High practice variation in risk stratification, baseline oncological staging, and follow-up strategies for T1 colorectal cancers in the Netherlands

Background and study aims Based on pathology, locally resected T1 colorectal cancer (T1-CRC) can be classified as having low- or high-risk for irradicality and/or lymph node metastasis, the latter requiring adjuvant surgery. Reporting and application of pathological high-risk criteria is likely variable, with inherited variation regarding baseline oncological staging, treatment and surveillance. Methods We assessed practice variation using an online survey among gastroenterologists and surgeons participating in the Dutch T1-CRC Working Group. Results Of the 130 invited physicians, 53 % participated. Regarding high-risk T1-CRC criteria, lymphangio-invasion is used by 100 %, positive or indeterminable margins by 93 %, poor differentiation by 90 %, tumor-free margin ≤ 1 mm by 78 %, tumor budding by 57 % and submucosal invasion > 1000 µm by 47 %. Fifty-two percent of the respondents do not perform baseline staging in locally resected low-risk T1-CRC. In case of unoperated high-risk patients, we recorded 61 different surveillance strategies in 63 participants, using 19 different combinations of diagnostic tests. Endoscopy is used in all schedules. Mean follow-up time is 36 months for endoscopy, 26 months for rectal MRI and 30 months for abdominal CT (all varying 3–60 months). Conclusion We found variable use of pathological high-risk T1-CRC criteria, creating risk for misclassification as low-risk T1-CRC. This has serious implications, as most participants will not proceed to oncological staging in low-risk patients and adjuvant surgery nor radiological surveillance is considered. On the other hand, oncological surveillance in patients with a locally resected high-risk T1-CRC who do not wish adjuvant surgery is highly variable emphasizing the need for a uniform surveillance protocol.

Baseline staging imaging for distant metastasis in women with stage I, II, and III breast cancer

Background In Ontario, there is no clearly defined standard of care for staging for distant metastasis in women with newly diagnosed and biopsy-confirmed breast cancer whose clinical presentation is suggestive of early-stage disease. This guideline addresses baseline imaging investigations for women with newly diagnosed primary breast cancer who are otherwise asymptomatic for distant metastasis. Methods The medline and embase databases were systematically searched for evidence from January 2000 to April 2019, and the best available evidence was used to draft recommendations relevant to the use of baseline imaging investigation in women with newly diagnosed primary breast cancer who are otherwise asymptomatic. Final approval of this practice guideline was obtained from both the Staging in Early Stage Breast Cancer Advisory Committee and the Report Approval Panel of the Program in Evidence-Based Care. Recommendations These recommendations apply to all women with newly diagnosed primary breast cancer (originating in the breast) who have no symptoms of distant metastasis Staging tests using conventional anatomic imaging [chest radiography, liver ultrasonography, chest–abdomen– pelvis computed tomography (ct)] or metabolic imaging modalities [integrated positron-emission tomography (pet)/ct, integrated pet/magnetic resonance imaging (mri), bone scintigraphy] should not be routinely ordered for women newly diagnosed with clinical stage i or stage ii breast cancer who have no symptoms of distant metastasis, regardless of biomarker status. In women newly diagnosed with stage iii breast cancer, baseline staging tests using either anatomic imaging (chest radiography, liver ultrasonography, chest–abdomen–pelvis ct) or metabolic imaging modalities (pet/ct, pet/ mri, bone scintigraphy) should be considered regardless of whether the patient is symptomatic for distant metastasis and regardless of biomarker profile.

Value of PET-CT Staging in Lymphoma Patients at Baseline over Clinical Staging

Objectives:Lymphoma is the cancer of lymphatic system.Treatment strategy of lymphoma depends upon the staging of disease.Accurate staging can guide the required regimen and can minimize the therapeutic toxic effect and reduces the morbidity and mortality associated with over treatment. The purpose of this study was to observe the upstaging or down staging of lymphoma patients at baseline by performing PET-CT imaging over clinical staging who were referred to National Institute of Nuclear Medicine & Allied Sciences (NINMAS) for baseline staging. Patients and Methods: This cross sectional observational type of study was carried out in NINMAS from July 2017 to June 2018. A total of 26 newly diagnosed lymphoma patients referred to NINMAS for PET-CT scan for baseline staging were included in this study. Results: Out of the 26 patients (14male and 12 female; mean age: 43.42 ± 17.98 years), 14(53.8%) patients were diagnosed with Hodgkin Lymphoma and 12(46.2%) with Non Hodgkin Lymphoma. In this study, 14(53%) patients were upstaged in PET-CT scan based staging in comparison to clinical staging. Key lesion was assessed by SUVmax in PET-CT scan of different stages of lymphoma. Highest key lesion was found in stage IV. Out of 26 patients, 7(27%) showed extranodal involvement in bone (3 lesions), liver (3 lesions), lung (1 lesion) and spleen (1 lesion). Conclusion: This study was undertaken to assess the role of FDG PET-CT scan for staging of lymphoma patient at baseline. In this study, 53% of the patients were upstaged in PET-CT scan based staging in comparison to clinical staging. PET-CT plays animportant role for accurate staging in lymphoma patients at baseline which increases the accuracy of subsequent response assessment. Bangladesh J. Nuclear Med. 22(1): 15-22, Jan 2019