Impact of structured report on the quality of preoperative CT staging of pancreatic ductal adenocarcinoma: assessment of intra- and inter-reader variability

An update on pancreatic cancer imaging, staging, and use of the PACT-UK radiology template pre- and post-neoadjuvant treatment

Pancreatic ductal adenocarcinoma continues to have a poor prognosis, although recent advances in neoadjuvant treatments (NATs) have provided some hope. Imaging assessment of suspected tumours can be challenging and requires a specific approach, with pancreas protocol CT being the primary imaging modality for staging with other modalities used as problem-solving tools to facilitate appropriate management. Imaging assessment post NAT can be particularly difficult due to a current lack of robust radiological criteria to predict response and differentiate treatment induced fibrosis/inflammation from residual tumour. This review aims to provide an update of pancreatic ductal adenocarcinoma with particular focus on three points: tumour staging pre- and post-NAT including vascular assessment, structured reporting with introduction of the PAncreatic Cancer reporting Template-UK (PACT-UK) radiology template, and the potential future role of artificial intelligence in the diagnosis and staging of pancreatic cancer.

Real-World Validation of Coregistration and Structured Reporting for Magnetic Resonance Imaging Monitoring in Multiple Sclerosis

OBJECTIVE

The objectives of this research were to assess the effectiveness of computer-assisted detection reading (CADR) and structured reports in monitoring patients with multiple sclerosis (MS) and to evaluate the role of radiology technicians in this context.

METHODS

Eighty-seven patients with MS who underwent at least 2 sequential magnetic resonance imaging (MRI) follow-ups analyzed by 2 radiologists and a technician. Progression of disease (POD) was identified through the emergence of T2 fluid-attenuated inversion recovery white matter hyperintensities or contrast enhancements and evaluated both qualitatively (progression vs stability) and quantitatively (count of new white matter hyperintensities).

RESULTS

CADR increased the accuracy by 11%, enhancing interobserver consensus on qualitative progression and saving approximately 2 minutes per examination. Although structured reports did not improve these metrics, it may improve clinical communication and permit technicians to achieve approximately 80% accuracy in MRI readings.

CONCLUSIONS

The use of CADR improves the accuracy, agreement, and interpretation time in MRI follow-ups of MS. With the help of computer tools, radiology technicians could represent a significant aid in the follow-up of these patients.

Accuracy of Outsourced Radiology Reports in Emergency Surgical Care: Do They Provide a High-Quality, Cost-Effective Service?

Background Computed tomography (CT) scans play a crucial role in emergency surgical care, serving both diagnostic and prognostic functions. They significantly contribute to timely and effective patient care. This study aims to compare abdominal CT scan reports prepared by locally employed radiologists with those from outsourced radiology reporting services for patients presenting with acute surgical conditions. Additionally, the study evaluates how different reporting styles, such as free-text versus structured formats, influence the overall quality of the reports. Methods The study was conducted in the general surgery unit of North Manchester General Hospital, Manchester, a district general hospital in North West England. Patients admitted through the accident and emergency (A&E) under the general surgery team who underwent abdominal CT scans between August 2023 and October 2023 were included. Trauma patients and those who received non-abdominal CT scans were excluded. Local radiology reports were compared to outsourced reports using statistical analysis. The clarity and comprehensiveness of the reports were carefully evaluated, and the impact of free-text versus structured reporting formats was also considered. Results A total of 192 patients were included in the study, with a median age of 59 years. Compared to locally reported scans, outsourced radiology reports frequently omitted commentary on key anatomical structures, including the biliary system, spleen, kidneys, lymph nodes, mesentery and peritoneum, vasculature, bones and soft tissues, and lung bases. Reports using a structured format provided more thorough commentary on the spleen, adrenal glands, mesentery and peritoneum, and bones and soft tissues compared to free-text reports. Conclusion Outsourced radiology reports significantly underreported important abdominal anatomical structures. Free-text reporting was associated with significant omissions in abdominal anatomical structures, which could negatively affect clinical decision-making and management plans. Further studies are recommended to evaluate the comprehensiveness of outsourced radiology reporting and to ensure standardization in reporting, ultimately providing patients with high-quality emergency care.

Impact of Structured Reporting of Lower Extremity CT Angiography on Report Quality and Workflow Efficiency

We assessed the effects of structured reporting (SR) of lower extremity CT angiography (CTA) on report quality and workflow efficiency compared with conventional reports (CR). Surveys were conducted at an academic radiology department before and after the introduction of an SR template. Participants (n = 39, 21) rated report quality and report creation effort (1: very dissatisfied/low to 10: very satisfied/high) and whether SR represents an improvement over CR (1: completely disagree to 5: completely agree). Four residents and two supervising radiologists created both CR and SR of 40 CTA examinations. Report creation time was measured and the factual accuracy of residents' reports was judged. Report completeness (median 8.0 vs. 7.0, p = 0.016) and clinical usefulness (7.0 vs. 4.0, p = 0.029) were rated higher for SR. Supervising radiologists found report clarity improved by SR (8.0 vs. 4.5, p = 0.029). Report creation effort was unchanged (7.0 vs. 6.0, p > 0.05). SR was considered an improvement over CR (median 4.0, IQR,3.0-5.0). Report supervision was shortened by SR (6.2 ± 2.0 min vs. 10.6 ± 3.5 min, p < 0.001) but total time for report creation remained unchanged (36.6 ± 12.8 min vs. 36.4 ± 11.0 min, p > 0.05). Factual accuracy of residents' SR was deemed higher (8.0/9.5 vs. 7.0/7.0, p = 0.006/ < 0.001). In conclusion, SR has the potential to improve report quality and workflow efficiency for lower extremity CTA.

Large Language Models for Automated Synoptic Reports and Resectability Categorization in Pancreatic Cancer

Background Structured radiology reports for pancreatic ductal adenocarcinoma (PDAC) improve surgical decision-making over free-text reports, but radiologist adoption is variable. Resectability criteria are applied inconsistently. Purpose To evaluate the performance of large language models (LLMs) in automatically creating PDAC synoptic reports from original reports and to explore performance in categorizing tumor resectability. Materials and Methods In this institutional review board-approved retrospective study, 180 consecutive PDAC staging CT reports on patients referred to the authors' European Society for Medical Oncology-designated cancer center from January to December 2018 were included. Reports were reviewed by two radiologists to establish the reference standard for 14 key findings and National Comprehensive Cancer Network (NCCN) resectability category. GPT-3.5 and GPT-4 (accessed September 18-29, 2023) were prompted to create synoptic reports from original reports with the same 14 features, and their performance was evaluated (recall, precision, F1 score). To categorize resectability, three prompting strategies (default knowledge, in-context knowledge, chain-of-thought) were used for both LLMs. Hepatopancreaticobiliary surgeons reviewed original and artificial intelligence (AI)-generated reports to determine resectability, with accuracy and review time compared. The McNemar test, t test, Wilcoxon signed-rank test, and mixed effects logistic regression models were used where appropriate. Results GPT-4 outperformed GPT-3.5 in the creation of synoptic reports (F1 score: 0.997 vs 0.967, respectively). Compared with GPT-3.5, GPT-4 achieved equal or higher F1 scores for all 14 extracted features. GPT-4 had higher precision than GPT-3.5 for extracting superior mesenteric artery involvement (100% vs 88.8%, respectively). For categorizing resectability, GPT-4 outperformed GPT-3.5 for each prompting strategy. For GPT-4, chain-of-thought prompting was most accurate, outperforming in-context knowledge prompting (92% vs 83%, respectively; P = .002), which outperformed the default knowledge strategy (83% vs 67%, P < .001). Surgeons were more accurate in categorizing resectability using AI-generated reports than original reports (83% vs 76%, respectively; P = .03), while spending less time on each report (58%; 95% CI: 0.53, 0.62). Conclusion GPT-4 created near-perfect PDAC synoptic reports from original reports. GPT-4 with chain-of-thought achieved high accuracy in categorizing resectability. Surgeons were more accurate and efficient using AI-generated reports. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Chang in this issue.

[Interdisciplinary case discussions]

BACKGROUND

Interdisciplinary case discussions, especially tumor conferences, represent a large part of the clinical radiologist's daily work. Radiology plays a key role in tumor conferences, since imaging findings have a direct influence on therapy decisions.

METHODS AND OBJECTIVES

This article discusses the requirements for the radiologist in preparing and conducting tumor conferences. Furthermore, the general conditions and forms of implementation of tumor conferences will be highlighted. Information technology (IT) tools for process automation and systems for assessing the course of tumor diseases will be presented.

RESULTS

Detailed preparation of tumor conferences and clear communication of findings is essential. The radiological expertise in tumor conferences often leads to changes or adjustments of initially planned therapies. In addition to traditional face-to-face meetings, hybrid solutions have become established for tumor conferences in which the core team is on site and other participants (external referring physicians, internal participants outside the core team) are connected via video conference. Various systems have been established for assessing the course of tumor diseases. Due to its broad applicability, RECIST 1.1. is the most widely used. IT tools enable previously marked lesions to be displayed over time in a matrix view (lesion tracking). Artificial intelligence (AI) can also be used to automatically detect lesions and assess their volumes.

CONCLUSION

Preparing and conducting tumor conferences is time-consuming for radiologists. IT tools can automate and thus facilitate the processes. Hybrid solutions combining face-to-face meetings and video conferences make it easier for external referring physicians to present their patients in tumor conferences.

Imaging Assessment of Pancreatic Cancer Resectability After Neoadjuvant Therapy: AJR Expert Panel Narrative Review

Despite important innovations in the treatment of pancreatic ductal adenocarcinoma (PDAC), PDAC remains a disease with poor prognosis and high mortality. A key area for potential improvement in the management of PDAC, aside from earlier detection in patients with treatable disease, is the improved ability of imaging techniques to differentiate treatment response after neoadjuvant therapy (NAT) from worsening disease. It is well established that current imaging techniques cannot reliably make this distinction. This narrative review provides an update on the imaging assessment of pancreatic cancer resectability after NAT. Current definitions of borderline resectable PDAC, as well as implications for determining likely patient benefit from NAT, are described. Challenges associated with PDAC pathologic evaluation and surgical decision making that are of relevance to radiologists are discussed. Also explored are the specific limitations of imaging in differentiating the response after NAT from stable or worsening disease, including issues relating to protocol optimization, tumor size assessment, vascular assessment, and liver metastasis detection. The roles of MRI as well as PET and/or hybrid imaging are considered. Finally, a short PDAC reporting template is provided for use after NAT. The highlighted methods seek to improve radiologists' assessment of PDAC treatment response after NAT.

Structured reporting in radiology: a systematic review to explore its potential

OBJECTIVES

Structured reporting (SR) in radiology reporting is suggested to be a promising tool in clinical practice. In order to implement such an emerging innovation, it is necessary to verify that radiology reporting can benefit from SR. Therefore, the purpose of this systematic review is to explore the level of evidence of structured reporting in radiology. Additionally, this review provides an overview on the current status of SR in radiology.

METHODS

A narrative systematic review was conducted, searching PubMed, Embase, and the Cochrane Library using the syntax 'radiol*' AND 'structur*' AND 'report*'. Structured reporting was divided in SR level 1, structured layout (use of templates and checklists), and SR level 2, structured content (a drop-down menu, point-and-click or clickable decision trees). Two reviewers screened the search results and included all quantitative experimental studies that discussed SR in radiology. A thematic analysis was performed to appraise the evidence level.

RESULTS

The search resulted in 63 relevant full text articles out of a total of 8561 articles. Thematic analysis resulted in 44 SR level 1 and 19 level 2 reports. Only one paper was scored as highest level of evidence, which concerned a double cohort study with randomized trial design.

CONCLUSION

The level of evidence for implementing SR in radiology is still low and outcomes should be interpreted with caution.

KEY POINTS

• Structured reporting is increasingly being used in radiology, especially in abdominal and neuroradiological CT and MRI reports. • SR can be subdivided into structured layout (SR level 1) and structured content (SR level 2), in which the first is defined as being a template in which the reporter has to report; the latter is an IT-based manner in which the content of the radiology report can be inserted and displayed into the report. • Despite the extensive amount of research on the subject of structured reporting, the level of evidence is low.

Structured CT reporting of pancreatic ductal adenocarcinoma: impact on completeness of information and interdisciplinary communication for surgical planning

PURPOSE

With the rise in popularity of structured reports in radiology, we sought to evaluate whether free-text CT reports on pancreatic ductal adenocarcinoma (PDAC) staging at our institute met published guidelines and assess feedback of pancreatic surgeons comparing free-text and structured report styles with the same information content.

METHODS

We retrospectively evaluated 298 free-text preoperative CT reports from 2015 to 2017 for the inclusion of key tumor descriptors. Two surgeons independently evaluated 50 free-text reports followed by evaluation of the same reports in a structured format using a 7-question survey to assess the usefulness and ease of information extraction. Fisher's exact test and Chi-square test for independence were utilized for categorical responses and an independent samples t test for comparing mean ratings of report quality as rated on a 5-point Likert scale.

RESULTS

The most commonly included descriptors in free-text reports were tumor location (99%), liver lesions (97%), and suspicious lymph nodes (97%). The most commonly excluded descriptors were variant arterial anatomy and peritoneal/omental nodularity, which were present in only 23% and 42% of the reports, respectively. For vascular involvement, a mention of the presence or absence of perivascular disease with the main portal vein was most commonly included (87%). Both surgeons' rating of overall report quality was significantly higher for structured reports (p < 0.001).

CONCLUSION

Our results indicate that free-text reports may not include key descriptors for staging PDAC. Surgeons rated structured reports that presented the same information as free-text reports but in a template format superior for guiding clinical management, convenience of use, and overall report quality.

Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma: Role of the Radiologist and Oncologist in the Era of Precision Medicine

The incidence and mortality of pancreatic ductal adenocarcinoma are growing over time. The management of patients with pancreatic ductal adenocarcinoma involves a multidisciplinary team, ideally involving experts from surgery, diagnostic imaging, interventional endoscopy, medical oncology, radiation oncology, pathology, geriatric medicine, and palliative care. An adequate staging of pancreatic ductal adenocarcinoma and re-assessment of the tumor after neoadjuvant therapy allows the multidisciplinary team to choose the most appropriate treatment for the patient. This review article discusses advancement in the molecular basis of pancreatic ductal adenocarcinoma, diagnostic tools available for staging and tumor response assessment, and management of resectable or borderline resectable pancreatic cancer.

Assessing the Impact of Structured Reports for Fluoroscopic Double-Contrast Barium Esophagrams

Fluoroscopic barium swallow examinations are a commonly performed radiologic study in the evaluation of dysphagia. These studies remain essential in the diagnostic work-up despite the increasing utilization of endoscopy, but current residents are often less experienced with fluoroscopy. Structured reporting has been demonstrated to improve comprehensiveness of reports in multiple settings, but has not been evaluated for barium swallow examinations. A retrospective review identified patients who underwent barium swallow examinations pre-structured reporting in 2017 and followed a multidisciplinary proposal for and adoption of an optional structured report in 2020. Reports were assessed for comprehensiveness by evaluating presence/absence each element (total of 10 elements). Differences in report elements between groups and multiple subgroups was performed utilizing a Mann-Whitney U test. χ² tests were also utilized to evaluate inclusion of each individual element of the report. A total of 487 reports from 2020 and 757 reports from 2017 were analyzed. Certain elements showed substantial differences in reporting, with greater than 90% of structured reports including them, but much lower numbers including them in non-structured reports from 2017 and 2020. Reports generated in 2020 had a statistically significant increase in report elements included when compared to 2017 (p < 0.01). This statistically significant increase was also observed in comparison of structured reports and non-structured reports from either period (p < 0.01). Adoption of structured reporting for fluoroscopic barium swallow examinations led to significant increase in report comprehensiveness and should be considered after a multidisciplinary approach to development.

[Structured reporting in daily practice-status quo and future]

CLINICAL/METHODICAL ISSUE

Introduction and application of structured reporting in radiology private practice.

STANDARD RADIOLOGICAL METHODS

Ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), digital x‑ray (DR), mammography (MG).

METHODOLOGICAL INNOVATIONS

Structuring and predefinition of entire reports and report parts.

PERFORMANCE

Structured reporting in radiology presumably allows for higher report quality, reproducibility and easier access to data mining. Also the communication with the referring physicians can be improved. Although these advantages are well acknowledged, structured reporting does not prevail in private radiology practices. This article sheds light on the current situation of structured reporting in radiology private practice and provides information for the faltering implementation as well as perspective for individual potential solutions to overcome this situation.

ACHIEVEMENTS

Structured reporting is not yet standard. Growing acceptance of structured reporting can be expected.

PRACTICAL RECOMMENDATIONS

The application of structured reporting can improve report quality. The use of structured reporting should be considered for common examinations.

Contextual Structured Reporting in Radiology: Implementation and Long-Term Evaluation in Improving the Communication of Critical Findings

Structured reporting contributes to the completeness of radiology reports and improves quality. Both the content and the structure are essential for successful implementation of structured reporting. Contextual structured reporting is tailored to a specific scenario and can contain information retrieved from the context. Critical findings detected by imaging need urgent communication to the referring physician. According to guidelines, the occurrence of this communication should be documented in the radiology reports and should contain when, to whom and how was communicated. In free-text reporting, one or more of these required items might be omitted. We developed a contextual structured reporting template to ensure complete documentation of the communication of critical findings. The WHEN and HOW items were included automatically, and the insertion of the WHO-item was facilitated by the template. A pre- and post-implementation study demonstrated a substantial improvement in guideline adherence. The template usage improved in the long-term post-implementation study compared with the short-term results. The two most often occurring categories of critical findings are “infection / inflammation” and “oncology”, corresponding to the a large part of urgency level 2 (to be reported within 6 h) and level 3 (to be reported within 6 days), respectively. We conclude that contextual structured reporting is feasible for required elements in radiology reporting and for automated insertion of context-dependent data. Contextual structured reporting improves guideline adherence for communication of critical findings.