Diagnostic accuracy of whole-body MRI versus standard imaging pathways for metastatic disease in newly diagnosed non-small-cell lung cancer: the prospective Streamline L trial

Published on Jun 1, 2019in The Lancet Respiratory Medicine
· DOI :10.1016/S2213-2600(19)30090-6
Stuart A. Taylor60
Estimated H-index: 60
(UCL: University College London),
Susan Mallett60
Estimated H-index: 60
(University of Birmingham)
+ 202 AuthorsSarah Howling2
Estimated H-index: 2
Sources
Abstract
Summary Background Whole-body magnetic resonance imaging (WB-MRI) could be an alternative to multi-modality staging of non-small-cell lung cancer (NSCLC), 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 NSCLC. Methods The Streamline L trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed NSCLC that was potentially radically treatable on diagnostic chest CT (defined as stage IIIb or less). Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or histologies other than NSCLC. 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 ISRCTN50436483, and is complete. Findings Between Feb 26, 2013, and Sept 5, 2016, 976 patients were screened for eligibility. 353 patients were recruited, 187 of whom completed the trial; 52 (28%) had metastasis at baseline. Pathway sensitivity was 50% (95% CI 37–63) for WB-MRI and 54% (41–67) for standard pathways, a difference of 4% (−7 to 15, p=0·73). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (93% [88–96]) and standard pathways (95% [91–98], p=0·45). Agreement with the multidisciplinary team's final treatment decision was 98% for WB-MRI and 99% for the standard pathway. Time to complete staging was shorter for WB-MRI (13 days [12–14]) than for the standard pathway (19 days [17–21]); a 6-day (4–8) difference. The number of tests required was similar WB-MRI (one [1–1]) and standard pathways (one [1–2]). Mean per-patient costs were £317 (273–361) for WBI-MRI and £620 (574–666) for standard pathways. Interpretation WB-MRI staging pathways have similar accuracy to standard pathways, and reduce the staging time and costs. Funding UK National Institute for Health Research.
Figures & Tables
Download
📖 Papers frequently viewed together
135 Citations
1 Citations
19 Citations
References34
Newest
#1Stuart A. Taylor (UCL: University College London)H-Index: 60
#2Susan Mallett (University of Birmingham)H-Index: 60
Last. Sara LockH-Index: 9
view all 205 authors...
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. Eli...
28 CitationsSource
#1Anne Miles (Birkbeck, University of London)H-Index: 24
#2Stuart A. Taylor (UCL: University College London)H-Index: 60
view all 14 authors...
Objectives To determine the importance placed by patients on attributes associated with whole-body MRI (WB-MRI) and standard cancer staging pathways and ascertain drivers of preference.
11 CitationsSource
#1Ross Maconachie (National Institute for Health and Care Excellence)H-Index: 2
#2Toby Mercer (National Institute for Health and Care Excellence)H-Index: 1
Last. Gary E. McVeigh (Belfast Health and Social Care Trust)H-Index: 34
view all 4 authors...
### What you need to know This National Institute for Health and Care Excellence (NICE) guideline update covers the diagnosis and treatment of lung cancer.1 Recommendations on referral for suspected cancer are covered in a separate guideline.2 ### Why did it need updating? New trials and systematic reviews have been published in several relevant areas since the 2011 update of this guideline, particularly in the areas of staging, radiotherapy, and systemic treatments. ### Who is it for? The new r...
23 CitationsSource
#1Neal Navani (UCLH: University College Hospital)H-Index: 24
#2David FisherH-Index: 23
Last. X.-N. YangH-Index: 8
view all 29 authors...
Background Clinical staging of non-small cell lung cancer (NSCLC) helps determine the prognosis and treatment of patients; few data exist on the accuracy of clinical staging and the impact on treatment and survival of patients. We assessed whether participant or trial characteristics were associated with clinical staging accuracy as well as impact on survival. Methods We used individual participant data from randomized controlled trials (RCTs), supplied for a meta-analysis of preoperative chemot...
17 CitationsSource
Abstract Although radiation dose in computed tomography (CT) decreased and CT became safer examinations than before, CT is the most significant source of the medical radiation exposure. Knowledge about available radiation dose reduction methods in CT is essential. Substantial improvement occurred regarding tube current selection (automatic exposure control) and image production method (iterative reconstruction). Optimizing the tube potential selection is expected to contribute to further CT radi...
19 CitationsSource
#1Ruth E.C. Evans (Birkbeck, University of London)H-Index: 10
#2Stuart A. Taylor (UCL: University College London)H-Index: 60
Last. Anne Miles (Birkbeck, University of London)H-Index: 24
view all 8 authors...
Objective:To evaluate perceived patient burden and acceptability of whole body MRI (WB-MRI) compared to standard staging investigations, and identify predictors of reduced tolerance.Methods:Patients recruited to multicentre trials comparing WB-MRI with standard staging scans for lung and colorectal cancer were invited to complete two questionnaires: a baseline questionnaire at recruitment, measuring demographics, comorbidities, and distress; and a follow-up questionnaire after staging, measuring...
16 CitationsSource
#1Anne M. J. B. SmetsH-Index: 15
#2E. E. DeurlooH-Index: 1
Last. Shandra BipatH-Index: 53
view all 5 authors...
Background Many solid neoplasms have a propensity for osteomedullary metastases of which detection is important for staging and subsequent treatment. Whole-body magnetic resonance imaging (WB-MRI) has been shown to accurately detect osteomedullary metastases in adults, but these findings cannot be unconditionally extrapolated to staging of children with malignant solid tumors.
15 CitationsSource
#1Ruth E.C. Evans (Birkbeck, University of London)H-Index: 10
#2Stuart A. Taylor (UCL: University College London)H-Index: 60
Last. Anne Miles (Birkbeck, University of London)H-Index: 24
view all 10 authors...
Objective To describe the experience and acceptability of whole-body magnetic resonance imaging (WB-MRI) staging compared with standard scans among patients with highly suspected or known colorectal or lung cancer. Design Qualitative study using one-to-one interviews with thematic analysis. Setting Patients recruited from 10 hospitals in London, East and South East England between March 2013 and July 2014. Participants 51 patients (31 male, age range 40–89 years), with varying levels of social d...
22 CitationsSource
#1Stuart A. Taylor (UCL: University College London)H-Index: 60
#2Susan Mallett (University of Birmingham)H-Index: 60
Last. Steve Halligan (UCL: University College London)H-Index: 81
view all 19 authors...
Abstract Background and aims Rapid and accurate cancer staging following diagnosis underpins patient management, in particular the identification of distant metastatic disease. Current staging guidelines recommend sequential deployment of various imaging platforms such as computerised tomography (CT) and positron emission tomography (PET) which can be time and resource intensive and onerous for patients. Recent studies demonstrate that whole body magnetic resonance Imaging (WB-MRI) may stage can...
16 CitationsSource
#1Cyprian Olchowy (Wrocław Medical University)H-Index: 5
#2Kamil Cebulski (Wrocław Medical University)H-Index: 3
Last. Urszula Zaleska-Dorobisz (Wrocław Medical University)H-Index: 11
view all 7 authors...
Background and purpose Gadolinium based contrast agents (GBCAs) are widely used in magnetic resonance imaging, but recently, high signal intensity in the cerebellum structures was reported after repeated administrations of contrast- enhanced magnetic resonance images. The aim of this systematic review was to investigate the association between increased signal intensity in the dentate nucleus and globus pallidus in the brain and repeated administrations of GBCAs. Additionally, we focused on poss...
109 CitationsSource
Cited By28
Newest
#1Alexander Radbruch (University of Mainz)
#2Daniel Paech (University Hospital Bonn)
Last. Konstantin Nikolaou (University of Tübingen)H-Index: 74
view all 9 authors...
ABSTRACT: The second part of this review deals with experiences in neuroradiological and pediatric examinations using modern magnetic resonance imaging systems with 1.5 T and 3 T, with special attention paid to experiences in pediatric cardiac imaging. In addition, whole-body examinations, which are widely used for diagnostic purposes in systemic diseases, are compared with respect to the image quality obtained in different body parts at both field strengths. A systematic overview of the technic...
Source
#1Anne Miles (Birkbeck, University of London)H-Index: 24
#2Ruth E.C. Evans (Birkbeck, University of London)H-Index: 10
Last. Stuart A. Taylor (UCL: University College London)H-Index: 60
view all 3 authors...
People undergoing investigations for suspected cancer have to undergo a number of investigations before they know their full diagnosis and treatment plan. We examined predictors of distress among p...
Source
#1Giuseppe Petralia (IEO: European Institute of Oncology)H-Index: 23
#2Fabio Zugni (IEO: European Institute of Oncology)H-Index: 5
Last. Anwar R. Padhani (Mount Vernon Hospital)H-Index: 91
view all 9 authors...
Whole-body magnetic resonance imaging (WB-MRI) is currently recommended for cancer screening in adult and paediatric subjects with cancer predisposition syndromes, representing a substantial aid for prolonging health and survival of these subjects with a high oncological risk. Additionally, the number of studies exploring the use of WB-MRI for cancer screening in asymptomatic subjects from the general population is growing. The primary aim of this review was to analyse the acquisition protocols ...
Source
#1Kehan QiH-Index: 5
Last. Shanshan WangH-Index: 18
view all 7 authors...
Image Quality Assessment (IQA) is of great value in the workflow of Magnetic Resonance Imaging (MRI)-based analysis. Blind IQA (BIQA) methods are especially required since high-quality reference MRI images are usually not available. Recently, many efforts have been devoted to developing deep learning-based BIQA approaches. However, the performance of these methods is limited due to the utilization of simple content-non-adaptive network parameters and the waste of the important 3D spatial informa...
Successful treatment of oligometastatic disease (OMD) is facilitated through timely detection and localization of disease, both at the time of initial diagnosis (synchronous OMD) and following the initial therapy (metachronous OMD). Hence, imaging plays an indispensable role in management of patients with OMD. However, the challenges and complexities of OMD management are also reflected in the imaging of this entity. While innovations and advances in imaging technology have made a tremendous imp...
Source
#1Katrina M. Ingley (UCL: University College London)
#2Simon Wan (UCLH: University College Hospital)H-Index: 10
Last. Sandra J. Strauss (UCL: University College London)H-Index: 27
view all 7 authors...
Primary malignant bone sarcomas are rare and Ewing sarcoma (ES), along with osteosarcoma, predominates in teenagers and young adults. The well-established multimodality treatment incorporates systemic chemotherapy with local control in the form of surgery, with or without radiation. The presence and extent of metastases at diagnosis remains the most important prognostic factor in determining patient outcome; patients with skeletal metastases or bone marrow infiltration having a significantly wor...
Source
#1Júlio Brandão Guimarães (UNIFESP: Federal University of São Paulo)H-Index: 1
Last. Laura M. Fayad (Johns Hopkins University)H-Index: 36
view all 7 authors...
Whole-body magnetic resonance imaging (WB-MRI) has gained importance in the field of musculoskeletal oncology over the last decades, consisting in a one-stop imaging method that allows a wide coverage assessment of both bone and soft tissue involvement. WB-MRI is valuable for diagnosis, staging, and follow-up in many oncologic diseases and is especially advantageous for the pediatric population since it avoids redundant examinations and exposure to ionizing radiation in patients who often underg...
Source
#1Wenrui Jiang (Fourth Military Medical University)
#2Zhiping Han (Fourth Military Medical University)H-Index: 4
Last. Jian Zhang (Fourth Military Medical University)H-Index: 36
view all 5 authors...
OBJECTIVES The purpose of this study was to analyze the diagnostic performance and clinical application of diffusion-weighted imaging (DWI) in patients with suspected pleural malignancy (PM). METHODS A retrospective review of patients with suspected PM was performed from March 2014 to August 2018 (NCT02320617). All patients underwent chest DWI and computed tomography (CT) with cytological or histopathological findings as reference standards. The diagnostic performance of DWI and CT was analyzed ...
Source
Source
#1Elsie T. Nguyen (TGH: Toronto General Hospital)H-Index: 11
#2Hamid Bayanati (U of O: University of Ottawa)
Last. Anastasia Oikonomou (Sunnybrook Health Sciences Centre)H-Index: 24
view all 8 authors...
Historically thoracic MRI has been limited by the lower proton density of lung parenchyma, cardiac and respiratory motion artifacts and long acquisition times. Recent technological advancements in MR hardware systems and improvement in MR pulse sequences have helped overcome these limitations and expand clinical opportunities for non-vascular thoracic MRI. Non-vascular thoracic MRI has been established as a problem-solving imaging modality for characterization of thymic, mediastinal, pleural che...
Source