Abstract
BACKGROUND:
Imaging reports that consistently document all disease sites with potential to increase surgical complexity or morbidity can facilitate ovarian cancer treatment planning.
OBJECTIVES:
To compare simple structured reports and synoptic reports for pre-treatment CT examinations in patients with advanced ovarian cancer in terms of completeness of documenting involvement of clinically relevant anatomic sites and to evaluate physician satisfaction with synoptic reports.
METHODS:
This retrospective study included 205 patients (median age, 65 years) who underwent contrast-enhanced abdominopelvic CT before primary treatment for advanced ovarian cancer from June 1, 2018 to January 31, 2022. A total of 128 reports generated on or before March 31, 2020 used a simple structured report (free text organized into sections); 77 reports generated on or after April 1, 2020 used a synoptic report (list of 45 anatomic sites relevant to ovarian cancer management, each classified in terms of disease absence versus presence). Reports were reviewed for completeness of documentation of involvement of the 45 sites. In patients who underwent neoadjuvant chemotherapy based on diagnostic laparoscopy findings or who underwent primary debulking surgery with suboptimal resection, EMR was reviewed to identify surgically established sites of unresectable or challenging-to-resect disease. Gynecologic oncology surgeons were electronically surveyed.
RESULTS:
Mean report turnaround time was 29.8 minutes for simple structured reports versus 54.5 minutes for synoptic reports (p<.001). Mean of 17.6/45 sites (range, 4 – 43) were mentioned by simple structured reports, versus 44.5/45 sites (range, 39 – 45) for synoptic reports (p<.001). Forty-three patients had surgically established unresectable or challenging-to-resect disease; involvement of anatomic site(s) with such disease was mentioned in 37% (11/30) of simple structured reports versus in 100% (13/13) of synoptic reports (p<.001). All eight surveyed gynecologic oncology surgeons completed the survey.
CONCLUSION:
A synoptic report improved completeness of pre-treatment CT reports in patients with advanced ovarian cancer, including for established sites of unresectable or challenging-to-resect disease.
CLINICAL IMPACT:
The findings indicate the role of disease-specific synoptic reports to facilitate referrer communication and potentially guide clinical decision-making.
Keywords: ovarian cancer, computed tomography, free-text reports, synoptic reporting, standardized lexicon
INTRODUCTION
Ovarian cancer is the fifth most common cause of cancer death among women in the United States [1]. Absence of early-stage symptoms and rapid peritoneal dissemination result in a high rate of widespread disease at presentation [2, 3]. The traditional first-line treatment for advanced ovarian cancer is primary debulking surgery [4, 5] with the goal of removing all visible and palpable tumors (i.e., complete resection) [6–8]. If complete resection is not feasible, then optimal resection (i.e., resection that leaves residual disease measuring ≤1 cm) is pursued [6–9]. Debulking that leaves residual disease measuring >1 cm (i.e., suboptimal resection or futile laparotomy) should be avoided because of high morbidity and lack of survival benefit [6–8].
Neoadjuvant chemotherapy followed by interval debulking surgery is a potential alternative to upfront surgery. Neoadjuvant chemotherapy can decrease tumor burden, in turn increasing the complete resection rate and reducing surgical morbidity [10–14]. The criteria for selecting between primary debulking surgery versus neoadjuvant chemotherapy followed by interval debulking surgery are under investigation [15]. At present, the NCCN and the European Society of Surgical Oncology recommend primary debulking surgery if complete or optimal resection is deemed feasible based on imaging and/or diagnostic laparoscopy [4, 5]. If primary debulking surgery is not feasible due to the presence of difficult-to-resect or unresectable disease, then neoadjuvant chemotherapy followed by interval debulking surgery is performed [4, 5].
CT is the current standard-of-care imaging test to determine tumor extent in patients with ovarian cancer. An accurate imaging report is essential to guide clinical decision-making in these patients. Imaging reports that consistently document all disease sites with the potential to increase surgical complexity or morbidity can facilitate treatment selection and planning [9].
Traditional free-text radiology reports frequently omit key findings relevant to the examination indication and thus may be insufficient as a communication tool [16, 17]. Report templates with pre-defined sections remind the radiologist to comment on specific areas and make it easier for referring physicians to locate these findings in a report. Nonetheless, when using such reports, radiologists may still omit relevant findings within the pre-defined sections, use variable language across the practice, or use expressions that are ambiguous to the referring physician. Due to comparable issues, pathologists have adopted disease-specific checklist-based reporting, whereby reports contain tailored common data elements that link relevant questions with a list of pre-defined answer choices [18]. The data collected through these checklists can be converted to human-friendly reports that standardize communication. Such reports that use pre-defined response options have been described as synoptic reports [19, 20].
Professional societies have developed multiple standardized radiology reporting lexicons [21–24]. In 2022, the Society of Abdominal Radiology (SAR) Uterine and Ovarian Cancer Disease-Focused Panel and the European Society of Urogenital Radiology (ESUR) Female Pelvic Imaging Working Group published a joint standardized lexicon for CT and MRI reporting in patients with ovarian cancer (hereafter, the SAR/ESUR lexicon) [25]. However, limited data have systematically evaluated the role of synoptic reports using a standardized lexicon in patients with ovarian cancer [26].
This study’s aim was to compare simple structured reports and synoptic reports for pre-treatment CT examinations in patients with suspected advanced ovarian cancer in terms of the completeness of documenting involvement of clinically relevant anatomic sites, with attention to unresectable or challenging-to-resect sites of established disease, and to evaluate physician satisfaction with synoptic reports.
METHODS
Study Setting and Development of Synoptic Report
The institutional review board approved this HIPAA-compliant study and waived the requirement for written informed consent. The study was conducted at Memorial Sloan Kettering Cancer Center. The members of Memorial Sloan Kettering Cancer Center Team Ovary are listed in Appendix 1.
At the study institution, CT examinations ordered by ovarian cancer-focused gynecologic oncologic surgeons who are members of a gynecologic oncology multidisciplinary disease management team (DMT) were historically interpreted using a simple structured report template (i.e., free text organized into sections based on organ systems), as described by Schwartz et al. [16]. On April 1, 2020, an ovarian-cancer synoptic report was introduced for clinical use. The report was developed by radiologist members of the DMT in consultation with the gynecologic oncologic surgeons. The synoptic report included a comprehensive list of 45 anatomic sites relevant to ovarian cancer management, organized into sections and subsections (eight involving the liver; six involving the spleen; 15 involving abdominopelvic lymph nodes; two involving pelvic organs; eleven involving the peritoneum, mesentery, and bowel; one involving the abdominal wall; and two involving the pleura) (Appendix 2). For each site, the report included two pre-defined options for describing disease involvement (“absent” and “present”); the report also included a field for optional free-text description for each site. The report was initially modeled on the SAR/ESUR Ovarian Cancer Lexicon [25], but was then modified based on input from the gynecologic oncologic surgeons by incorporating disease sites relevant to institutional protocols for determining surgical resectability, primary treatment selection, and surgical planning (which in turn was informed by results of prior studies [27–30]). Before the synoptic report was implemented clinically, one investigator (I.N., a radiologist with 6 years of post-training experience) gave a presentation to the radiologist DMT members. This presentation reviewed the synoptic report’s sections, subsections, anatomic sites, and response. It also included images showing examples of disease in the various anatomic sites mentioned in the synoptic report [9]. After the implementation, the synoptic report was used when requested at the time of CT order entry by the referring physician from the DMT. Use of the synoptic report was requested in patients in whom advanced ovarian cancer was suspected.
Patients
The EMR was searched for consecutive patients ≥18 years old who underwent primary treatment at the study institution for known or suspected advanced ovarian cancer, and who underwent pre-treatment abdominopelvic CT with IV contrast media at the study institution from June 1, 2018 to January 31, 2022. This search yielded 290 patients. Patients were then excluded for the following reasons: non-surgical candidate (n=18); treatment by an approach other than debulking surgery due to presence of early-stage disease (n = 5); and benign or borderline ovarian tumor, or non-ovarian primary neoplasm (n = 62). The final exclusion was incorporated due to distinct treatment paradigms for such entities in comparison with treatment for advanced ovarian cancer. These exclusions resulted in a final sample of 205 patients (median age, 65 years; IQR=57–72 years; all women). Patients were divided into two groups based on the type of pre-treatment CT report (i.e., simple structured report vs synoptic report). The pre-treatment CT was reported using a simple structured report from June 1, 2018 to March 31, 2020 in 128 patients, and using a synoptic report from April 1, 2020 to January 31, 2022 in 77 patients. Figure 1 shows the flow of patient selection.
Figure 1:
Flowchart of patient selection for study.
EMR Review
The EMR was manually reviewed to record a range of characteristics for each patient, including age, serum CA-125 level, histopathologic diagnosis, stage, primary treatment approach (primary debulking surgery or neoadjuvant chemotherapy-interval debulking surgery), and whether diagnostic laparoscopy was performed during initial workup. The decision of whether to perform diagnostic laparoscopy was at the surgeon’s discretion regarding the need to assess whether attempted complete or optimal resection would be feasible. In addition, in patients who underwent primary debulking surgery (rather than neoadjuvant chemotherapy-interval debulking surgery), the cytoreductive outcome was determined, based on the size of residual disease as assessed by the surgeon at the end of laparotomy. Residual disease measuring >1 cm was considered to indicate suboptimal resection, residual disease measuring 0.1–1.0 cm was considered to indicate optimal resection, and an absence of visible or palpable residual disease was considered to indicate complete resection [6–8]. Patients who underwent neoadjuvant chemotherapy-interval debulking surgery (i.e., patients in whom complete or optimal resection was considered not feasible based on results of diagnostic laparoscopy during initial workup), as well as patients who had suboptimal resection at primary debulking surgery, were considered to have unresectable or challenging-to-resect disease. The EMR was reviewed for patients with unresectable or challenging-to-resect disease to identify the diseased anatomic sites(s) that were deemed to either preclude resection at diagnostic laparoscopy (and therefore require neoadjuvant chemotherapy) or to result in suboptimal resection at primary debulking surgery.
CT Reports
The CT examinations ordered by surgeon members of the gynecologic oncology multidisciplinary DMT were historically interpreted preferentially (but not exclusively) by the team’s radiologist members. On May 15, 2020, the departmental workflow was updated whereby imaging studies ordered by clinicians from any DMT were assigned for reporting exclusively to radiologist members of that particular DMT. Thus, beginning on that date, the CT examinations were interpreted exclusively by radiologist members of the gynecologic oncology multidisciplinary DMT.
The simple structured reports were generated by one of 34 fellowship-trained oncologic abdominal radiologists (3–30 years of post-training experience). The synoptic reports were generated by one of 14 fellowship-trained oncologic abdominal radiologists (3–30 years of post-training experience). Thirteen radiologists participated in generation of both sets of reports. The differences in the number of radiologists between these two groups related to the presence of radiologists who left or joined the institution between the two periods, as well as to the previously noted interval change in departmental workflow for interpretation of imaging examinations ordered by clinicians from a DMT. All reports (both simple structured reports and synoptic reports) were generated as part of routine clinical care using a commercially available speech recognition dictation system [PowerScribe (Nuance Technology, Burlington, MA)]. For each report, the reporting time was computed as the difference between the report completion time and report creation time. These times were extracted from the dictation system using automated software (mPower Clinical Analytics, Nuance Technology).
CT Report Analysis
Each simple structured report and synoptic report was reviewed by one of three fellowship-trained radiologists [PCA with 3 years, IN with 6 years, and YL with 15 years, respectively of post-training experience in oncologic body imaging (70, 67, and 68 reports reviewed, respectively)], who all participated in the generation of the clinical reports during both periods. The allocation of individual reports to the three radiologists for review was random. The radiologist recorded whether the report documented the presence or absence of disease in each of the 45 anatomic sites described in the synoptic report. When the radiologist was uncertain regarding whether the report mentioned the presence of disease at a particular site in a given report, the radiologist presented the report to all three radiologists, to discuss the case and reach consensus. For each report, the number and percentage of the 45 anatomic sites for which the presence versus absence of disease was mentioned was determined (with the percentage hereafter described as the overall documentation rate). Following completion of that process, in patients with unresectable or challenging-to-resect disease (i.e., patients who underwent diagnostic laparoscopy resulting in decision to administer neoadjuvant chemotherapy, or who underwent primary debulking surgery with suboptimal resection), one of the three previously noted radiologists (PCA) re-reviewed the pre-treatment CT report to determine if the report mentioned the presence of disease in the anatomic site(s) precluding resection based on findings from diagnostic laparoscopy or resulting in suboptimal resection at primary debulking surgery. In patients with multiple sites of unresectable or difficult-to-resect disease, this assessment required the pre-treatment CT report to mention all such sites. Uncertainty during this additional review was also discussed by the three radiologists to reach consensus. The images were not reviewed during any of these steps.
Referring Physician and Radiologist Surveys
An electronic survey was conducted of all eight ovarian cancer-focused gynecologic oncology surgeons (range, 3–26 years of post-training experience) who were members of the gynecologic oncology DMT at the institution at the time of survey administration. This survey assessed satisfaction with the ovarian-cancer synoptic report as a clinical decision-support tool. A survey was also conducted of all eleven radiologist members of the gynecologic oncology DMT (range, 3–30 years of post-training experience) who interpreted pre-treatment CT scans in patients with suspected advanced ovarian cancer at the institution at the time of survey administration. This survey assessed the perceived impact of the synoptic report on daily workload. Both surveys were designed based on prior surveys evaluating structured radiology reports [31, 32]. Each survey included four yes/no questions and also allowed the respondent to provide free-text comments on the topic. The surveys were conducted using web-based software (SurveyMonkey). The surveys were first distributed on August 1, 2021; a single reminder was sent.
Statistical Analysis
Patient age and serum CA-125 level were compared between patients whose CT examinations were interpreted using simple structured reports and synoptic reports using the Wilcoxon rank sum test. Other clinical characteristics were compared between the two groups using the Fisher’s exact test. The mean report turnaround time was compared between the two groups using a 2-sample t test. The mean number of anatomic sites for which the presence versus absence of disease was documented was compared between the two groups using the Wilcoxon rank sum test. The mean overall documentation rate was also computed for each group. The frequency with which reports documented disease involvement for each of the 45 anatomic sites was compared between the two groups using Fisher’s exact test, with adjustment of p values for multiple comparisons using the false-discovery rate [33]. The frequency with which reports mentioned involvement of established sites of unresectable or difficult-to-resect disease was compared between groups using Fisher’s exact test. The survey results were summarized descriptively. A p value of < .05 was considered statistically significant. Analysis was performed using R statistical software (R Foundation for Statistical Computing, version 4.2.1; June 2022).
RESULTS
Patient Sample
Patients’ clinical characteristics are summarized in Table 1. A total of 89% (182/205) of patients had high-grade serous ovarian cancer. A total of 60% (122/205) of patients were managed with primary debulking surgery, and 40% (83/205) were managed with neoadjuvant chemotherapy-interval debulking surgery. A total of 30% (61/205) of patients underwent diagnostic laparoscopy during initial workup. Of patients who underwent primary debulking surgery, 94% (115/122) had complete or optimal resection, and 6% (7/122) had suboptimal resection.
TABLE 1:
Patient characteristics and primary management.
| Characteristic | Entire Sample (n=205)1 | Simple Structured Report (n=128) | Synoptic Report (n=77) | pa |
|---|---|---|---|---|
| Age (y), median (IQR) | 65 (57, 72) | 64 (57, 73) | 65 (56, 72) | .62 |
| CA-125 level (U/mL), median (IQR) | 470 (161, 1497) | 413 (165, 1207) | 744 (150, 2728) | .27 |
| Histologic type | >.99 | |||
| High-grade serous ovarian carcinoma | 182/205 (89) | 113/128 (88) | 69/77 (90) | |
| Endometrioid carcinoma | 3/205 (2) | 2/128 (2) | 1/77 (1) | |
| Clear-cell carcinoma | 3/205 (2) | 2/128 (2) | 1/77 (1) | |
| Other | 17/205 (8) | 11/128 (9) | 6/77 (8) | |
| FIGO stage | .004 | |||
| II | 5/205 (2) | 0 (0) | 5/77 (7) | |
| III | 109/205 (53) | 65/128 (51) | 44/77 (57) | |
| IV | 91/205 (44) | 63/128 (49) | 28/77 (36) | |
| Primary treatment approach | <.001 | |||
| Primary debulking surgery | 122/205 (60) | 88/128 (69) | 34/77 (44) | |
| Neoadjuvant chemotherapy-interval debulking surgery | 83/205 (40) | 40/128 (31) | 43/77 (56) | |
| Diagnostic laparoscopy at initial workup | .16 | |||
| Performed | 61/205 (30) | 43/128 (34) | 18/77 (23) | |
| Not performed | 144/205 (70) | 85/128 (66) | 59/77 (77) | |
| Surgical outcomeb | <.001 | |||
| Complete or optimal resection | 115/122 (94) | 83/88 (94) | 32/34 (94) | |
| Suboptimal resection | 7/122 (6) | 5/88 (6) | 2/34 (6) |
Note: Unless otherwise indicated, data are numerator and denominator, with percentage in parentheses. Percentages do not always total 100% owing to rounding.
FIGO = International Federation of Gynecology and Obstetrics
Wilcoxon rank sum test or Fisher’s exact test
Among patients who underwent primary debulking surgery
Patients who received a simple structured report, in comparison with patients who received a synoptic report, had a significantly higher frequency of FIGO stage-IV disease (49% vs 36%, p=.004), and a significantly higher frequency of undergoing neoadjuvant chemotherapy-interval debulking surgery (69% vs 56%, p<.001). Patients in the two groups showed no significant difference in terms of age (p = .62), serum CA-125 (p = .27), or tumor histology (p = .99).
Report Turnaround Time
The mean report turnaround time was significantly shorter for simple structured reports [29.8 minutes (range: 7.3 – 119.7 minutes)] than for synoptic reports [54.5 minutes (range: 19.7 – 112.9 minutes)] (p<.001).
Documentation of Disease Sites
During the report review, the assigned radiologist was uncertain regarding whether the report mentioned the presence of disease for a total of 47 sites in 19 unique simple structured reports; 16 of these sites were considered to be mentioned based on the subsequent consensus review by the three reviewers. The assigned radiologist was certain regarding whether the report mentioned the presence of disease for all sites in all patients for synoptic reports. In the later review of sites of surgically established unresectable or challenging-to-resect disease, the radiologist was uncertain regarding a total of 18 sites in 9 unique simple structured reports; disease involvement of the site was considered to be mentioned in 5 of these sites based on the subsequent consensus review by the three reviewers. For this assessment, the radiologist was certain for all sites in all patients for synoptic reports.
Of the 45 anatomic sites, a mean of 17.6 sites (range, 4 – 43 sites) were mentioned by simple structured reports, compared with a mean of 44.5 sites (range, 39 – 45 sites) for synoptic reports (p < .001). The mean overall documentation rate was 39% for simple structured reports versus 99% for synoptic reports. Table 2 summarizes the frequency with which reports documented disease involvement for each of the 45 anatomic sites. The percentage of reports that mentioned the given location for simple structured reports ranged from 5% (6/128) for small bowel mesentery to 91% (117/128) for right adnexa, and for synoptic reports ranged from 78% (60/77) for small bowel mesentery to 100% (77/77) for 36 locations.
Table 2:
Frequency with which pre-treatment CT reports for patients with suspected advanced ovarian cancer mentioned the presence versus absence of disease involving 45 clinically relevant anatomic sites, stratified by type of CT report generated.
| Anatomic Site | Simple Structured Report (n=128) | Synoptic Report (n=77) | Adjusted pa |
|---|---|---|---|
| Hepatobiliary | |||
| Parenchymal metastasis(es) | 114/128 (89) | 77 (100) | .001 |
| Capsular implant | |||
| Subdiaphragmatic | 32 (25) | 77 (100) | <.001 |
| Perihepatic | 36 (28) | 77 (100) | <.001 |
| Hepatorenal recess | 19 (15) | 77 (100) | <.001 |
| Fissure for ligamentum venosum | 14 (11) | 77 (100) | <.001 |
| Falciform ligament | 23 (18) | 77 (100) | <.001 |
| Porta hepatis | 15 (12) | 77 (100) | <.001 |
| Gallbladder fossa | 13 (10) | 77 (100) | <.001 |
| Spleen | |||
| Parenchymal metastasis(es) | 115 (90) | 77 (100) | <.001 |
| Capsular implant | |||
| Subdiaphragmatic | 15 (12) | 77 (100) | <.001 |
| Hilar | 18 (14) | 77 (100) | <.001 |
| Gastrosplenic ligament | 10/128 (8) | 77 (100) | <.001 |
| Splenocolic ligament | 11/128 (9) | 77 (100) | <.001 |
| Splenorenal ligament | 7/128 (5) | 77 (100) | <.001 |
| Abdominopelvic lymph nodes | |||
| Supradiaphragmatic | 89 (70) | 71 (92) | <.001 |
| Retrocrural | 31 (24) | 72 (94) | <.001 |
| Abdominal lymph nodes | |||
| Gastrohepatic | 70 (55) | 77 (100) | <.001 |
| Porta hepatis | 70 (55) | 77 (100) | <.001 |
| Portocaval | 74 (58) | 77 (100) | <.001 |
| Suprarenal retroperitoneal | 72 (56) | 77 (100) | <.001 |
| Infrarenal retroperitoneal | 80 (62) | 77 (100) | <.001 |
| Mesenteric | 72 (56) | 77 (100) | <.001 |
| Pelvic lymph nodes | |||
| Common iliac | 75 (59) | 76 (99) | <.001 |
| External iliac | 80 (63) | 77 (100) | <.001 |
| Internal iliac | 68 (53) | 76 (99) | <.001 |
| Obturator | 71 (55) | 76 (99) | <.001 |
| Mesorectal | 69 (54) | 76 (99) | <.001 |
| Superior rectal | 70 (55) | 75 (97) | <.001 |
| Inguinal | 73 (57) | 76 (99) | <.001 |
| Pelvic organs | |||
| Right adnexa | 117 (91) | 77 (100) | .008 |
| Left adnexa | 116 (91) | 77 (100) | .004 |
| Peritoneum, mesentery, and bowel | |||
| Implants | |||
| Omental | 91 (71) | 77 (100) | <.001 |
| Right paracolic gutter | 19 (15) | 77 (100) | <.001 |
| Left paracolic gutter | 18 (14) | 77 (100) | <.001 |
| Lesser sac | 26 (20) | 77 (100) | <.001 |
| Gastrocolic ligament | 21 (16) | 77 (100) | <.001 |
| Small bowel mesentery | 6 (5) | 60 (78) | <.001 |
| Small bowel serosa | 43 (34) | 77 (100) | <.001 |
| Colonic wall | 32 (25) | 77 (100) | <.001 |
| Gastric wall | 12 (9) | 77 (100) | <.001 |
| Cul-de-sac | 49 (38) | 77 (100) | <.001 |
| Ascites | 114 (89) | 77 (100) | .001 |
| Abdominal wall metastasis(es) | 16 (13) | 77 (100) | <.001 |
| Other | |||
| Pleural effusion(s) | 62 (48) | 77 (100) | <.001 |
| Pleural nodule(s) | 8 (6) | 77 (100) | <.001 |
Note—Exept where otherwise indicated, data are number with percentage in parentheses.
Fisher’s exact test with adjustment of p values for multiple comparisons based on false-discovery rate.
A total of 21% (43/205) of patients (30 with a simple structured report, 13 with a synoptic report) were deemed to have unresectable or challenging-to-resect disease based on having undergone diagnostic laparoscopy resulting in decision for neoadjuvant chemotherapy (n=36) or having undergone primary debulking surgery with suboptimal resection (n=7). The most commonly involved sites resulting in unresectable or challenging-to-resect disease were the small bowel serosa (31/43; 72%), small bowel mesentery (24/43; 56%), colonic wall (34/43; 79%), gastric wall (15/43; 35%), and subdiaphragmatic region (6/43; 14%). Involvement of the anatomic site(s) with unresectable or challenging-to-resect disease was mentioned in 37% (11/30) of simple structured reports versus 100% (13/13) of synoptic reports (p<.001). Figure 2 shows an example of a patient with sites of unresectable or challenging-to-resect disease that were not mentioned on a simple structured report. Figure 3 shows an example of a patient with sites of unresectable or challenging-to-resect disease that were mentioned on a synoptic report.
Figure 2.
62-year-old woman who underwent pre-treatment CT for suspected advanced ovarian cancer. Simple structured CT report described presence of peritoneal implants in 6 anatomic locations. Disease was considered resectable based on CT report, and primary debulking surgery was performed. However, this surgery yielded suboptimal resection. Axial contrast-enhanced images from pre-treatment CT show disease involvement of sites of residual disease at surgery that were not mentioned in the report, including the gastric wall (stars, A), colonic wall (arrows, B and C), and small bowel mesentery (arrowhead, D).
Figure 3.
74-year-old woman who underwent pre-treatment CT for suspected advanced ovarian cancer. Axial contrast-enhanced images (A-C) and coronal contrast-enhanced image (D) show sites of disease mentioned on synoptic CT report. Specifically, CT report described presence of disease involving the colonic wall (arrows) and small bowel mesentery (arrowheads). Diagnostic laparoscopy was performed given the CT findings, which confirmed multisite colonic and small bowel disease. Therefore, disease was considered unresectable, and patient underwent neoadjuvant chemotherapy-interval debulking surgery rather than primary debulking surgery.
Physician Surveys
Table 3 shows the results of the survey of gynecologic surgeons subspecialized in ovarian cancer management. All eight surgeons responded to the survey. None stated that the synoptic report negatively impacted their clinical workflow or slowed patient workup. All surgeons reported that the information in the synoptic report positively impacted their selection of patients to undergo primary debulking surgery or laparoscopy, and was beneficial to their practice. Table 4 shows the results of the survey of radiologists involved in ovarian-cancer synoptic reporting. All eleven radiologists responded to the survey. A total of 82% (9/11) agreed that the synoptic report improved report quality. A total of 91% (10/11) thought that the synoptic report increased the time required for reporting. A total of 91% (10/11) found the synoptic report to be easy and self-explanatory to complete. A total of 36% (4/11) considered the synoptic report to be a valuable educational tool. The tables give additional free-text comments provided by the respondents to the two surveys.
Table 3:
Responses to survey of ovarian cancer-focused gynecologic oncology surgeons about their satisfaction with synoptic CT report as a clinical decision-support tool.
| Survey Question | No | Yes |
|---|---|---|
| 1. Has the Ovarian Cancer Synoptic Report negatively impacted your clinical workflow? If yes, how so? | 8/8 (100) | 0/8 (0) |
| 2. Does it take longer to work up patients and get through your clinical workload because of the Ovarian Cancer Synoptic Report? | 8/8 (100) | 0/8 (0) |
| 3. Do you think that you are more selective in who you offer primary debulking surgery or laparoscopic biopsy to because of the Ovarian Cancer Synoptic Report? | 0/8 (0) | 8/8 (100) |
| 4. Overall, do you think that the Ovarian Cancer Synoptic Report is beneficial to your practice? | 0/8 (0) | 8/8 (100) |
Note--Additional free-text comments included the following:
“The synoptic report is critical, and a must.”
“The specificity of the report makes interpreting the report so much easier and systematic and makes decisions regarding primary debulking so much easier.”
“The level of detail in the synoptic report is an example of how we elevate care for our patients - I always tell patients how the review of their CTs is how we can give them the most precise and best care.”
Table 4:
Survey responses of radiologists who interpreted pre-treatment CT scans in patients with suspected advanced ovarian cancer about regarding their perception of the impact of the synoptic report on their daily clinical work.
| Survey Question | No | Yes |
|---|---|---|
| 1. Do you feel the Ovarian Cancer Synoptic Report has improved the quality of your reports for ovarian cancer staging? | 2/11 (18) | 9/11 (82) |
| 2. Has the implementation of the Ovarian Cancer Synoptic Report negatively affected your workflow, including the increased time needed for reporting? | 1/11 (9) | 10/11 (91) |
| 3. Have you found it easy and self-explanatory to complete the Ovarian Cancer Synoptic Report? | 1/11 (9) | 10/11 (91) |
| 4. Do you consider the Ovarian Cancer Synoptic Report as an educational tool? | 7/11 (64) | 4/11 (36) |
Note--Additional free-text comments:
“It takes more time to report - but I feel I am providing a much higher quality and relevant report than I would without the template. So even though it takes longer, I think it is worth it for the patient, surgeon, and clinical outcomes.”
“It is helpful to educate fellows and residents of what is important to mention in the report to improve treatment planning.”
“It does help residents and fellows to fill in the necessary elements.”
DISCUSSION
In this retrospective study, we evaluated a synoptic report implemented at our institution for pre-treatment CT examinations in patients with suspected advanced ovarian cancer. The report was developed in collaboration with ovarian cancer gynecologic oncology surgeons and expanded upon the SAR/ESUR lexicon [25]. Synoptic reports, in comparison with simple structured reports, resulted in significantly greater documentation of involvement of anatomic sites relevant to ovarian cancer primary treatment selection. In addition, among patients with unresectable or difficult-to-resect disease at initial diagnostic laparoscopy or at primary debulking surgery, involvement of the anatomic site(s) with such disease was mentioned in 100% of synoptic reports versus in 37% of simple structured reports.
Gynecologic oncology surgeons were highly satisfied with the synoptic reports, reporting a favorable impact for surgical planning without adversely affecting their clinical workflow. Radiologists likewise identified benefits from the synoptic reports, for example to improve the quality of their reports and to serve as an educational tool. However, the radiologists believed that use of synoptic reports increased the time needed for report generation. Indeed, the mean report turnaround time was 29.8 minutes for simple structured reports versus 54.5 minutes for synoptic reports.
Patients with ovarian cancer commonly present with advanced disease. Unlike many other malignancies, advanced ovarian cancer is often considered resectable despite the presence of peritoneal dissemination, lymph node metastases, or distant metastases. If a patient is a surgical candidate, then the distribution of disease impacts primary treatment selection and pre-surgical planning (including the timing and extent of debulking surgery). Accurate, complete, and easy-to-understand descriptions of disease extent in the staging CT report is critical for optimal clinical decision-making [25, 27, 29]. When documenting disease extent to help determine the feasibility of upfront resection, the presence of disease in potentially unresectable or difficult-to-resect locations is more important than disease stage per se [9]. For example, limited or focal pleural implants, limited or focal hepatic parenchymal invasion, anterior supradiaphragmatic adenopathy, and inguinal lymph node metastases are all considered stage-IV disease yet can be potentially resected at the time of primary debulking surgery.
The present findings are overall concordant with a retrospective study by Franconeri et al. [34] in a smaller sample of 24 patients with newly diagnosed ovarian cancer who underwent pre-treatment CT followed by debulking surgery (primary debulking surgery in 17; neoadjuvant chemotherapy-interval debulking surgery in 7). In that study, each CT received both a simple structured report generated as part of routine clinical care and an additional ovarian cancer-specific structured report retrospectively dictated solely for investigational purposes; the investigational reports included specific section headings but no listing of standardized lexicon terms for comprehensively describing disease sites. Similar to the present results, the disease-specific reports yielded significantly greater documentation of disease extent, with 0–2 versus 7–14 disease sites not mentioned in the disease-specific versus simple structured reports, respectively [34]. In contrast with the study by Franconeri et al., the synoptic reports in the present study were generated as part of routine clinical care and used a standardized lexicon. This use of a standardized lexicon addresses a concern raised by Franconeri et al. that even disease-specific structured reports may contain inconsistent and/or ambiguous language if ultimately completed using free-text responses. Morevoer, Franconeri et al. did not correlate imaging findings documented in the report with resectability as determined at diagnostic laparoscopy or laparotomy; in comparison, the present study evaluated documentation of established disease sites in a subset of patients with unresectable or difficult-to-resect disease at diagnostic laparoscopy or primary debulking surgery. Finally, while Franconeri et al. surveyed referring surgeons regarding the disease-specific reports (yielding favorable results similar to the present study), they did not also survey radiologists.
The present findings also align with a prospective multicenter study by Patel et al. [32] that evaluated the completeness of free-text versus disease-specific structured radiology reports for the staging of lung, prostate, cervical, endometrial, colon, and rectal cancers across multiple centers in the United Kingdom. In that study, disease-specific structured reports provided more complete staging information than did free-text reports for each evaluated cancer type and reduced the variation across reports in the number of documented disease sites. Similar to the present results, referring clinicians thought that the disease-specific reports improved assessment of disease extent (77%) and facilitated data collection (80%), while the radiologists indicated that the disease-specific reports improved report quality (50%) and were easy to complete (56%), but required more interpretation time (71%) [32]. The current results additionally support the findings of a recent study by Shirley et al. [35], who found that synoptic operative reports in patients with suspected ovarian cancer contained 20% more data elements than simple operative reports, including better documentation of more critical data elements.
This study had limitations. First, it was a single-center study conducted at a tertiary cancer center with a small number of participating surgeons and radiologists. Second, a fewer number of patients received a synoptic report than a simple structured report, possibly because ovarian cancer synoptic reporting was implemented during the COVID-19 pandemic when fewer patients presented to the center for non-emergent procedures. Third, the two groups were different in terms of disease stage and primary treatment approach. Fourth, different (partially overlapping) groups of radiologists generated the simple structured reports and synoptic reports; this difference in part relates to an interval change in departmental workflow whereby imaging studies ordered by clinicians belonging to a DMT were assigned for reporting exclusively to radiologist members of that DMT. Nonetheless, interpreting radiologists for all reports were fellowship-trained oncologic abdominal radiologists. Fifth, the radiologist survey was completed by radiologist members of the gynecologic oncologic multidisciplinary DMT. These radiologists were potentially inclined to view ovarian cancer synoptic reports in a favorable manner given that the synoptic report was developed in collaboration with the DMT. Sixth, the presence versus absence of disease was not described for some sites even for synoptic reports, indicating the need for radiologist education and additional quality assurance efforts when implementing synoptic reports. Seventh, reporting times were significantly greater for synoptic reports, which may pose a challenge to synoptic report implementation. Eighth, the synoptic report was modeled on the SAR/ESUR lexicon, although differed in listing a large number of sites. The sited listed in the report reflected disease sites deemed relevant to clinical decision making for advanced ovarian cancer by the ovarian cancer gynecologic oncologic surgeons at the study institution. However, given a lack of universally accepted resectability criteria as well as variations in surgical skill, the relevant disease sites may vary across institutions, leading to implementation of different synoptic reports. Ninth, the staging accuracy could not be compared between simple structured and synoptic reports due to the lack of a reference standard for this determination (e.g., synoptic operative reports). Finally, given the use of clinical reports, each examination was interpreted by a single radiologist, and inter-reader agreement was not evaluated.
In conclusion, implementation of a synoptic report improved the completeness of pre-treatment CT reports in patients with advanced ovarian cancer in comparison with simple structured reports. In particular, the synoptic report resulted in significantly more frequent reporting of disease in unresectable or difficult-to-resect sites. The findings indicate the role of disease-specific synoptic reports to facilitate communication with gynecologic oncology surgeons and thereby help guide clinical decision-making.
HIGHLIGHTS.
KEY FINDING:
In patients who underwent CT before ovarian cancer treatment, involvement of surgically established unresectable or challenging-to-resect disease sites was mentioned in 37% (11/30) of simple structured reports versus 100% (13/13) of disease-specific synoptic reports; all surveyed gynecologic oncology surgeons reported that synoptic reports impacted treatment selection and benefitted their practice.
IMPORTANCE:
An ovarian cancer synoptic report increased completeness of reporting, facilitating referrer communication and having the potential to improve clinical decision-making.
Appendix 1-. Members of Memorial Sloan Kettering Cancer Center Team Ovary
| Name | Department | |
|---|---|---|
| Authors | Pamela Causa Andrieu, MD | Radiology |
| Ines Nikolovski, MBBS | Radiology | |
| Aaron M. Praiss, MD | Surgery | |
| Weining Ma, MD | Surgery | |
| Jean M. Torrisi, MD | Radiology | |
| Yukio Sonoda, MD | Surgery | |
| Dennis S. Chi, MD | Surgery | |
| Yulia Lakhman, MD | Radiology | |
| Emily A. Aherne, MD | Radiology | |
| Oguz Akin, MD | Radiology | |
| Vance Broach, MD | Surgery | |
| Shannan Dickinson, MBBS | Radiology | |
| Ginger J. Gardner, MD | Surgery | |
| Rachel Grisham, MD | Medicine | |
| Sara A. Hayes, MD | Radiology | |
| Roisin O’Cearbhaill, MD | Medicine | |
| Kara Long Roche, MD, MSc | Surgery | |
| Viktoriya Paroder, MD, PhD | Radiology | |
| Iva Petkovska, MD | Radiology | |
| Debra M. Sarasohn, MD | Radiology | |
| William Tew, MD | Medicine | |
| Hebert A. Vargas, MD | Radiology | |
| Jae Ward, MPH | Surgery | |
| Andreas G. Wibmer, MD | Radiology | |
| Sungmin Woo, MD, PhD | Radiology | |
| Oliver Zivanovic, MD, PhD | Surgery |
Appendix 2-. Ovarian-cancer synoptic report template.
CLINICAL STATEMENT:
Suspected/known ovarian cancer staging.
TECHNIQUE:
Multislice helical sections were obtained from the domes of the diaphragm to the pubic symphysis after oral and intravenous contrast administration.
RADIATION DOSE (DLP):
[] mGy-cm
COMPARISON:
[]
CORRELATION:
[]
FINDINGS:
HEPATOBILIARY:
Parenchymal metastases: [absent/present] [free-text description]
Capsular implants:
* Subdiaphragmatic: [absent/present] [free-text description]
* Perihepatic: [absent/present] [free-text description]
* Hepatorenal recess: [absent/present] [free-text description]
* Fissure for ligamentum venosum: [absent/present] [free-text description]
* Falciform ligament: [absent/present] [free-text description]
* Porta hepatis: [absent/present] [free-text description]
* Gallbladder fossa: [absent/present] [free-text description]
SPLEEN:
Parenchymal metastases: [absent/present] [free-text description]
Capsular implants:
* Subdiaphragmatic: [absent/present] [free-text description]
* Hilar: [absent/present] [free-text description]
* Gastrosplenic ligament: [absent/present] [free-text description]
* Splenocolic ligament: [absent/present] [free-text description]
* Splenorenal ligament: [absent/present] [free-text description]
PANCREAS:
Unremarkable.
ADRENAL GLANDS:
Unremarkable.
KIDNEYS:
Unremarkable.
ABDOMINOPELVIC NODES:
* Supradiaphragmatic: [absent/present] [free-text description]
* Retrocrural: [absent/present] [free-text description]
* Abdominal:
-- Gastrohepatic: [absent/present] [free-text description]
-- Porta hepatis: [absent/present] [free-text description]
-- Portocaval: [absent/present] [free-text description]
-- Suprarenal retroperitoneal: [absent/present] [free-text description]
-- Infrarenal retroperitoneal: [absent/present] [free-text description]
-- Mesenteric: [absent/present] [free-text description]
* Pelvic:
-- Common iliac: [absent/present] [free-text description]
-- External iliac: [absent/present] [free-text description]
-- Internal iliac: [absent/present] [free-text description]
-- Obturator: [absent/present] [free-text description]
-- Mesorectal: [absent/present] [free-text description]
-- Inguinal: [absent/present] [free-text description]
-- Superior rectal: [absent/present] [free-text description]
PELVIC ORGANS:
Right adnexal mass: [absent/present] [free-text description]
Left adnexal mass: [absent/present] [free-text description]
PERITONEUM /MESENTERY/BOWEL:
Implants:
* Omental: [absent/present] [free-text description]
* Right paracolic gutter: [absent/present] [free-text description]
* Left paracolic gutter: [absent/present] [free-text description]
* Lesser sac: [absent/present] [free-text description]
* Gastrocolic ligament: [absent/present] [free-text description]
* Small bowel mesentery: [absent/present] [free-text description]
* Small bowel serosa: [absent/present] [free-text description]
* Gastric wall: [absent/present] [free-text description]
* Colonic wall: [absent/present] [free-text description]
* Cul de sac: [absent/present] [free-text description]
Ascites: [absent/present] [free-text description]
BONES/SOFT TISSUES:
No suspicious osseous lesion.
Abdominal wall metastases: [absent/present] [free-text description]
OTHER:
Pleural effusion: [absent/present] [free-text description]
Pleural nodules: [absent/present] [free-text description]
IMPRESSION:
[free-text description]
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