) has been emphasized in its diagnosis and management. Magnetic resonance imaging (MRI) has advanced technically, and recent international cooperation has provided a standardized imaging and reporting system for prostate MRI. Accordingly, prostate MRI has recently been investigated and utilized as a triage tool before biopsy to guide tissue sampling to increase the detection rate of CSC beyond the staging tool for patients in whom PCa was already confirmed on conventional systematic biopsy. Radiologists must understand the current paradigm shift for better PCa diagnosis and management. This article reviewed the recent literature, demonstrating the diagnostic value of pre-biopsy prostate MRI with targeted biopsy and discussed unsolved issues regarding the paradigm shift in the diagnosis of PCa.

A Comparative Study of Serum Angiogenic Biomarkers in Cirrhosis and Hepatocellular Carcinoma

Simple SummaryThe progression of liver disease is accompanied by pathological angiogenesis, a prerequisite for the development of HCC. In this paper, we analyzed the clinical significance of serum angiogenic markers VEGF, Ang-1, Ang-2, angiopoietin receptor Tie1/2, HGF, and PECAM-1 in 62 patients with liver disease, out of which 33 were diagnosed with HCC and 29 with liver cirrhosis without signs of neoplasia. Biomarkers levels were investigated as a function of “Model for End-Stage Liver Disease” (MELD) score and Fibrosis Index (FI). HCC patients showed higher HGF levels than ones with cirrhosis, while high Ang-1 levels appeared to have a protective role in HCC as well as prognostic significance; we also found a strong correlation between HGF levels, Ang-2, and VEGF levels, further supporting their role in tumor angiogenesis. Due to the complexity of angiogenesis and the small size of the study group, further investigations are widely desired especially in the era of immunotherapy and HCC-targeted anti-angiogenic drugs.Background: Hepatocellular carcinoma (HCC) is a global health problem associated with chronic liver disease. Its pathogenesis varies according to the underlying etiological factors, although in most cases it develops from liver cirrhosis. The disease progression is accompanied by pathological angiogenesis, which is a prerequisite that favors the development of HCC. Aims: This study aims at contributing to our understanding of the role of angiogenic factors in the progression of liver disease. For this purpose, we evaluate the clinical significance of serum angiogenic markers (VEGF, Ang-1, Ang-2, the angiopoietin receptor Tie1/2, HGF, and PECAM-1) first in cirrhotic and HCC patients separately, and then comparing cirrhotic patients with and without HCC. Materials and Methods: We enrolled 62 patients, out of whom 33 were diagnosed with HCC and 29 with liver cirrhosis without signs of neoplasia. Patients underwent venous blood sampling before and after receiving treatments for the diagnosed disease. Serum markers were evaluated using ELISA assays for Tie1 and the Bio-Plex Multiplex system for the remaining ones. Biomarker levels were investigated as a function of clinical scores for disease staging (MELD and Fibrosis Index, FI). Results: In cirrhotic patients, Ang-1 and Ang-2 correlate with MELD (ρAng-1 = −0.73, p = 2E−5) and FI (ρAng-1 = −0.52, p = 7E−3, ρAng-2 = 0.53, p = 3E−3). A reduction of Ang-2 levels (p = 0.047) and of the Ang-2/Ang-1 ratio (p = 0.031) is observed in cirrhotic patients diagnosed with viral hepatitis after antiviral treatments. In HCC patients, Ang-1 negatively correlates with FI (ρ = −0.63, p = 1E−4), and PECAM-1 positively correlates with MELD (ρ = 0.44, p = 0.01). A significant Ang-1 reduction was observed in deceased patients during the study compared to ones who survived (p = 0.01). In HCC patients, VEGF levels were increased after tumor treatment (p = 0.037). Notably, HGF levels in cirrhotic patients with HCC are significantly raised (p = 0.017) compared to that in those without HCC. Conclusions: Our results suggest that serum angiogenic markers, with emphasis on Ang-1/2, can contribute to the development of quantitative tools for liver disease staging and therapy monitoring. The comparison between cirrhotic patients with and without HCC suggests that HGF levels are potentially useful for monitoring the insurgence of HCC after a cirrhosis diagnosis. High Ang-1 levels in HCC patients appear to have a protective role as well as prognostic significance.

P-OGC36 Staging Laparoscopy in Oesophago-gastric cancers; A highly selective approach and its impact on patient outcome during COVID 19

BackgroundStaging laparoscopy is performed in all Oesophago-gastric cancer patients suitable for radical treatment with tumour staged ≥T2 prior to neoadjuvant chemotherapy. In response to COVID 19 pandemic, on 25th March 2020, the joint statement issued by the Royal College of Surgeons and AUGIS advised all laparoscopic procedures should be avoided due to the risk of virus transmission associated with aerosol-generating procedures. In accordance with the guidance, a more selective approach on who underwent a staging laparoscopy was followed. This audit explores its impact on patient outcome comparing data from pre COVID period with the COVID period.MethodsRetrospective and prospective data was collected for 24months on all OG cancer patients from 25th March2019 to 24th March2021. ‘Pre COVID’ period was defined as 25th March 2019 to 24th March 2020 and ‘COVID’ period was defined as 25th March 2020 to 24th March 2021. All patients with Oesophago-gastric cancer with MDT cancer staged ≥T2, suitable for neoadjuvant chemotherapy were included. Patients with tumour staged <T2 and or diagnosed with squamous cell carcinoma involving upper or middle third of oesophagus were excluded. Fishers Exact model using SPSS V24 was used to identify any statistically significant differences between the 2 groups.ResultsPre-COVID Period: 80patients underwent staging laparoscopy. Of these, 9patients(11.6%) with tumour staged as ≥T3 were declined curative surgery due to advanced disease(n = 2), metastatic disease(n = 3) or both(n = 4). In total, 40patients underwent curative surgery and there were 0 open/close laparotomies.COVID Period: Of the 79patients suitable for staging laparoscopy, only 7patients(8.7%) underwent laparoscopy. Of these, 3patients(3.8%) with tumour staged as ≥T3 were declined curative surgery due to advanced disease(n = 2) and metastatic disease(n = 1). In total, 33patients underwent curative surgery and only 1patient had an open/close laparotomy due to a liver metastases. No statistically significant difference was found p = 0.0913ConclusionsStaging laparoscopy is a useful tool for accurate staging of Oesophago-gastric cancers. It helps avoid unnecessary open and close laparotomy due to advanced disease and also allows us to assess patient fitness to major surgery. During the pandemic, the number of staging laparoscopies performed declined significantly but with no statistically significant difference to patient outcome. Thus we conclude, the COVID 19 pandemic has enabled us to have a selective approach to performing staging laparoscopy in Oesophago-gastric patients with advanced disease staged ≥T3 only.

Effect of endoscopic submucosal dissection on histologic diagnosis in Barrett’s esophagus visible neoplasia

Data are limited on the role of endoscopic submucosal dissection (ESD) as a potential diagnostic and staging tool in Barrett's esophagus (BE) neoplasia. We aimed to evaluate the frequency and factors associated with change of histologic diagnosis by ESD compared with pre-ESD histology. This was a multicenter, prospective cohort study of patients who underwent ESD for BE visible neoplasia. A change in histologic diagnosis was defined as "upstaged" or "downstaged" if the ESD specimen had a higher or lower degree, respectively, of dysplasia or neoplasia when compared with pre-ESD specimens. Two hundred five patients (median age, 69 years; 81% men) with BE visible neoplasia underwent ESD from 2016 to 2021. Baseline histology was obtained using forceps (n= 182) or EMR (n= 23). ESD changed the histologic diagnosis in 55.1% of cases (113/205), of which 68.1% were upstaged and 31.9% downstaged. The frequency of change in diagnosis after ESD was similar whether baseline histology was obtained using forceps (55.5%) or EMR (52.2%) (P= .83). In aggregate, 23.9% of cases (49/205) were upstaged to invasive cancer on ESD histopathology. On multivariate analysis, lesions in the distal esophagus and gastroesophageal junction (odds ratio, 2.1; 95 confidence interval, 1.1-3.9; P= .02) and prior radiofrequency ablation (odds ratio, 2.5; 95% confidence interval, 1.2-5.5; P= .02) were predictors of change in histologic diagnosis. ESD led to a change of diagnosis in more than half of patients with BE visible neoplasia. Selective ESD can serve as a potential diagnostic and staging tool, particularly in those with suspected invasive disease. (Clinical trial registration number: NCT02989818.).

Metabolic Associated Fatty Liver Disease in Children-From Atomistic to Holistic.

Non-alcoholic fatty liver disease has become the most common chronic liver disease in children due to the alarmingly increasing incidence of pediatric obesity. It is well-documented that MAFLD prevalence is directly related to an incremental increase in BMI. The multiple hits theory was designed for providing insights regarding the pathogenesis of steatohepatitis and fibrosis in MAFLD. Recent evidence suggested that the microbiome is a crucial contributor in the pathogenesis of MAFLD. Aside from obesity, the most common risk factors for pediatric MAFLD include male gender, low-birth weight, family history of obesity, MAFLD, insulin resistance, type 2 diabetes mellitus, obstructive sleep apnea, and polycystic ovarium syndrome. Usually, pediatric patients with MAFLD have nonspecific symptoms consisting of fatigue, malaise, or diffuse abdominal pain. A wide spectrum of biomarkers was proposed for the diagnosis of MAFLD and NASH, as well as for quantifying the degree of fibrosis, but liver biopsy remains the key diagnostic and staging tool. Nevertheless, elastography-based methods present promising results in this age group as potential non-invasive replacers for liver biopsy. Despite the lack of current guidelines regarding MAFLD treatment in children, lifestyle intervention was proven to be crucial in the management of these patients.

Validation of the Korean Quick Dementia Rating System (K-QDRS).

The Quick Dementia Rating System (QDRS) is a brief and rapid dementia staging tool that does not require a trained rater. The purpose of this study is to demonstrate the validity, reliability, and diagnostic usefulness of the Korean version of the QDRS (K-QDRS). We collected a total of 411 subject-informant dyads including cognitively unimpaired (CU, n = 22), mild cognitive impairment (MCI, n = 198), and dementia (n = 191). The Clinical Dementia Rating (CDR) scale, Korean version of the Mini-Mental State Examination (K-MMSE), Korean version of instrumental activity of daily living (K-IADL), Short Form of the Geriatric Depression Scale, Caregiver-Administered Neuropsychiatric Inventory (CGA-NPI), and detailed neuropsychological tests were administered as gold standards of dementia staging, cognition, function, mood, and behavior. Internal consistency of the K-QDRS was excellent with Cronbach's alpha of 0.933. Concurrent validity was also satisfactory, with the K-QDRS correlating highly with the CDR Sum of Boxes (Pearson's r = 0.791), K-MMSE (Pearson's r = -0.518), K-IADL (Pearson's r = 0.727), and CGA-NPI (Pearson's r = 0.700). The K-QDRS was highly correlated with the global CDR, K-IADL, and CGA-NPI. We suggested two types of comparisons (for initial diagnosis and for follow-up evaluation). The cutoff scores for follow-up were 1.0 for MCI, 3.5 for very mild dementia, 6.5 for mild dementia, and 11.0 for moderate dementia. The K-QDRS is a valid and reliable dementia rating questionnaire and can be used, briefly and rapidly, in various settings like clinical practices, longitudinal cohort studies, and community primary care.

Adapting Imaging Protocols for PET-CT and PET-MRI for Immunotherapy Monitoring.

Simple SummaryIn this review, we discuss the possible advantages and methods to overcome potential obstacles of applying combined imaging protocols of PET-CT and PET-MRI, within the context of staging and restaging of patients under immunotherapy, in order to achieve “multi-hybrid imaging” in one single visit.Hybrid imaging with positron emission tomography (PET) in combination with computer tomography (CT) is a well-established diagnostic tool in oncological staging and restaging. The combination of PET with magnetic resonance imaging (MRI) as a clinical scanner was introduced approximately 10 years ago. Although MRI provides superb soft tissue contrast and functional information without the radiation exposure of CT, PET-MRI is not as widely introduced in oncologic imaging as PET-CT. One reason for this hesitancy lies in the relatively long acquisition times for a PET-MRI scan, if the full diagnostic potential of MRI is exploited. In this review, we discuss the possible advantages of combined imaging protocols of PET-CT and PET-MRI, within the context of staging and restaging of patients under immunotherapy, in order to achieve “multi-hybrid imaging” in one single patient visit.

A Modified T-Stage Classification for Gastric Neuroendocrine Tumors

The eighth edition of the American Joint Committee on Cancer (AJCC) staging manual's TNM staging classification for gastric neuroendocrine tumors has been shown to have poor prognostic discriminability. The aim of present study was to propose a modified T-stage classification, and externally validate its performance in a separate population data registry. A modified T-stage classification with tumor size and extent of tumor invasion was generated from the National Cancer Database between 2004 and 2014 (n=1249). External validation was performed using the Surveillance, Epidemiology, and End Results registry between 1973 and 2013 (n=539). In the National Cancer Database population, using the AJCC T-stage classification, the 5-y survival rates were 85.7%, 80.8%, 64.5%, and 46.1% in T1, T2, T3, and T4 patients respectively (P < 0.001). These rates were more contrasting with the modified T-stage (mT) classification at 87.0%, 78.2%, 59.0%, and 40.3% respectively (P < 0.001). When patients within each of the AJCC T stages were stratified by mT stages, significant survival heterogeneity was observed within each of the AJCC T2 to T4 stages (P < 0.01). Conversely, when mT stages were stratified by AJCC T stage, no survival difference was observed in any of the mT stages (P > 0.05).The same analyses were performed using Surveillance, Epidemiology, and End Results data, and all the observed results were validated. The current AJCC T stage classification categorizes patients into groups with heterogenous prognosis, thus failing to serve as an effective staging tool. A modified T-stage classification demonstrated significantly improved stratification for patients with gastric neuroendocrine tumors.

Got Stage Fright? A Fellow-Led Initiative to Improve Cancer Staging Documentation

INTRODUCTION Accurate cancer staging is essential for determining prognosis and treatment. However, only 6.1% of new patient visits (NPV) at our Comprehensive Cancer Center (CCC) were staged at baseline using our electronic health record staging tool (EST). We used Quality Improvement (QI) methods, targeting oncology fellows, to improve fellow-seen NPV staging rates by the end of the 2018-19 academic year. METHODS We aimed to increase fellow monthly EST usage rate for solid tumor NPVs to 70% at our Cancer Center by June 2019. In our first Plan-Do-Study-Act (PDSA) cycle, we moved our EST into the visit navigator that unifies all components needed to complete an encounter. In our second PDSA cycle, we specifically engaged fellows with monthly reminder emails, periodic surveys, and individualized outreach to low performers. We tracked fellow-seen NPV staging rates, and, using statistical process control charting, CCC-wide NPV staging rates. RESULTS Monthly fellow-seen NPV staging rose from 47% in July 2018 to a mean of 75% during PDSA 1 and 70% during PDSA 2. CCC-wide NPV staging rose from 6.1% to 16% during PDSA 1 and 13% during PDSA 2. Staging rates decreased with the arrival of new fellows. CONCLUSIONS Our initiative improved timely staging rates for fellow-seen NPVs. Although fellows see only a minority of NPVs at our CCC, we found that our fellow-oriented QI initiative appeared to improve CCC-wide NPV staging rates as well (in the absence of any comparable initiatives). Future steps include the development of note templates with embedded staging tools to promote sustainability.

Diagnostic accuracy of transvaginal ultrasound examination for local staging of cervical cancer: a systematic review and meta-analysis.

Transvaginal ultrasonography (TVUS) has shown varying results in the staging of cervical cancer patients aroundthe world. Hence, the current review was done to assess the diagnostic accuracy of TVUS for identifying parametrial, stromalinvasion and lymph node metastasis among cervical cancer patients. We conducted a systematicsearch for all studies reporting the diagnostic accuracy of TVUS for staging of cervical cancer in the databases of PubMedCentral, MEDLINE, EMBASE, MEDLINE, SCOPUS and Cochrane library from inception till March 2021. Meta-analysiswas performed using STATA software "midas" package. Eleven studies with 760 patients were included. The pooledsensitivity and specificity of TVUS for diagnosing parametrial invasion were 62% (95% CI, 40-80) and 91% (95% CI, 79-97),for stromal invasion were 84% (95% CI, 77-90) and 80% (95% CI, 61-91), for lymph node metastasis were 52% (95% CI,8-93) and 95% (95% CI, 68-99). There was significant heterogeneity found with all the outcomes with significant chi-squaretest and I2 statistic >75%. TVUS has limited applicability and use as a screening or diagnostic tool for local stagingof cervical cancer patients. Further reviews comparing multiple non-invasive imaging modalities are required to pick thebest tool for local staging of cervical cancer.

91-Year-Old Man With Recurrent Falls

A 91-year-old man with probable Alzheimer dementia (Functional Assessment Staging Tool stage 6B, with no recent cognitive testing), major depressive disorder, insomnia, repeated falls, atrial fibrillation not on anticoagulation, hypertension, chronic kidney disease, urinary retention requiring self-catheterization, bilateral cataracts, osteoarthritis of the hips and lumbar spine, and constipation was seen in a memory-care unit after recent hospitalization for left hip fracture sustained in a ground-level fall.

Current update on imaging for pancreatic neuroendocrine neoplasms.

Pancreatic neuroendocrine neoplasms (panNEN) are a heterogeneous group of tumors with differing pathological, genetic, and clinical features. Based on clinical findings, they may be categorized into functioning and nonfunctioning tumors. Adoption of the 2017 World Health Organization classification system, particularly its differentiation between grade 3, well-differentiated pancreatic neuroendocrine tumors (panNET) and grade 3, poorly-differentiated pancreatic neuroendocrine carcinomas (panNEC) has emphasized the role imaging plays in characterizing these lesions. Endoscopic ultrasound can help obtain biopsy specimen and assess tumor margins and local spread. Enhancement patterns on computed tomography (CT) and magnetic resonance imaging (MRI) may be used to classify panNEN. Contrast enhanced MRI and diffusion-weighted imaging have been reported to be useful for characterization of panNEN and quantifying metastatic burden. Current and emerging radiotracers have broadened the utility of functional imaging in evaluating panNEN. Fluorine-18 fluorodeoxyglucose positron emission tomography (PET)/CT and somatostatin receptor imaging such as Gallium-68 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid–octreotate PET/CT may be useful for improved identification of panNEN in comparison to anatomic modalities. These new techniques can also play a direct role in optimizing the selection of treatment for individuals and predicting tumor response based on somatostatin receptor expression. In addition, emerging methods of radiomics such as texture analysis may be a potential tool for staging and outcome prediction in panNEN, however further investigation is required before clinical implementation.

Role of MDCT in Diagnosis and Staging of Carcinoma Oesophagus

Background: Esophageal cancer is the eighth most common malignant tumor and the sixth most common cause of cancer death worldwide. Early detection of carcinoma esophagus and its appropriate staging can be life-saving for many patients. Multi-Detector Computed Tomography (MDCT) plays a crucial role in early detection, local invasion, and metastasis of carcinoma oesophagus, which also helps in appropriate staging and deciding a further plan of management. The present study describes various findings of oesophageal carcinoma on CT to aid in its staging. Materials and Methods: After ethical clearance, a retrospective and prospective hospital-based study were carried out in the Department of Radiodiagnosis, Mahatma Gandhi medical college and hospital Jaipur, Rajasthan, India over a period of last 5 years. After obtaining consent, 60 patients presenting with clinical symptoms and signs pertaining to carcinoma of oesophagus, were studied with a Multi-Detector CT scanner (128 slices GE Optima CT Machine) using thin sections. Oral and IV contrast was used. Three-dimensional reconstructions were done and various CT findings of oesophageal cancer were studied. The diagnosis and staging were confirmed by postoperative histopathological findings. Results: Carcinoma oesophagus was commonly seen in the age group between 60 to 70 years (35%) with males (63%) more commonly affected than females (37%). The most common presenting symptom was dysphagia. Alcohol and smoking were associated risk factors. The lower 1/3rd of oesophagus was affected more commonly compared to other parts. The wall thickness in a majority of the cases measured between 10-20mm (71.6%). T3N1M0 was the most common staging found in CT. Out of 60 cases 40% of cases presented with metastasis. Squamous cell carcinoma (80%) was the more common histopathological type. Out of 60patients when CT staging was compared with the postoperative histopathological staging, the sensitivity of CT-scan for ‘T 1-T2’ stage was 50%, for T3 stage was 73.5 %, in ‘N’ stage 81%, and in ‘M’ stage was 100%. Conclusion: MDCT is a modality of higher sensitivity and specificity for CA esophagus early diagnosis and staging. By early identification of loss of fat planes, detection of lymph nodal involvement, and metastasis to various organs with an overall diagnostic accuracy value of 74 to 84%, MDCT remains an outstanding tool in early diagnosis and staging of carcinoma oesophagus.

Improving palliative care integration for patients with stage IV lung cancer at UConn Health by initiating a best practice advisory (BPA) in the electronic medical record (EMR).

331 Background: The American Society of Clinical Oncology (ASCO) practice updates on the integration of palliative care into standard oncology practice provides a key recommendation that patients with advanced cancer should receive palliative care services. Specifically, ASCO recommends that all patients with stage IV cancer receive a referral to an interdisciplinary palliative care team early in their course of disease and within 8 weeks of diagnosis. At UConn Health, it has been previously documented that only 28% of patients with stage IV cancer receive a referral to the palliative care team. To improve the quality of cancer care, a BPA with standardized criteria for palliative care referral was developed and implemented for patients with stage IV lung cancer. In this pilot study, the goal was to get 80-90% of patients a referral to palliative care team within 8 weeks of stage IV lung cancer diagnosis. Methods: The Model for Improvement using Plan-Do-Study-Act Cycles was completed: 1) created an EMR report to identify patients with stage IV lung cancer; 2) completed a retrospective review of patients with stage IV lung cancer referred to palliative care 6 months prior to BPA implementation; 3) created and implemented BPA; 4) educated providers about palliative care referral and BPA; 5) retrospectively reviewed referrals 6 months following BPA implementation; and 6) evaluated potential barriers. The palliative care EMR BPA was developed in collaboration with information technology specialists. The BPA alert populates the EMR when the provider opens a patient chart or visit encounter for all patients with 1) diagnosis of lung cancer; 2) stage IV disease; and 3) does not have a current order for palliative care referral. Results: Prior to BPA implementation (January 1, 2020- July 31, 2020), 8 of 28 patients (32%) with stage IV lung cancer were referred to palliative care service. The BPA became active on 9/15/2020. Within the six months following BPA implementation, 16 patients were newly diagnosed with stage IV lung cancer. Of these 16 patients, 81% of them had a referral to palliative care made within 8 weeks of clinical staging. Several barriers were identified with current process, including lack of staging tool use by all providers; lack of documentation of all data required for staging tool to automatically calculate stage, and inability to track patients who declined palliative care appointment. Conclusions: Incorporating a BPA reminding providers to consider a palliative care referral improved referrals of patients with newly diagnosed stage IV lung cancer to the palliative care clinic within 8 weeks of diagnosis, improving compliance with ASCO’s practice guidance on integration of palliative care. Next steps are to address barriers and expand the use of palliative care referral BPA to all patients with stage IV cancer.

Comparison between tumour metabolism derived from 18F-FDG PET/CT and accurate cytogenetic stratification in newly diagnosed multiple myeloma patients.

18F-fluorodeoxyglucose positron emission tomography integrated with computed tomography (18F-FDG PET/CT) is a useful tool for baseline staging in newly diagnosed multiple myeloma (MM) but also for prognostic stratification. This monocentric retrospective study aimed at examining the relation between baseline tumour metabolism assessed by 18F-FDG PET/CT and linear predictor (LP) score, a new cytogenetic stratification score. From March 2012 to March 2019, 57 patients with newly diagnosed MM addressed to our institution for baseline 18F-FDG PET/CT were included. LP score was determined on systematic iliac crest bone marrow samples. Obtained on CD138-sorted bone marrow plasma cells, this recent composite cytogenetic stratification is a 6-marker based weighted score using fluorescence in situ hybridization (FISH) ± single nucleotide polymorphism (SNP) arrays. We compared quantitative metabolic parameters and LP score using a Kruskal-Wallis test and visual suspicion of diffuse bone marrow involvement (DBI; based on hepatic background as threshold of positivity) and cytogenetic data using a Chi-squared test. The distribution of total metabolic tumour volume (TMTV) and total lesion glycolysis (TLG) values among the three LP score categories was almost stochastic, with no significant association (P=0.70). Additionally, no significant association between TMTV/TLG and any of the six cytogenetic abnormalities included in LP score calculation. A significant association was found between visual high suspicion of DBI and LP score (P=0.036), and between this visual parameter and the presence of 1q gain (P=0.049). There is no significant association between quantitative metabolic parameters assessed with 18F-FDG PET/CT and LP score in patients with newly diagnosed MM, suggesting a potential complementarity of these biomarkers for prognostic stratification. A significant association was found between high visual suspicion of DBI and LP score.

PET/CT in the Staging of Non-Small Cell Lung Cancer

Abstract Background NSCLC accounts for about 80% of all lung cancers. The current criteria for its staging is based on the TNM system that determines treatment options and predicts survival rate in patients. Objective To evaluate the diagnostic accuracy of 18F-FDG PET/CT in staging of NSCLC patients Methods A prospective study, conducted at Ain Shams University hospitals on pathologically proven patients of NSCLC, the patients were investigated using CT and PET/CT in the period between October 2018 till end of June 2019. Results A total of 40 patients were evaluated with the age ranging from 37 to 77 years old, whether the mean was 55.63 years (SD ± 10.29). There were 31 male cases and 9 female cases. When we compared CECT against PET-CT for staging, PET-CT helped upstage disease in 10 of 40 patients (25%) and downstage in 3 of 40 patients (7.5%). Conclusion PET/CT is a useful imaging tool in initial staging of the newely diagnosed patients with NSCLC. It is better thаn СT alone for detection of malignant lesions for accurate staging. It can change the strategy of treatment according to its findings

Tre-P-03 - Retrospective analysis of standard-of-care imaging in patients with cutaneous T-cell lymphoma

Lymph node involvement is associated with a worse prognosis for patients with CTCL. However, current radiologic criteria, including RECIST and WHO criteria, may not provide adequate assessment of nodal involvement or response to therapy. Standard radiologic techniques using unidimensional measurement changes to assess lymph node status and response to therapy in CTCL are prone to inter-observer variability. These shortcomings underscore the need for better methodology for staging and assessment of responses in the lymph nodes of CTCL patients. Using a novel algorithm developed by the Department of Radiology at Columbia University for robust and reliable segmentation of lymph nodes on volumetric CT images, we analyzed the CT scans of a cohort of 40 subjects enrolled in the MAVORIC clinical trial. This algorithm combines volumetric, radiomic, and kinetic modeling and was shown to improve accuracy and reproducibility of response assessments in other cancers. We then explored relationships between measured lymph node changes and observed clinical responses. Our radiologists were blinded to the clinical outcomes. In the MAVORIC trial, an investigator and independent reviewer characterized clinical responses in the skin, blood, and lymph nodes. In our cohort, 50% of lymph node response assessments differed between the investigator and independent reviewer. Using our novel CT volumetric technique, we were able to demonstrate remarkable consistency in nodal assessments. Decrease in lymph node volume showed significant correlation with clinical responses in the skin and blood but increase in lymph node volume was not predictive of skin and blood responses or disease progression. For the first time, we were able to provide a novel validated tool for accurate staging and response assessment, applicable to future clinical trials and clinical practice.

P-012: Automatic bone marrow segmentation in whole-body magnetic resonance imaging: towards comprehensive, objective MRI-phenotypic bone marrow characterization in multiple myeloma

<h3>Background</h3> Whole-body magnetic resonance imaging (wb-MRI) is an important diagnostic tool for staging, risk assessment and response evaluation in myeloma. Wb-MRIs contain approximately 110 million voxels per sequence, and only a limited amount of this information can be processed and reported by radiologists to date. Deep learning has brought striking advances in biomedical image segmentation in recent years. The goal of this work was to establish an automatic whole-body bone marrow (BM) segmentation algorithm for T1-weighted MRI sequence, and to use these segmentations for comprehensive MRI-phenotypic characterization of the BM by subsequent radiomics analysis, bone by bone. <h3>Methods</h3> For 66 patients with smoldering multiple myeloma (SMM), BM was manually segmented on T1-w images. Thirty different BM compartments were individually labelled: right and left humerus, second to seventh vertebral bodies of the cervical spine (C2-C7), all vertebral bodies of the thoracic (T1-T12) and lumbar (L1-L5) spine, sacrum, right and left hip bone and right and left femur. Data was split by date by a 3:1 ratio into training-set and independent test-set. A nnU-Net, which is state of the art deep learning framework for medical image segmentation, was trained on the 52 training cases for segmentation of BM compartments, and postprocessing was used to distinguish sides of paired bones (humeri, hip bones, femora). Mean Dice scores report accuracy of automatic segmentations on the test-cases and interrater variability between two radiologists. This study was approved by the institutional review board. <h3>Results</h3> The mean Dice scores of the nnU-Net segmentation on the 14 test-cases for BM of right and left humerus, C2-C7, T1-T12, L1-L5, sacrum, right and left hip bone, right and left femur were 0.95, 0.94, 0.87, 0.86, 0.84, 0.80, 0.82, 0.84, 0.86, 0.87, 0.88, 0.91, 0.85, 0.85, 0.83, 0.83, 0.87, 0.91, 0.93, 0.93, 0.89, 0.85, 0.85, 0.81, 0.76, 0.88, 0.93, 0.93, 0.97 and 0.97, respectively. The mean Dice scores between segmentations from 2 radiologists on 2 cases for these BM compartments in the same order were 0.94, 0.95, 0.79, 0.86, 0.88, 0.81, 0.78, 0.79, 0.84, 0.81, 0.91, 0.85, 0.89, 0.90, 0.91, 0.91, 0.92, 0.90, 0.90, 0.89, 0.88, 0.92, 0.93, 0.88, 0.88, 0.81, 0.89, 0.89, 0.95, 0.94, respectively. On a descriptive level, we found differences in radiomics signatures between vertebrae with physiological bone marrow, vertebrae with focal lesions and vertebrae with diffuse infiltration in exemplary cases. <h3>Conclusion</h3> We established automatic, bone by bone BM segmentation in SMM patients with accuracy only slightly worse compared to the interrater variability of radiologists, mostly due to lumbosacral transitional vertebra. In exemplary cases we found different radiomics-signatures between physiological BM and different pathologies, indicating that such BM segmentations can be used for in depth BM characterization from wb-MRI when combined with subsequent radiomics analysis.