Total body MRI gevolgd door verdere specifieke diagnose van uitgezaaide darmkanker is beter en leidt sneller tot nauwkeuriger behandelplan dan standaard diagnose.

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15 mei 2019: Bron: The Lancet

Wanneer bij patienten met uitgezaaide darmkanker als eerste diagnosetechniek een Total Body MRI wordt uitgevoerd en daarna gevolgd door specifiekere diagnosetechnieken als biopsie, vaststelling van gradatie enz. dan blijkt er een nauwkeuriger behandelplan uit te rollen in vergelijking met de standaard manier van diagnostiek met o.a. PET-CT scan, CT scans, MRI lokaal enz.. Ook was een behandelplan sneller voorhanden dan bij een standaard diagnostische procedure. (8 vs 13 dagen).

Ook bleek uit een deelstudie van de grote Streamline C studie dat door de total body MRI er vaak een verschil zat in vaststellen van gradatie en in de behandelvoorstellen in vergelijking met standaard diagnoseprocedures. Nauwkeurigheid van de diagnose was 4 procent beter voor extra total body MRI in vergelijking met standaard diagnose.

Na 1 jaar was er geen verschil in de belangrijkste behandelingsoptie maar wel in correctere vaststelling van gradering en effectiviteit van behandelingen.

Uit het abstract:

WB-MRI was nauwkeuriger en efficienter en verminderde het aantal testen, verminderde de tijd tot een compleet behandelplan en de kosten waren minder.

WB-MRI is daarom beter in het vaststellen van gradering in de klinische praktijk. Verder onderzoek zal moeten uitwijzen of total body MRI ook beter is als controle na genezende behandeling.

Dit blijkt uit een langjarige postpectieve studie (Streamline C studie) over de periode 1990 t/m 2018 en gepubliceerd in The Lancet.

Aanvullend werd een studie opgezet met 1020 patienten in de periode 26 maart 2013 en 19 Augustus 19, 2016 Uiteindelijk werden 370 patienten aangenomen waarvan er 71 alsnog werden uitgesloten. Zie verder deze grafiek (figure 1).

En onderstaande grafiek geeft de verschillen weer:

Table 2 Per-patient sensitivity and specificity for metastatic disease

	Patients with metastatic disease ^*	Sensitivity				Patients without metastatic disease ^*	Specificity
		WB-MRI staging pathway ^†	Standard staging pathway	Difference	p value		WB-MRI staging pathway ^†	Standard staging pathway	Difference	p value
Diagnostic accuracy ^‡	68	67% (56 to 78)	63% (51 to 74)	4% (−5 to 13)	0·51	231	95% (92 to 97)	93% (90 to 96)	2% (−2 to 6)	0·48
Equivocal lesions considered positive	68	71% (59 to 80)	68% (56 to 78)	3% (−6 to 12)	..	231	95% (91 to 97)	92% (88 to 95)	3% (−2 to 7)	..
Equivocal lesions considered negative	68	65% (53 to 75)	58% (46 to 68)	7% (−2 to 17)	..	231	98% (94 to 99)	98% (95 to 99)	0% (−3 to 2)	..

Data are n or % (95% CI).

* Patients by consensus reference standard.

† WB-MRI plus additional generated tests.

‡ Equivocal results considered positive for colonic tumours and negative for rectal tumours.

Het volledige studierapport:

Diagnostic accuracy of whole-body MRI versus standard imaging pathways for metastatic disease in newly diagnosed colorectal cancer: the prospective Streamline C trial is gratis in te zien.

Hier het abstract:

Open AccessPublished:May 09, 2019DOI:https://doi.org/10.1016/S2468-1253(19)30056-1

Articles|Online First

Diagnostic accuracy of whole-body MRI versus standard imaging pathways for metastatic disease in newly diagnosed colorectal cancer: the prospective Streamline C trial

Prof Stuart A Taylor, FRCR

Stuart A Taylor
Correspondence
Correspondence to: Prof Stuart A Taylor, Centre for Medical Imaging, University College London, London W1W 7TS, UK

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Centre for Medical Imaging, University College London, London, UK

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† Members listed in the appendix (p 1)

Summary

Background

Whole-body MRI (WB-MRI) could be an alternative to multimodality staging of colorectal cancer, but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in colorectal cancer.

Methods

The Streamline C trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed colorectal cancer. Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or polyp cancer. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs), and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN43958015, and is complete.

Findings

Between March 26, 2013, and Aug 19, 2016, 1020 patients were screened for eligibility. 370 patients were recruited, 299 of whom completed the trial; 68 (23%) had metastasis at baseline. Pathway sensitivity was 67% (95% CI 56 to 78) for WB-MRI and 63% (51 to 74) for standard pathways, a difference in sensitivity of 4% (−5 to 13, p=0·51). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (95% [95% CI 92–97]) and standard pathways (93% [90–96], p=0·48). Agreement with the multidisciplinary team's final treatment decision was 96% for WB-MRI and 95% for the standard pathway. Time to complete staging was shorter for WB-MRI (median, 8 days [IQR 6–9]) than for the standard pathway (13 days [11–15]); a 5-day (3–7) difference. WB-MRI required fewer tests (median, one [95% CI 1 to 1]) than did standard pathways (two [2 to 2]), a difference of one (1 to 1). Mean per-patient staging costs were £216 (95% CI 211–221) for WB-MRI and £285 (260–310) for standard pathways.