Implementation of template-based reporting for rectal cancer

In the July 2024 issue of Acta Radiologica Open, Dr. Alvfeldt from Karolinska, Stockholm, assessed adherence to the national radiology reporting template for rectal cancer staging. The study evaluated the impact of this template by comparing and analyzing differences in content and completeness of magnetic resonance imaging (MRI) reports between 2010 and 2016 (1). MRI is routinely used to stratify patients into low-, intermediate-, and high-risk groups based on key factors such as tumor (T) stage, nodal (N) stage, and mesorectal fascia involvement. Guidelines advocate the use of structured reporting templates to reduce the variability of reporting and optimize treatment decisions, with missing information potentially influencing disease-free survival (2,3). MRI reports from 10 hospitals in four Swedish regions were collected. The study protocol was approved by the Swedish Ethical Review Authority. A total of 467 reports from 2010 and 567 reports from 2016 were analyzed for 18 tumor-specific categories. The completeness of unstructured reports increased from 48% in 2010 to 64% in 2016. Structured reports in 2016, using the national reporting template, achieved a relative completeness of 93%.

Significantly, the reporting of extramural depth of invasion increased from 23% in 2010 to 80% in 2016. Information on the presence or absence of mucinous tumor content improved from 10% in older reports to 100% in new template reports. Reporting of extramural vascular invasion (EMVI) rose from 19% in 2010 to 100% in structured reports (1). A comparative study from Yorkshire, UK, found that EMVI status was included in 52% of prose reports versus 99% in template MRI reports from 2016 (4).

EMVI is recognized as an independent poor prognostic factor that should be considered during baseline staging and risk stratification. It involves the spread of malignant cells beyond the rectal wall into adjacent perirectal blood vessels and is a critical risk factor for local recurrence, distant metastasis, and decreased overall survival. Targeted training is necessary to assist inexperienced radiologists in acquiring adequate experience in MRI EMVI evaluation for rectal cancer (5).

Diffusion-weighted imaging has shown high specificity and moderate sensitivity in assessing EMVI and tumor deposits in patients with locally advanced rectal cancer after neoadjuvant therapy (6). A recent study demonstrated that a deep learning-based tumor segmentation model on primary MRI enhances EMVI classification results (7).

Template descriptions not only enhance the completeness of MRI assessments for rectal cancer but also influence the computed tomography staging of colon cancer (8). In a Danish survey, referring physicians preferred template reports over prose descriptions (9). In the UK, only 32% of radiologists used templates reporting rectal cancer. Further research should evaluate the professional barriers preventing adoption of consensus guidance in routine clinical practice (10). I concur with the final statement by Alvfeldt et al., that implementing template-based reporting is essential for adhering to evidence-based practices (1). Patients with rectal cancer are preoperatively reviewed by a certified interdisciplinary tumor board of the medical center where the therapy will be carried out. This of course includes a reassessment of imaging material by a specialized radiologist. Therefore, an incomplete report is corrected or completed in its relevant parts at the time of therapy decision-making.