NI-RADS: Structured Reporting for Head and Neck Cancer

Transcription

1 NI-RADS: Structured Reporting for Head and Neck Cancer ASHNR 2018 Disclosures Part of group that initiated NI-RADS Colleagues A. Aiken & P. Hudgins: ACR NIRADS committee members Kristen Lloyd Baugnon, M.D. Associate Professor of Radiology Emory University School of Medicine Outline ACRRADS Story of NI-RADS ACR NI-RADS Resources Cases & practical application Initial data ACR RADS (Reporting and Data Systems) Standardized terminology, report organization, assessment classification Most have binary outcomes: cancer or not Linked management actionable reports ACR NI-RADS committee Multidisciplinary consensus 4 levels of suspicion for recurrent HNSCC with linked management NI-RADS evolved Started using with CT & SCC Now use for surveillance of all H&N Ca & all modalities (MRI, PET) To provide a validated template to report findings & guide management in H&N cancer surveillance imaging: 1. Consensus for a revised risk stratification system & template: ACR NI-RADS 2. Lexicon to distinguish benign post tx vs residual/ recurrent disease

2 ACR- NI-RADS Category 0 New baseline, priors pending Category 1 No evidence of recurrence Category 2 Low suspicion of recurrence Ill-defined, hypoenhancing, only mild FDG uptake 2a: superficial 2b: deep Category 3 High suspicion of recurrence Discrete, new or enlarging, intense FDG uptake Category 4 Definitive recurrence Path proven, clinical or radiographic progression *ACR- NI-RADS ACR- NI-RADS Category Linked Recommendation NIRADS 0 Score after review of priors ACR NI-RADS Template FINDINGS: [<No evidence of recurrent disease is demonstrated at the primary site. >] [<No pathologically enlarged, necrotic, or otherwise abnormal lymph nodes. >] NIRADS 1 NIRADS 2 NIRADS 3 NIRADS 4 Routine f/u (6 mo) 2a- direct inspection 2b- shorter f/u (3 mo) or PET Biopsy Treatment of dz, w or wo bx Expected post-treatment changes are noted including [<supraglottic mucosal edema and thickening of the skin and subcutaneous soft tissues.>] There are no findings to suggest a second primary in the imaged aerodigestive tract. Evaluation of the visualized portions of brain, orbits, spine and lungs show no aggressive lesions suspicious for metastatic involvement. IMPRESSION: Primary: [1]. [<Expected post-treatment changes in the neck without evidence of recurrent disease in the primary site >] Neck: [1], [<No evidence of abnormal lymph nodes.>] ACR NIRADS Template Legend CECT Surveillance Legend: NIRADS 0 imaging features A legend is included at the bottom of every NIRADS report Allows interpretation by any clinician viewing the report with direct guidance based on category making NIRADS accessible to primary care and ENT alike Primary 1: No evidence of recurrence: routine surveillance 2: Low suspicion a) Superficial abnormality (skin, mucosal surface): direct visual inspection b) Ill-defined deep abnormality: short interval follow-up*or PET 3: High suspicion (new or enlarging discrete nodule/ mass): biopsy 4: Definitive recurrence (path proven or clinical progression): no biopsy needed Nodes 1: No evidence of recurrence: routine surveillance 2: Low suspicion (ill- defined): short interval follow-up or PET 3: High suspicion (new or enlarging lymph node): biopsy if clinically needed 4: Definitive recurrence (path proven or clinical progression): no biopsy needed *short interval follow- up: 3 months at our institution New baseline study without any prior imaging available AND knowledge that prior imaging exists and will become available as comparison* Assign score in addendum after prior imaging examinations become available

3 T1 N1 right BOT s/p CRT 8/16 Baseline prior in the same patient 11/7/16 6/30/17 Primary: 1 Neck: 0 Primary: 1 Neck: 1 NIRADS 1 imaging features T1 N2c BOT SCCA, s/p CRT Expected post-treatment changes with non- mass like distortion of soft tissues NI-RADS 1 lexicon: CECT: low density submucosal edema, hypo-enhancing effacement of fat planes, linear diffuse mucosal enhancement, nodal tissue with no FDG PET: no significant FDG uptake Primary: 1 Neck: 1 Routine surveillance, 6 mo CECT T1N1 GTS SCCA s/p TORS & ND T4a N2b FOM SCCA s/p resection, partial glossectomy, mandibulectomy & FFF recon Primary: 1 Neck: 1 Routine surveillance, 6 mo CECT Primary: 1 Routine surveillance, 6 mo CECT

4 NIRADS 1: Pearls & pitfalls 1. Postop changes can be confusing: Review surgical & pathology reports 2. Tongue fasiculations after partial glossectomy 3. Diffuse mucosal C+ =mucositis (NIRADS 1), focal mucosal C+ =tumor or radiation injury (NIRADS 2) NIRADS 2 imaging features Low suspicion NI-RADS 2 lexicon: CECT: focal mucosal C+, ill-defined soft tissue with only mild differential C+, no discrete nodule/ mass, growing node w/o morphologically abnormal features PET: mild FDG w/o discrete nodule, residual nodal tissue w/ mild FDG Mismatch between CECT and PET Primary: a) Mucosal surface direct visual inspection b) Deep short interval F/U (3 months) or PET (if CECT alone) T4a BOT SCCA s/p CRT T4a N2a BOT SCCA s/p CRT Primary: 2a Direct inspection: radiation injury, f/u PET neg Primary: 1 Neck: 2 Earlier f/u at 3 mo. NIRADS 2: Pearls & pitfalls 1. Work backwards, considering do I want to biopsy this now (NIRADS 3) or would it be prudent to wait 3 months and re-image (NIRADS 2)? 2. In most cases, waiting for 3 months will NOT change the options 3. NIRADS 2a = special category for mucosal dz bc surgeons can easily look PET esp. helpful in post-radiated larynx to direct clinical inspection NIRADS 3 Imaging features High suspicion discrete nodule or mass NI-RADS 3 lexicon: CECT: intense differential C+ from surrounding soft tissues, morphologically abnormal node (necrosis / ENE) PET: Intense FDG uptake, growing node w/ intense FDG uptake CECT & PET matched suspicion/ concordant

5 Maxillary SCCA s/p maxillectomy & exenteration T4aN0 larynx SCCA s/p TL, BL ND, XRT 4 month post resection & CRT PET/CECT Primary: 3 CT biopsy- persistent SCCA Primary: 3 Endoscopic biopsy- recurrent SCCA Angiosarcoma of the scalp T4aN1 SCCA tonsil s/p CRT 12 months 18 months Neck: 3 US biopsy- recurrent angiosarcoma Primary: 3 Biopsy- inflammation, necrosis F/u PET decreased uptake NIRADS 3: Pearls & pitfalls Radiation injury to soft tissue or bone can be tumefactive & mimic tumor, ie false positive T4aN2c SCCA larynx s/p TL & NDs, exam c/f recurrence at stoma Generally- call NIRADS 3 when willing to biopsy Neck: 4 Biopsy proven disease Definitive clinical/radiographic progression of dz

6 Primary site Diffuse linear C+ Superficial/ mucosal Focal C+ and/or FDG uptake 1 Ill-defined enhancing Deep 2 Discrete mass Definite primary site recurrence 3 4: Treatment of disease with or without biopsy 618 total sites (primary + nodes) 1: Routine Surveillance 2a: Direct inspection No FDG uptake Mild/ mod FDG uptake or no PET Mild/mod FDG uptake or no PET intense FDG uptake NI-RADS % (528) NI-RADS 2 9.4% (58) NI-RADS 3 5.2% (32) 1: Routine Surveillance 2b: Short F/ U (3 month) or PET 2b: Short F/U (3 month) or PET 3: Biopsy Positive residual/ recurrence rate 1 Most mucosal abnormalities are assigned a NI-RADS 2a category as the surgeons can best assess the mucosal surfaces. However, more discrete mucosal or very superficial submucosal abnormalities can be upgraded to a NI-RADS 3 especially if they develop after the post treatment baseline study. 2 Outside of the post treatment baseline study, surveillance may be done with a CECT or MRI without a PET. Recommendation for PET may be NI-RADS 2 management. 3 Based on pathologic confirmation or definitive radiologic progression. Biopsies may be needed so that patients can enroll in a trial or otherwise continue with treatment. 3.8% (20) 17.2% (10) 59.4% (19) ACR Database: Interobserver agreement Summary: NI-RADS adds value in H&N cancer surveillance imaging 1. Simplify communication 2. Clearly direct management It s OK to be unsure of diagnosis, but need to be sure of the next step 3. Facilitate rad-path correlation for QI 4. Foster evidence based practice 5. Patient centered care Putting Patients First: Emory Radiology ACR 8/2017 Acknowledgements NI-RADS H &N Rad team Ashley Aiken Pat Hudgins Kristen Baugnon Amanda Corey Cynthia Wu Sarah Cantrell NI-RADS Committee Ashley Aiken Pat Hudgins Yoshimi Anzai Char Branstetter Tanya Rath Rick Wiggins Christine Glastonbury Doug Phillips Amy Juliano Jenny Hoang Rich Brown Collaborators Mihir Patel Mark El-Deiry Amy Chen Derek Hsu Ajeet Mehta Sheila Kori Daniel Krieger Gopi Nayak