Chronic Liver Disease and Liver Cancer: What the Hepatologists, Oncologists, and Surgeons Want to Know from Radiologists.

Effective communication between radiologists and physicians involved in the management of patients with chronic liver disease is paramount to ensuring appropriate and advantageous incorporation of liver imaging findings into patient care. This review discusses the clinical benefits of innovations in radiology reporting, what information the various stakeholders wish to know from the radiologist, and how radiology can help to ensure the effective communication of findings.

Retrospective review of efficacy of radiofrequency ablation for treatment of colorectal cancer liver metastases from a Canadian perspective.

PURPOSE: A retrospective single-center review of ultrasound-guided radiofrequency ablation (RFA) treatment of colorectal cancer liver metastases was performed. This study reviews the primary and secondary technical effectiveness, overall survival of patients, recurrence-free survival, tumour-free survival, rates of local recurrence, and postprocedural RFA complications. Technical effectiveness and rates of complication with respect to tumour location and size were evaluated. Our results were compared with similar studies from Europe and North America. METHODS: A total of 63 patients (109 tumours) treated with RFA between February 2004 and December 2009 were reviewed. Average and median follow-up time was 19.4 and 16.5 months, respectively (range, 1-54 months). Data from patient charts, pathology, and Picture Archiving and Communication System was integrated into an Excel database. Statistical Analysis Software was used for statistical analysis. RESULTS: Primary and secondary technical effectiveness of percutaneous and intraoperative RFA were 90.8% and 92.7%, respectively. Average (SE) tumour-free survival was 14.4 ± 1.4 months (range, 1-43 months), and average (SE) recurrence-free survival was 33.5 ± 2.3 months (range, 2-50 months). Local recurrence was seen in 31.2% of treated tumours (range, 2-50 months) (34/109). Overall survival was 89.4% at 1 year, 70.0% at 2 years, and 38.1% at 3 years, with an average (SE) overall survival of 37.0 ± 2.8 months. There were 14 postprocedural complications. There was no statistically significant difference in technical effectiveness for small tumours (1-2 cm) vs intermediate ones (3-5 cm). There was no difference in technical effectiveness for peripheral vs parenchymal tumours. CONCLUSIONS: This study demonstrated good-quality outcomes for RFA treatment of colorectal cancer liver metastases from a Canadian perspective and compared favorably with published studies.

Improving equitable access to imaging under universal-access medicine: the ontario wait time information program and its impact on hospital policy and process.

In Canada, equal access to health care is the goal, but this is associated with wait times. Wait times should be fair rather than uniform, taking into account the urgency of the problem as well as the time an individual has already waited. In November 2004, the Ontario government began addressing this issue. One of the first steps was to institute benchmarks reflecting "acceptable" wait times for CT and MRI. A public Web site was developed indicating wait times at each Local Health Integration Network. Since starting the Wait Time Information Program, there has been a sustained reduction in wait times for Ontarians requiring CT and MRI. The average wait time for a CT scan went from 81 days in September 2005 to 47 days in September 2009. For MRI, the resulting wait time was reduced from 120 to 105 days. Increased patient scans have been achieved by purchasing new CT and MRI scanners, expanding hours of operation, and improving patient throughput using strategies learned from the Lean initiative, based on Toyota's manufacturing philosophy for car production. Institution-specific changes in booking procedures have been implemented. Concurrently, government guidelines have been developed to ensure accountability for monies received. The Ontario Wait Time Information Program is an innovative first step in improving fair and equitable access to publicly funded imaging services. There have been reductions in wait times for both CT and MRI. As various new processes are implemented, further review will be necessary for each step to determine their individual efficacy.

CT colonography versus optical colonoscopy for screening asymptomatic patients for colorectal cancer a patient, intervention, comparison, outcome (PICO) analysis.

RATIONALE AND OBJECTIVES: The American College of Radiology has recently endorsed the use of computed tomographic colonography (CTC) for colon cancer screening. With advances in technology and postprocessing software, the quality of computed tomographic colonographic studies has improved, and new techniques are being developed to reduce radiation exposure and increase patient acceptance of the procedure. The aim of colorectal cancer screening is to reduce the incidence of malignancy by identifying and removing presymptomatic lesions. The aim of this study was to answer the clinical question: In an asymptomatic patient at average risk for colon cancer, is CTC equivalent to optical colonoscopy (OC) for detecting clinically significant polyps? MATERIALS AND METHODS: A systematic literature review was conducted to evaluate CTC compared to OC, using the patient, intervention, comparison intervention, outcome (PICO) search strategy. The PubMed search used Medical Subject Headings, including the terms "computed tomography colonography," "colonoscopy," "screening," and "polyp." Each of the retrieved articles was assigned a level of evidence using the Centre for Evidence-Based Medicine's hierarchy of validity for diagnostic studies. RESULTS: PICO search criteria and review of abstracts identified 16 relevant studies. Using the Centre for Evidence-Based Medicine's hierarchy of validity, there were three level 1c studies, two level 2a studies, three level 2b studies, four level 3b studies, two level 4 studies, and two level 5 studies. All relevant studies demonstrated that CTC had high or moderately high per patient and per polyp sensitivity and specificity compared to OC for clinically relevant polyps (>5 mm). CONCLUSIONS: The majority of evidence suggests that CTC is an acceptable alternative to OC, particularly in the group of patients who are either unwilling or unable to undergo OC. The results of the large, multicenter American College of Radiology Imaging Network study are pending. This trial presented preliminary results in 2007 suggesting that the sensitivity and specificity of CTC are high and comparable to those of OC.

PET vs sentinel lymph node biopsy for staging melanoma: a patient intervention, comparison, outcome analysis.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is the gold standard to assess local lymph nodes in patients with melanoma. Positron emission tomography (PET) has been investigated as a noninvasive alternative to SLNB. METHODS: A systematic literature review was conducted to evaluate PET and PET/computed tomography (CT) compared with SLNB for staging local lymph nodes in patients with intermediate-risk melanoma using the patient, intervention, comparison, outcome (PICO) search strategy. The PubMed, Medline, CancerLit, and Cochrane Library databases were searched for relevant published materials. Guidelines of the American Society of Clinical Oncology (ASCO), and Cancer Care Ontario (CCO) were reviewed, as was the clinical resource, UpToDate. Studies were classified on the basis of levels of evidence delineated by the Oxford Centre for Evidence-Based Medicine. RESULTS: The PICO search criteria identified 20 studies. There was no level 1 evidence. There were 7 level 2b articles. One review article was consecutive and thus classified as level 3a evidence. Three review articles were retrieved and categorized as level 3b. Three single-center studies were classified as level 3b, and another 3 were classified as level 4. There were two published letters, considered expert opinion and thus classified as level 5 evidence. All identified papers favored SLNB over PET or PET/CT for identifying occult locoregional lymph node metastases. CONCLUSION: Despite a lack of high-level evidence, the studies concluded that SLNB is superior to PET for local lymph node staging in patients with intermediate-risk melanoma. National guidelines confirmed these conclusions. The likelihood of PET/CT identifying distant metastases in this patient population is equally low because of the small risk for having distant metastases at diagnosis. Further study is required, including larger multicenter prospective trials.

Review of phase II trial designs used in studies of molecular targeted agents: outcomes and predictors of success in phase III.

PURPOSE: Because the appropriate design and end points for phase II evaluation of targeted anticancer agents are unclear, we undertook a review of recent reports of phase II trials of targeted agents to determine the types of designs used, the planned end points, the outcomes, and the relationship between trial outcomes and regulatory approval. METHODS: We retrieved reports of single-agent phase II trials in six solid tumors for 19 targeted drugs. For each, we abstracted data regarding planned design and actual results. Response rates were examined for any relationship to eventual success of the agents, as determined by US Food and Drug Administration approval for at least one indication. RESULTS: Eighty-nine trials were identified. Objective response was the primary or coprimary end point in the majority of trials (61 of 89 trials). Fourteen reports were of randomized studies generally evaluating different doses of agents, not as controlled experiments. Enrichment for target expression was uncommon. Objective responses were seen in 38 trials; in 19 trials, response rates were more than 10%, and in eight, they were more than 20%. Agents with high response rates tended to have high nonprogression rates; renal cell carcinoma was the exception to this. Higher overall response rates were predictive of regulatory approval in the tumor types reviewed (P = .005). CONCLUSION: In practice, phase II design for targeted agents is similar to that for cytotoxics. Objective response seems to be a useful end point for screening new targeted agents because, in our review, its observation predicted for eventual success. Improvements in design are recommended, as is more frequent inclusion of biological questions as part of phase II trials.