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Upper GI Malignancies Imaging Guidelines for

the Management of Gastric, Oesophageal & Pancreatic Cancers

2012

| Upper GI CEG Imaging Guidelines Version 1.4 June 2012

Version Control

This is a controlled document please destroy all previous versions on receipt of a new version.

Date Approved: June 2012 Review Date: June 2014

Version Date Issued Review Date Brief Summary of Change Owner’s Name

Draft 1.1

October 2008 May 2009 Original guideline Network Imaging Group

Draft 1.2

May 2009 November 2009

Update formatting, bring into updated Network Guidelines

Network Imaging Group

1.2 November 2009

October 2010 Added Liver / Gallbladder sections

Network Imaging Group

1.3 October 2010 June 2012 Reviewed with guidelines – no changes

Upper GI NSSG

1.4 June 2012 With Network Guidelines

Reviewed with Network Guidelines October – February 2012

Upper GI CEG

For the latest version of these guidelines please see the NEYHCA (Cancer) website Please press control and click on the link below:

www.hyccn.nhs.uk/NetworkGuidelinesAndPublications/NetworkImagingGroup.htm

Signature Sheet Agreement of the NEYHCA (Cancer) Upper GI CEG Imaging Guidelines

These guidelines have been agreed by:

Title Name Date Agreed

Chair of the Upper GI CEG Dr Sam Khulusi 15.6.12

Mr Prashant Jain 15.6.12 Mr Kevin Wedgwood 15.6.12 Mr Mike Tilston 15.6.12

MDT Leads

Dr Mohan Hingorani 15.6.12 Chair of the NEYHCA (Cancer) Imaging Clinical Expert Group

Dr Ged Avery 15.6.12

Chair, NEYHCA Board / NEYHCA Cancer Management Group

Mrs Allison Cooke 5.7.12

The Upper GI CEG have agreed these guidelines 5.6.12

Upper GI CEG Imaging Guidelines Version 1.4 June 2012 |

Contents

Version Control ............................................................................................................................................. 2 Signature Sheet ............................................................................................................................................. 2 Contents......................................................................................................................................................... 3

1. Introduction ................................................................................................................................... 4

2. Oesophagus ................................................................................................................................... 4

2.1 Staging of oesophageal cancer (including GOJ tumours) ........................................................................ 4 2.1.1 CT scan protocol ................................................................................................................................... 5 2.1.2 Endoscopic Ultrasound ........................................................................................................................ 5 2.1.3 PET-CT ................................................................................................................................................... 5 2.1.4 Laparoscopy.......................................................................................................................................... 5

2.2 Initial Management..................................................................................................................................... 5 2.3 Restaging ..................................................................................................................................................... 5 2.4 High grade dysplasia in Barrett’s oesophagitis ......................................................................................... 5 2.5 Follow up ..................................................................................................................................................... 5

3. Stomach ......................................................................................................................................... 6

3.1 Staging of gastric cancer............................................................................................................................. 6 3.1.1 CT scan protocol ................................................................................................................................... 6 3.1.2 Laparoscopy.......................................................................................................................................... 6

3.2 Re-staging .................................................................................................................................................... 6 3.3 Follow up ..................................................................................................................................................... 6 3.4 GIST tumours................................................................................................................................................ 7

4. Pancreas ......................................................................................................................................... 7

4.1 Staging of pancreatic cancer ...................................................................................................................... 7 4.1.1 CT scan protocol ................................................................................................................................... 7 4.1.2 Endoscopic ultrasound......................................................................................................................... 7 4.1.3 MRI ........................................................................................................................................................ 8 4.1.4 PET-CT ................................................................................................................................................... 8

4.2 Follow up ..................................................................................................................................................... 8

5. Liver................................................................................................................................................ 8

5.1 Staging of malignant liver lesions.............................................................................................................. 8 5.1.1 CT scan protocol ................................................................................................................................... 8 5.1.2 MRI scan ................................................................................................................................................ 9 5.1.3 PET – CT................................................................................................................................................. 9

5.2 Follow up ..................................................................................................................................................... 9

6. Gallbladder..................................................................................................................................... 9

6.1 Staging of gallbladder carcinoma .............................................................................................................. 9 6.1.1 CT scan protocol ................................................................................................................................... 9 6.1.2 MRI scan ................................................................................................................................................ 9 6.1.3 PET-CT ................................................................................................................................................... 9

6.2 Follow up ..................................................................................................................................................... 9


1. Introduction ‘A Guideline is not a rigid constraint upon clinical practice, but a concept of good practice against which the requirements of the individual patient can be considered’. (RCR, 1990). It therefore remains the responsibility of the practising Clinicians to interpret the application of guidelines, taking into account local service constraints and the needs and wishes of the patients. This Guidance is based on the recommendations contained in

1. A Policy Framework for Commissioning Cancer Services: Calman Hine Report – published April 1995.

2. The Royal College of Radiologists – Recommendations for Cross-Sectional Imaging in

Cancer Management, Issue 2 – published August 2006. It is not intended to be prescriptive nor exhaustive, but a guide towards best practice. Imaging protocols may vary depending on local circumstances, and the quality of the imaging service should be supported by regular audit and by attendance at multidisciplinary meetings. Services should be planned to minimise travelling times whilst maintaining the highest standards of specialist care using local expertise and agreed protocols (Calman Hine report, paragraph 4.1.4). Patients should be scanned locally where there is suitable equipment and expertise. All clinical trials should be approved at the Upper GI CEG and if a patient is within a clinical trial which requires a change to the routine performance of the investigation or the scan to be reported against specific criteria it is the responsibility of the clinician leading the trial to discuss and agree the scanning protocols (including frequency, techniques, coverage and reporting) with the appropriate department prior to the trial commencing.

2. Oesophagus The diagnosis of oesophageal cancer is essentially made at endoscopy and confirmed by histology. If malignancy is suspected by other imaging modalities such as barium studies, this needs to be confirmed by endoscopy and histology.

2.1 Staging of oesophageal cancer (including GOJ tumours) The initial modality of staging is with CT scan to assess local disease and distant metastases. Local staging of oesophageal cancer is done by endoscopic ultrasound on patients who have resectable non-metastatic disease on CT. PET-CT scan is used as an adjunct for primary staging to assess for metastatic disease in patients considered for curative surgery.


2.1.1 CT scan protocol

CT of the thorax, abdomen and pelvis is performed. For tumours of the upper oesophagus, the neck is also included.

• Oral administration of 1 litre of water or diluted iodinated contrast medium with 400ml to be drunk immediately before going on the scanner to ensure maximum oesophago-gastric distension.

• 100 -150ml of intravenous iodinated contrast medium injected at 3-4ml/sec. • MDCT is commenced at 20-25sec (neck where applicable and chest) and 60-80seconds

(abdomen and pelvis). • Slice thickness are acquired and reformatted at 1.25-2.5mm.

2.1.2 Endoscopic Ultrasound

All patients deemed fit for surgery and with no evidence of metastatic disease should undergo endoscopic ultrasound for local staging.

2.1.3 PET-CT

All patients deemed fit for surgery and with no metastatic disease on CT or endoscopic ultrasound should undergo PET / CT for distant staging.

2.1.4 Laparoscopy

Patients who have a significant gastric component should be considered for laparoscopy to exclude omental / peritoneal disease.

2.2 Initial Management The majority of patients receive neo-adjuvant chemotherapy / radiotherapy followed by surgery.

2.3 Restaging Restaging by CT and endoscopic ultrasound is performed to assess response to neoadjuvant therapy and to ensure lack of progression.

2.4 High grade dysplasia in Barrett’s oesophagitis All patients considered for surgery should undergo similar initial staging with CT and endoscopic ultrasound. PET-CT not considered useful in this setting. The majority of patients undergo surgery as primary treatment.

2.5 Follow up Routine imaging is not considered essential following surgical resection. If resection is complete and no further treatment is considered necessary, then routine follow up imaging is not essential. Further follow up imaging is considered only if there is clinical suspicion of recurrence. If there is incomplete resection (R1) and further treatment is planned, then a baseline CT scan prior to commencement of chemotherapy/radiotherapy may be useful.


If palliative chemotherapy / radiotherapy is considered due to locally advanced or metastatic disease, follow up is performed by CT scan at a frequency corresponding to the chemotherapy regime which is decided at the MDT. Patients who have radical Chemo/Radiotherapy should be considered for a repeat EUS +/- biopsy at 3 to 6 months post treatment. These patients need to be discussed at the MDT. CT scan is not considered useful in this circumstance for assessment of complete response.

3. Stomach The diagnosis of stomach cancer is essentially made at endoscopy and confirmed by histology. If malignancy is suspected by other imaging modalities such as barium studies, this needs to be confirmed by endoscopy and histology.

3.1 Staging of gastric cancer The initial modality of staging is with CT scan to assess local disease and distant metastases. Local staging of primary gastric cancer by Endoscopic ultrasound is not considered essential. PET-CT scan is not considered useful in this setting.


CT of the thorax, abdomen and pelvis is performed.

• Oral administration of 1 litre of water or diluted iodinated contrast medium with 400ml to be drunk immediately before going on the scanner to ensure maximum gastric distension.

• 100 -150ml of intravenous iodinated contrast medium injected at 3-4ml/sec. • MDCT is commenced at 20-25sec (chest) and 60-80seconds (abdomen and pelvis). • Slice thickness are acquired at 1.25-2.5mm.

3.1.2 Laparoscopy

Patients who have do not have metastatic disease on CT should have laparoscopy to detect subtle peritoneal disease.

3.2 Re-staging Patients who receive neo-adjuvant chemotherapy need a follow up CT scan prior to surgery.

3.3 Follow up Routine imaging is not considered essential following surgical resection. If resection is complete and no further treatment is considered necessary, then routine follow up imaging is not essential. Further follow up imaging is considered only if there is clinical suspicion of recurrence. If there is incomplete resection (R1) and further treatment is planned, then a baseline CT scan prior to commencement of chemotherapy / radiotherapy may be useful. If palliative chemotherapy / radiotherapy is considered due to locally advanced or metastatic disease, follow up is performed by CT scan at a frequency corresponding to the chemotherapy regime which is decided at the MDT.


Patients who have radical Chemotherapy / Radiotherapy should be considered for a repeat EUS +/- biopsy at 3 to 6 months post treatment. These patients need to be discussed at the MDT. CT scan is not considered useful in this circumstance for assessment of complete response.

3.4 GIST tumours It is considered essential to perform EUS and biopsy (preferably tru-cut biopsy) to confirm sub-mucosal gastric tumours prior to surgical removal. MDT discussion is necessary. PET/CT Scan is considered as a baseline scan if decision to treat with Glivec is made at the MDT.

4. Pancreas Ductal adenocarcinoma is the commonest type of carcinoma. Although ampullary and distal common duct carcinomas have different pathological staging, the staging workup and therapeutic options are similar.

4.1 Staging of pancreatic cancer Patients often present late with locally advanced disease. CT scan is the primary modality for initial staging. If pancreatic neoplasm is suspected, either clinically or as a consequence of prior investigation including ultrasound and / or tumour markers, a dedicated staging CT should be performed. If pancreatic neoplasm is detected / suspected on CT undertaken as a survey abdominal scan, a recall for dedicated CT is often not essential.


CT of the thorax, abdomen and pelvis is performed. This should be ideally done without prior stenting of bile ducts which may preclude accurate staging.

• Oral administration of 1 litre of water as a contrast agent. • 100 -150ml of intravenous iodinated contrast medium injected at 3-4ml/sec. • MDCT is commenced at 35-40sec (pancreatic phase) and 60-80seconds (portal venous

phase). • Slice thickness are acquired at 1-1.25mm in the pancreatic phase and 2mm in the portal

venous phase.

• Although CT of chest is not considered essential, this may be necessary for patients with unresectable cancers undergoing chemotherapy or who can be enrolled in a study. CT scan of the chest can be performed at 20-25sec as part of the initial staging scan or can be performed separately if considered necessary (in the latter case a non-contrast study may be sufficient).

4.1.2 Endoscopic ultrasound

All patients considered fit for surgery and without metastatic disease on CT scan should have endoscopic ultrasound to assess local staging and resectability. This should be ideally done prior to decompression of the biliary system. Endoscopic ultrasound guided biopsy is also considered essential to confirm diagnosis in unresectable tumours.


4.1.3 MRI

May be useful for problem-solving in patients suspected to have liver metastasis or for further clarification of pancreatico-biliary anatomy. MRI as a primary modality of diagnosis/ staging is not considered to be a good technique at present.

4.1.4 PET-CT

This has not been shown to be value in staging of pancreatic cancer and may be considered in selective cases after discussion at the specialist MDT.

4.2 Follow up

CT scan at 3 months following surgery is recommended as a baseline for further assessment. Further follow up imaging is considered only if there is clinical suspicion of recurrence. If there is incomplete resection (R1) and further treatment is planned, then a baseline CT scan prior to commencement of chemotherapy may be useful. If palliative chemotherapy / radiotherapy is considered due to locally advanced or metastatic disease, follow up is performed by CT scan at a frequency corresponding to the chemotherapy regime after MDT decision.

5. Liver Liver metastases is the commonest form of liver disease in the UK. Benign liver lesions are frequently present and it is important to differentiate between benign and malignant lesions. This can be done by ultrasound, contrast ultrasound, CT or MRI. PET-CT can also be used in selective cases. HCC (hepato-cellular carcinomas) is the commonest primary malignant liver tumour although it represents only 1% of all liver tumours. It often occurs in a background of cirrhosis.

5.1 Staging of malignant liver lesions

Primary and secondary malignant lesions are staged in a similar manner. The primary modality of staging is by CT scan.


CT of the thorax, abdomen and pelvis is performed.

• Oral administration of 1 litre of water or diluted iodinated contrast medium is used. • 100 -150ml of intravenous iodinated contrast medium injected at 3-4ml/sec. • MDCT is commenced at 20-25sec (chest) and 60-80seconds (abdomen and pelvis) • Slice thickness are acquired at 1.25-2.5mm. • If possible the liver should be imaged at late arterial phase at 30-35sec or as part of the

arterial phase imaging of the chest.


5.1.2 MRI scan

If liver is the only site of metastasis and liver resection or ablative therapy is considered, then further imaging with MRI is essential. This should be performed with Gadolinium based contrast agent. Liver specific contrast agents may also be used to improve detection of lesions.

5.1.3 PET – CT

PET-CT if available is considered essential if liver resection is planned to exclude extra-hepatic metastasis.

5.2 Follow up

Follow up is done predominantly with CT scan following resection, ablative therapy or chemotherapy. MRI can be considered if lesions are difficult to visualise on CT scan. Follow up is initially at 3 months interval.

6. Gallbladder Gallbladder carcinoma is rare and most are found incidentally following cholecystectomy for benign disease. These tend to be early cancers and if organ confined and no nodal spread may not need further imaging. Gallbladder carcinomas identified by imaging either by ultrasound or CT scan have a propensity to invade adjacent liver and so carry a poor prognosis.

6.1 Staging of gallbladder carcinoma

Gallbladder carcinomas are initially staged by CT scan.


A similar protocol to staging of malignant liver lesion is followed.

6.1.2 MRI scan

If the tumour is not organ confined and invades the liver with no evidence of distant metastasis and liver resection is considered, then an MRI scan with contrast is considered essential.

6.1.3 PET-CT

If liver resection is considered, then a PET-CT scan is useful to assess for extra-hepatic spread.

6.2 Follow up Incidental organ confined gallbladder tumours without nodal spread do not necessitate follow up. If follow up is considered due to nodal spread or further treatment by chemotherapy, then this is done by CT scan.

neyhca cancer upper gi imaging guidelines june … docs/neyhca cancer...cancer management group mrs...

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