Adequacy of key standards in reporting pancreatic cancer [QSI Ref: XR-508]

Involvement of common hepatic artery, celiac artery and superior mesenteric artery changes the T stage of pancreatic cancer irrespective of the tumour size. Vascular involvement of pancreatic mass plays a key role in deciding resectability of pancreatic mass and can drastically change the management of pancreatic cancer.

Pancreatic cancers constitute 2.9% of all cancers in the UK. 

Primary treatment is surgical in which all macroscopic tumours can be excised. CT and MRI are similar in their capability to assess local tumour resectability (1).

It is the 5th biggest cancer killer in England with 7800 deaths every year. 7 in 10 people with pancreatic cancer do not receive any active treatment, including surgery, chemotherapy or radiotherapy.

1 in 10 people with pancreatic cancer will receive potentially curative surgery. 2 in 10 people will receive chemotherapy.

Pancreatic cancer has the lowest survival of all common cancers, with five-year survival less than 7%.

Five-year survival of pancreatic cancer in the UK ranks 28th out of 36 countries compared (2)

NICE guideline [NG85] recommends different treatment options for managing resectable and borderline resectable pancreatic cancer than locally advanced unresectable pancreatic cancer (3).

Vascular involvement by the pancreatic cancer upstages it to T4 stage irrespective of its size (4).

Criteria defining resectability status of pancreatic ductal adenocarcinoma is based on tumour relation with vessels around the head and neck of pancreas. (5)

What do surgeons expect from radiology report for pancreatic cancer? 

• Tumour size and involvement of visceral arteries and portal venous system (including any aberrant vessels) or attempts to provide a tentative T staging of pancreatic tumour which will help to decide resectability of the pancreatic cancer.
• Suggestions for further appropriate imaging, other investigations, intervention or appropriate referral. 
• They expect these radiology reports to be provided in a timely manner for reassurance, confirmation of diagnosis and communicated to the upper GI/hepato-pancreatico-biliary multidisciplinary team. 

This audit aims to check for adequacy of key standards in reporting pancreatic cancer which would help in classifying them into resectable, borderline resectable and unresectable categories (1).

The standard

Summary of key standards by RCR (6) states: 1. A radiology report should be actionable and prompt appropriate for the patient. 2. Further investigations or specialist referral should be suggested within the report when they contribute to patient management. O-P09  PACT-UK: PAncreatic Cancer reporting Template - a national pan-specialty collaborative consensus project to develop a standardised radiological reporting proforma for pancreatic cancer (7)

Target

100% for both standards.

Indicators

All reports of CT and MRI performed for pancreatic cancer should include: Tumour size and tumour relation with visceral arteries and portal venous system (including any aberrant vessels) or Provide provisional T stage of pancreatic mass. Advice on next appropriate step for further patient management which includes suggestions for further appropriate imaging, other investigations, intervention or appropriate referral.

Data items to be collected

Exclusion:

• Reports which are normal, with pancreatitis, cystic pancreatic lesions, PNET, periampullary and distal CBD cholangiocarcinoma.
• Follow up patients for whom reports prior to treatment/ intervention are not available. Patients discussed in MDT which underwent imaging elsewhere.

Analyse the report to answer the following questions:

• Did the report mention tumour size and tumour relation with visceral arteries and portal venous system (including any aberrant vessels) or provisional T stage of pancreatic mass?
• Was advice provided on next appropriate step for further patient management? 

Data analysis should include referral type (emergency or elective) and employment status (NHS, locum or teleradiologist).

Suggested number

40

Feedback via departmental/clinical governance meetings. Dissemination of audit report and structured template/ checklist for reporting pancreatic cancer highlighting on the standards. Presentation for radiologists revising the key findings deciding the resectability of pancreatic cancer. Re-audit.

Recommendations of cross-sectional imaging in cancer management, Third edition (Pancreas) BFCR (22)3 https://www.pancreaticcancer.org.uk

NICE guideline [NG85] Pancreatic cancer in adults: diagnosis and management (Published date: 07 February 2018) 

AJCC/UICC TNM Staging - 8th edition 

Pancreatic Adenocarcinoma Staging in Era of Chemotherapy and 

Radiation Therapy, Radiology: Volume 287: Number 2—May 2018 

Standards for interpretation and reporting of imaging investigations (second edition, March 2018) by RCR (Royal college of Radiologists)

https://academic.oup.com/bjs/article/108/Supplement_9/znab429.049/6462766/

https://www.bsgar.org/media/PACT-UK%20(plain%20text%20version)%20Aug21.docx

Dr Anmol Kakaria, Dr Bellam-Premnath Krishna Prasad, Dr Kishor Barhate

Dr Pravin Ghadge