Value of second-opinion review of outside institution PET-CT examinations

Clinical value of second opinions in oncology: A retrospective review of changes in diagnosis and treatment recommendations

BACKGROUND

Data on the clinical value of second opinions in oncology are limited. We examined diagnostic and treatment changes resulting from second opinions and the expected impact on morbidity and prognosis.

METHODS

This retrospective cohort study included patients presenting in 2018 to a high-volume cancer center for second opinions about newly diagnosed colorectal, head and neck, lung, and myeloma cancers or abnormal results. Two sub-specialty physicians from each cancer type reviewed 30 medical records (120 total) using a process and detailed data collection guide meant to mitigate institutional bias. The primary outcome measure was the rate of treatment changes that were "clinically meaningful", i.e., expected to impact morbidity and/or prognosis. Among those with treatment changes, another outcome measure was the rate of clinically meaningful diagnostic changes that led to treatment change.

RESULTS

Of 120 cases, forty-two had clinically meaningful changes in treatment with positive expected outcomes (7 colorectal, 17 head and neck, 11 lung, 7 myeloma; 23-57%). Two patients had negative expected outcomes from having sought a second opinion, with worse short-term morbidity and unchanged long-term morbidity and prognosis. All those with positive expected outcomes had improved expected morbidity (short- and/or long-term); 11 (0-23%) also had improved expected prognosis. Nine involved a shift from treatment to observation; 21 involved eliminating or reducing the extent of surgery, compared to 6 adding surgery or increasing its extent. Of the 42 with treatment changes, 13 were due to clinically meaningful diagnostic changes (1 colorectal, 5 head and neck, 3 lung, 4 myeloma; 3%-17%) .

CONCLUSIONS

Second-opinion consultations sometimes add clinical value by improving expected prognoses; more often, they offer treatment de-escalations, with corresponding reductions in expected short- and/or long-term morbidity. Future research could identify subgroups of patients most likely to benefit from second opinions.

Physician centred imaging interpretation is dying out - why should I be a nuclear medicine physician?

Radiomics, machine learning, and, more generally, artificial intelligence (AI) provide unique tools to improve the performances of nuclear medicine in all aspects. They may help rationalise the operational organisation of imaging departments, optimise resource allocations, and improve image quality while decreasing radiation exposure and maintaining qualitative accuracy. There is already convincing data that show AI detection, and interpretation algorithms can perform with equal or higher diagnostic accuracy in various specific indications than experts in the field. Preliminary data strongly suggest that AI will be able to process imaging data and information well beyond what is visible to the human eye, and it will be able to integrate features to provide signatures that may further drive personalised medicine. As exciting as these prospects are, they currently remain essentially projects with a long way to go before full validation and routine clinical implementation. AI uses a language that is totally unfamiliar to nuclear medicine physicians, who have not been trained to manage the highly complex concepts that rely primarily on mathematics, computer sciences, and engineering. Nuclear medicine physicians are mostly familiar with biology, pharmacology, and physics, yet, considering the disruptive nature of AI in medicine, we need to start acquiring the knowledge that will keep us in the position of being actors and not merely witnesses of the wonders developed by other stakeholders in front of our incredulous eyes. This will allow us to remain a useful and valid interface between the image, the data, and the patients and free us to pursue other, one might say nobler tasks, such as treating, caring and communicating with our patients or conducting research and development.

Detection of recurrent pancreatic cancer: value of second-opinion interpretations of cross-sectional images by subspecialized radiologists

PURPOSE

To investigate the value of second-opinion interpretation of cross-sectional images by subspecialized radiologists to diagnose recurrent pancreatic cancer after surgery.

METHODS

The IRB approved and issued a waiver of informed consent for this retrospective study. Initial and second-opinion interpretations of 69 consecutive submitted MRI or CT follow-up after pancreatic cancer resection between January 1, 2009 and December 31, 2013 were evaluated by one oncologic imaging radiologist, who was blinded to patient's clinical details and histopathologic data. The reviewer was asked to classify each interpretation in reference of the diagnosis of PDAC recurrence. It was also recorded if the radiologic interpretation recommended additional imaging studies to confirm recurrence. The diagnosis of recurrence was determined by pathology when available, otherwise by imaging follow-up, clinical, or laboratory assessments. Cohen's kappa statistic was used to assess agreement between initial and second-opinion interpretations. The differences between the initial and second-opinion interpretations were examined using McNemar test or Bowker's test of symmetry.

RESULTS

Disagreement on recurrence between the initial report and the second-opinion interpretation was observed in 32% of cases (22/69; k = 0.44). Second-opinion interpretations had a higher sensitivity and a higher specificity on recurrence compared to the initial interpretations (0.93 vs. 0.75 and 0.90 vs. 0.68, respectively), and the difference in specificity was significant (p = 0.016). Additional imaging studies were recommended more frequently in the initial interpretation (22% vs. 6%, p = 0.006).

CONCLUSIONS

Our study shows the second-opinion interpretation by subspecialized radiologists improves the detection of pancreatic cancer recurrence after surgical resection.

Global Challenges for Cancer Imaging

Imaging plays many essential roles in nearly all aspects of high-quality cancer care. However, challenges to the delivery of optimal cancer imaging in both developing and advanced countries are manifold. Developing countries typically face dramatic shortages of both imaging equipment and general radiologists, and efforts to improve cancer imaging in these countries are often complicated by poor infrastructure, cultural barriers, and other obstacles. In advanced countries, on the other hand, although imaging equipment and general radiologists are typically accessible, the complexity of oncologic imaging and the need for subspecialists in the field are largely unrecognized; as a result, training opportunities are lacking, and there is a shortage of radiologists with the necessary subspecialty expertise to provide optimal cancer care and participate in advanced clinical research. This article is intended to raise awareness of these challenges and catalyze further efforts to address them. Some promising strategies and ongoing efforts are reviewed, and some specific actions are proposed.

Does Second Reader Opinion Affect Patient Management in Pancreatic Ductal Adenocarcinoma?

RATIONALE AND OBJECTIVES

To determine the impact of second-opinion assessment on cancer staging and patient management in patients with pancreatic ductal adenocarcinoma.

METHODS AND MATERIALS

This retrospective study was approved by our institutional review board with a waiver of informed consent. Second-opinion reports between January 1, 2009 and December 31, 2013, alongside outside reports for 65 consecutive cases of biopsy-proven pancreatic adenocarcinomas, were presented in random order to two experienced abdominal surgeons who independently reviewed them blinded to the origin of the report, images of the examinations, and patient identifier. Each surgeon filled in a questionnaire for each report recommending cancer staging and patient management. Recommended patient management and staging were evaluated against reference standards (actual patient management at 6 months following second-opinion assessment, and pathology or other clinical and imaging reference standards at 6 months or longer, respectively) using Cohen kappa.

RESULTS

Cancer staging differed in 13% (9 of 65) of cases for surgeon 1 and in 18.4% (12 of 65) for surgeon 2. Patient management changed in 38.4% (25 of 65) of cases for surgeon 1 and in 20% (13 of 65) for surgeon 2. When compared to the pathologic staging gold standard, second opinion was correct in 85.7% (six of seven) of the time for both surgeons. Recommended patient management from second-opinion reports showed good agreement with the reference standard (weighted k = 0.6467 [0.4014-0.892] and weighted k = 0.6262 [0.3954-0.857] for surgeon 2).

CONCLUSION

Second-opinion review by subspecialized oncologic radiologists can impact patient care, specifically in terms of management decision.

Second opinion interpretation of breast ultrasound images-Is it worth another look?

PURPOSE

To determine if real-time breast ultrasound (RTUR) after second opinion reinterpretation of submitted static ultrasound images at a comprehensive cancer center impacts clinical management, specifically by detecting additional cancer and preventing unnecessary biopsy.

MATERIALS AND METHODS

In this IRB-approved and HIPAA-compliant retrospective study, 209 patients were included who had breast ultrasound studies from outside facilities submitted for second opinion review between January 2013 and May 2014, and who subsequently underwent RTUR at our institution within three months of the outside study. Findings on submitted exams were compared with those on RTUR and disagreements between them were annotated to indicate the presence or absence of suspicious lesions and recommendation for biopsy. Changes in management were defined as any additional biopsies performed or biopsies averted after RTUR and reported as frequencies and percentages using 95% confidence intervals.

RESULTS

Following RTUR, 49 additional biopsies were performed in 43/209 patients (20.6%; 95% CI 15.1-26.1%). Additional cancer was found in 12/49 (24.5%) biopsies in 11/209 patients (5.3%; 95% CI 2.2-8.2%). Forty biopsies in 31/209 (14.8%; CI 10.0-19.7%) patients originally recommended were canceled after RTUR. Overall, a change in management after RTUR was observed in 68/209 patients (32.5%; 95% CI 26.1-38.9%), including patients with either additional biopsies performed or biopsies averted.

CONCLUSION

RTUR was found to be an important tool in the management of patients at our comprehensive cancer center. Although additional false-positive lesions may be detected on RTUR, a great number of patients will benefit from RTUR in finding additional cancers or avoiding unnecessary biopsies.

Specialized second-opinion radiology review of PET/CT examinations for patients with diffuse large B-cell lymphoma impacts patient care and management

To identify discrepancies in fludeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) reports generated by general radiologists and subspecialized oncological radiologists for patients with diffuse large B-cell lymphoma (DLBCL), and to assess if such discrepancies impact patient management.Two radiologists retrospectively reviewed 72 PET/CT scans of patients with DLBCL referred to our institutions between 2009 and 2011, and recorded the discrepancies between the outside and second-opinion reports regarding multiple preset criteria using kappa statistic (Κ), including the disease stage. A multidisciplinary staging that considered all patient clinical data, pathology, and follow up radiological scans, was considered as standard of reference. A hemato-oncologist, blinded to the reports' origin, subjectively graded the quality and structure of these reports for each patient to determine if clinical stage and disease activity could be derived accurately from these reports.Agreement was not, or slightly, achieved between the reports regarding the binary and multilevel criteria (Κ < 0-0.2 and weighted Κ = 0.082, respectively). Second-opinion reviews of PET/CT scans were concordant with the multidisciplinary staging in 78% of cases with an almost perfect agreement (Κ = 0.860). A change in staging was demonstrated in 36% of cases. In addition, 68% of second-opinion reports were assigned the highest grades on quality (grades 4 and 5) by the hemato-oncologist, compared with 15% of outside reports, with no noted agreement (weighted Κ = -0.007).Second-opinion review of PET/CT scans by sub-specialized oncological radiologists increases accuracy of initial staging, posttreatment evaluation and also the clinical relevance of the radiology reports.