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Clinical Vignette: A 50-year-old woman presents to the emergency department with increasing abdominal pain. Abdominal computed tomography imaging reveals an expanded inferior vena cava-filling defect that is suspicious for a retroperitoneal sarcoma, possibly a primary leiomyosarcoma of the inferior vena cava. The surgery team discusses the case with the radiologist, and all agree that there are multiple challenges with obtaining a tissue diagnosis and determining resectability. Thus, it is decided that this patient should be discussed at a multidisciplinary case conference. In the present article, we feature a case-based scenario focusing on the role of the radiologist in this type of multidisciplinary team.
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BACKGROUND: Testing for mutation of the EGFR (epidermal growth factor receptor) gene is a standard of care for patients with advanced nonsquamous non-small-cell lung cancer (nsclc). To improve timely access to EGFR results, a few centres implemented reflex testing, defined as a request for EGFR testing by the pathologist at the time of a nonsquamous nsclc diagnosis. We evaluated the impact of reflex testing on EGFR testing rates. METHODS: A retrospective observational review of the Web-based AstraZeneca Canada EGFR Database from 1 April 2010 to 31 March 2014 found centres within Ontario that had requested EGFR testing through the database and that had implemented reflex testing (with at least 2 years' worth of data, including the pre- and post-implementation period). RESULTS: The 7 included centres had requested EGFR tests for 2214 patients. The proportion of pathologists requesting EGFR tests increased after implementation of reflex testing (53% vs. 4%); conversely, the proportion of medical oncologists requesting tests decreased (46% vs. 95%, p < 0.001). After implementation of reflex testing, the mean number of patients having EGFR testing per centre per month increased significantly [12.6 vs. 4.9 (range: 4.5-14.9), p < 0.001]. Before reflex testing, EGFR testing rates showed a significant monthly increase over time (1.37 more tests per month; 95% confidence interval: 1.19 to 1.55 tests; p < 0.001). That trend could not account for the observed increase with reflex testing, because an immediate increase in EGFR test requests was observed with the introduction of reflex testing (p = 0.003), and the overall trend was sustained throughout the post-reflex testing period (p < 0.001). CONCLUSIONS: Reflex EGFR testing for patients with nonsquamous nsclc was successfully implemented at multiple centres and was associated with an increase in EGFR testing.
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BACKGROUND: Although molecular testing has become standard in managing advanced nonsquamous non-small-cell lung cancer (nsclc), most patients undergo minimally invasive procedures, and the diagnostic tumour specimens available for testing are usually limited. A knowledge translation initiative to educate diagnostic specialists about sampling techniques and laboratory processes was undertaken to improve the uptake and application of molecular testing in advanced lung cancer. METHODS: A multidisciplinary panel of physician experts including pathologists, respirologists, interventional thoracic radiologists, thoracic surgeons, medical oncologists, and radiation oncologists developed a specialty-specific education program, adapting international clinical guidelines to the local Ontario context. Expert recommendations from the program are reported here. RESULTS: Panel experts agreed that specialists procuring samples for lung cancer diagnosis should choose biopsy techniques that maximize tumour cellularity, and that conservation strategies to maximize tissue for molecular testing should be used in tissue processing. The timeliness of molecular reporting can be improved by pathologist-initiated reflex testing upon confirmation of nonsquamous nsclc and by prompt transportation of specimens to designated molecular diagnostic centres. To coordinate timely molecular testing and optimal treatment, collaboration and communication between all clinicians involved in diagnosing patients with advanced lung cancer are mandatory. CONCLUSIONS: Knowledge transfer to diagnostic lung cancer specialists could potentially improve molecular testing and treatment for advanced lung cancer patients.
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Crohn's disease affects any part of the GI tract, commonly the terminal ileum. To decrease radiation exposure we developed a low-radiation-dose unenhanced CT (modified small Bowel CT, MBCT) to evaluate the small bowel using hyperdense oral contrast. Technique. MBCT was investigated in patients with pathologically proven Crohn's disease presenting with new symptoms from recurrent inflammation or stricture. After ethics board approval, 98 consecutive patients were retrospectively evaluated. Kappa values from two independent reviewers were calculated for presence of obstruction, active inflammation versus chronic stricture, and ancillary findings. Forty-two patients underwent surgery or colonoscopy within 3 months. Results. Kappa was 0.84 for presence of abnormality versus a normal exam and 0.89 for differentiating active inflammation from chronic stricture. Level of agreement for presence of skip areas, abscess formation, and fistula was 0.62, 0.75, and 0.78, respectively. In the subset with "gold standard" follow-up, there was 83% agreement. Conclusions. MBCT is a low-radiation technique with good to very good interobserver agreement for determining presence of obstruction and degree of disease activity in patients with Crohn's disease. Further investigation is required to refine parameters of disease activity compared to CT enterography and small bowel follow through.