Added value of abdominal cross-sectional imaging

(CT or MRI) in staging of Wilms tumours

K. McDonald
a,
*
, P. Duffy
b
, T. Chowdhury
c
, K. McHugh
a
a
Department of Paediatric Radiology, The Royal London Hospital, London, UK
b
Department of Urology, Great Ormond Street Hospital for Children, London, UK
c
Department of Oncology, Great Ormond Street Hospital for Children, London, UK
arti cle informati on
Article history:
Received 23 January 2012
Received in revised form
17 April 2012
Accepted 1 May 2012
AIM: To assess the added information gained from computed tomography (CT) or magnetic
resonance imaging (MRI) of the abdomen over abdominal ultrasound in children undergoing
staging of Wilms tumours.
MATERIALS AND METHOD: Fifty-two consecutive patients with histologically proven Wilms
tumours were identied. Each had an initial staging abdominal ultrasound followed by either
a CT or MRI examination of the abdomen. Details including tumour size, site, and character-
istics, presence of lymph nodes, local invasion, evidence of nephroblastomatosis, and any other
relevant nding were gathered from the report of each ultrasound and CT or MRI. Each CT/MRI
was then re-reviewed by a consultant paediatric radiologist and a paediatric radiology fellow.
The difference in ndings between the ultrasound and cross-sectional imaging were noted.
RESULTS: Twelve patients were excluded from the study because the CT/MRI was performed
before the ultrasound, or imaging was incomplete. Twenty-six patients were female, 14 male.
The ages ranged from 9 months to 10.8 years (mean 3.75 years). Twenty-one patients out of
the remaining 40 had additional ndings detected on the CT or MRI examination that had not
been reported on the ultrasound. The most important additional ndings included three
patients with nephroblastomatosis and two with contralateral tumours. Other ndings
included two patients with tumour haemorrhage, four with abdominal lymph node enlarge-
ment, three with inferior vena cava (IVC)/renal vein thrombus, four with adjacent organ
invasion, one patient where the origin of the abdominal tumour was conrmed as renal, and
one patient where possible liver invasion was excluded.
CONCLUSION: In over half the patients, CT or MRI added additional information in the local
staging of Wilms tumours. Sole reliance on ultrasound for Wilms staging risks missing
signicant abnormalities.
2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction
Wilms tumour is the commonest malignant tumour
arising from the kidney in childhood, and the prognosis has
improved dramatically in recent years. The management of
Wilms tumours differs in Europe and North America. In
European countries and elsewhere treatment strategies are
based on the International Society of Paediatric Oncology
(SIOP) protocols, where chemotherapy is followed by
surgery. This favours tumour reduction prior to surgical
resection, thus reducing the risk of tumour spill/rupture at
the time of surgery,
1
as well as reducing surgical stage, and
therefore, potentially, the intensity of postoperative
* Guarantor and correspondent: K. McDonald, Department of Paedi-
atric Radiology, The Royal London Hospital, London E1 1BB, UK. Tel.:
44 (0) 7793750803; fax: 44 (0) 2078298665.
E-mail address: kmcdonald@doctors.org.uk (K. McDonald).
Contents lists available at SciVerse ScienceDirect
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0009-9260/$ e see front matter 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.crad.2012.05.006
Clinical Radiology 68 (2013) 16e20
chemotherapy. In North America management is based on
the National Wilms Tumour Study Group (NWTSG) guide-
lines, which advocates surgery prior to chemotherapy.
1
The
outcomes for each strategy are similar.
2
Formal tumour staging is done at the time of surgery.
3
However, assessment of localized versus metastatic disease
at presentation will determine the intensity of preoperative
chemotherapy according to the European SIOP strategy, and
must include imaging of the primary and metastatic sites.
According to the European SIOP protocol, imaging of the
primary includes ultrasound as mandatory, and CT/MRI
abdomen is strongly advised in the UK or if further detail is
required. Chest x-ray is mandatory for assessment of meta-
static sites and chest CT for doubtful metastases, although
chest CT is highly recommended for all patients in the UK.
Abdominal imaging at the time of presentation provides
valuable information ontumour origin, size, extent, invasion
of adjacent structures; presence of tumour thrombus in the
renal vein, inferior vena cava (IVC) and right atrium; the
presence of contralateral tumour(s) or nephrogenic rests;
lymph node enlargement; tumour rupture; and metastatic
spread to the liver.
4
Preoperative imaging undoubtedly aids
surgical planning and in Europe it is extremely important in
the assessment of tumour response to preoperative
chemotherapy. This is particularly relevant in the case of
bilateral Wilms tumours where further courses of chemo-
therapy in chemoresponsive tumours may improve the
chances of nephron-sparing surgery being possible.
The preferred imaging strategy for abdominal staging
varies across Europe. Some countries, such as the
Netherlands (R. van Rijn, pers. comm.), may rely mainly on
abdominal ultrasound, whilst other countries, including the
UK, use either CT or MRI of the abdomen, in addition to
routine ultrasound in every patient at presentation and for
preoperative tumour response assessment and surgical
planning. In a retrospective observational study, the added
information gained from CT or MRI of the abdomen at the
time of presentation in children undergoing abdominal
staging for Wilms tumours was assessed at our institution
a tertiary paediatric oncology centre in the UK.
Materials and methods
Ethical approval was not considered necessary by the
local Ethics Committee, but the study was registered with
the local Research and Development ofce.
Fifty-two consecutive patients with histologically proven
Wilms tumours were identiedretrospectively. Eachhad an
initial diagnostic abdominal ultrasound (performed either
by consultant paediatric radiologists or senior paediatric
radiology trainees and experienced paediatric sonographers
withreviewby the consultant) followedbyeither a CTor MRI
examination of the abdomen, depending on the availability
of the machines, anaesthetic team, and patient MRI safety
issues. A subsequent preoperative ultrasound followed by
either CT or MRI were performed after chemotherapy. Chil-
dren who had their CT/MRI prior to the ultrasound were
excluded as this may have biased the ultrasound ndings
(this occurred on some occasions at this institution when
patients were transferred from other institutions, with
cross-sectional imagingperformedelsewhere). Inthereport,
the presence or absence of specic ndings from each
examination were sought. These included tumour size, site,
origin and characteristics; presence of enlarged lymph
nodes; local invasion; evidence of nephroblastomatosis in
the ipsilateral or contralateral kidney; anyother abnormality
of the contralateral kidney; and any other relevant nding.
Each CT/MRI was then re-reviewed by a consultant paedi-
atric radiologist and paediatric radiology fellow. The ultra-
sound images were not re-reviewed as it is an operator-
dependent technique, where the ndings are usually docu-
mentedwitha fewrepresentative images andfurther review
seldom nds signicant ndings that were not reported at
the time of the examination. The report for the ultrasound
examination is thus largely taken at face value, and this is
generally accepted at the weekly multidisciplinary team
(MDT) oncology meeting.
The difference in ndings between the initial diagnostic
ultrasound and cross-sectional imaging were noted and
correlation was made with the histopathology results and
surgical ndings.
Results
Twelve patients were excluded from the study because
the CT/MRI was performed before the ultrasound, or the
patients imaging was incomplete. Twenty-six patients
were female, 14 male. Their ages ranged from 9 months to
10.8 years (mean 3.75 years).
Eighteen patients out of the remaining 40 had 19
additional ndings detected on the CT (n 22) or MRI
(n 18) examination that had not been reported on the
ultrasound, and were conrmed at the time of resection
or at histology. The most important additional ndings
included two patients with contralateral tumours (Fig 1),
one with an additional ipsilateral tumour, and three with
contralateral nephroblastomatosis (Fig 2). Other ndings
included two patients with tumour haemorrhage/
rupture, three with abdominal lymph node enlargement,
two with IVC/renal vein thrombus, four with adjacent
organ adhesion/possible invasion (Fig 3), one patient
where the origin of the abdominal tumour was difcult
to determine on ultrasound was conrmed as renal and
one patient where possible liver invasion was excluded
(Fig 4).
On correlation with the histology results and surgical
ndings ve patients were found to have false-negative
results, and six patients were found to have false-positive
results on cross-sectional imaging. The false-negative
results included two patients found to have IVC thrombus,
and three patients with enlarged abdominal lymph nodes at
the time of surgery. The false-positive results included one
patient each with a contained tumour rupture, IVC
thrombus, lymph node enlargement, psoas invasion, liver
metastasis, and adrenal invasion that were not conrmed at
surgery or at histology.
K. McDonald et al. / Clinical Radiology 68 (2013) 16e20 17
The time difference between the initial diagnostic
imaging and surgical resection ranged from 1 week to 5
months. For the patients with false-negative and false-
positive ndings on cross-sectional imaging, the range
was 1e8 weeks (mean 4.5 weeks).
Discussion
Ultrasound is a non-invasive technique, does not involve
irradiation, or require sedation, and should be the rst-line
investigation of patients with suspected abdominal
tumours. It also has excellent capacity to assess the renal
vein and IVC for tumour thrombus extension. However, it is
operator-dependent, requires a co-operative child, and has
other limitations; for example, bowel gas may obscure the
retroperitoneum rendering assessment of lymph nodes
difcult or impossible.
Cross-sectional imaging with CT or MRI provides excel-
lent anatomical detail.
5,6
Although todays modern MRI
systems enable much shorter examination times, most
young patients with Wilms masses will require sedation or
general anaesthesia, which are not without risk. Many of
those who undergo CT may not require sedation but CT has
the additional disadvantage of a radiation burden.
In some European countries, only abdominal ultrasound,
plus chest radiography, is used for staging Wilms tumours
prior to chemotherapy. However, the extra anatomical
detail available with CT or MRI has resulted in these
becoming part of the routine abdominal staging protocol in
the majority of European countries, including the UK, and in
North America. Indeed, it is undoubtedly better practice to
corroborate positive or negative ndings in these children
(such as metastases or no hepatic metastases) with two
imaging techniques, rather than relying solely on
ultrasound.
Oncologists at our institution insist on the additional
information afforded by CT or MRI in this study, with MRI
being optimal for the reasons described above. MRI has
informed situations where the tumour origin was uncertain
and the diagnosis in question, thus inuencing oncological
and surgical management. The existence of contralateral
tumours or nephroblastomatosis, particularly in the syn-
dromic child, will also inuence oncological management
and surgical planning, as well as surveillance during and
after treatment.
7
This study contains a number of deciencies. It is retro-
spective. The ultrasound studies were not individually
reviewed, although the CT and MRI studies were, for the
reasons already stated above. It is likely that the ultrasound
results were known to those reporting the CT or MRI, whilst
the ultrasound studies were the rst examination, when
Figure 1 A 2-year-old male patient with chromosome 11 deletion,
undergoing surveillance due to increased risk of developing Wilms
tumours. T2-weighted, fat-saturated, axial image. Horseshoe kidney
with hydronephrosis of the right moiety due to tumour extending
into the right renal pelvis (not shown on this section, but identied
on ultrasound), and a 2 cm rounded lesion, with intermediate signal
in the lower part of the left moiety, close to the isthmus (arrow; not
identied on ultrasound).
Figure 2 An 8-month-old male patient with large, left-sided mass. (a)
Longitudinal ultrasound image of the right kidney, which appears
normal. (b) Coronal, contrast-enhanced, fat-suppressed image
showing the large left-sided renal tumour, and a small low signal
lesion medially in the right kidney (arrow), in keeping with contra-
lateral nephroblastomatosis.
K. McDonald et al. / Clinical Radiology 68 (2013) 16e20 18
information about the patients would have been limited.
Not all the patients had repeat pre-surgical CT or MRI. There
was an inevitable delay between initial imaging and later
surgery or histology assessment. The false-negative results
are probably acceptable as involved lymph nodes, in
particular, are typically immediately adjacent to the tumour
and indistinguishable from the primary lesion at initial
diagnosis. The false positives may be false because there has
been chemotherapy and the passage of time between CT or
MRI assessment and surgery or histological conrmation.
There is a growing body of opinion within oncology and
radiology circles that the traditional prose-style radiology
report may be becoming inadequate. Traditional reports
frequently omit key facts essential for accurate staging.
8
In
one study, information necessary for surgical planning was
missing in 85% of unstructured reports. Therefore, it is likely
that some of the missing data from the ultrasound and
initial CT or MRI examinations reports are simply omis-
sions, rather than missed abnormalities.
Despite these limitations the present study shows that
ultrasoundandCT/MRI arecomplementary inthe evaluation
of new renal tumours at diagnosis and that CT or MRI inev-
itably adds crucial information, in addition tothe ultrasound
ndings, to inform decision-making in these children.
In conclusion, the ndings of the present study indicate
that in just under half the patients CT or MRI added
additional information in the local assessment of Wilms
tumours at diagnosis, which may have inuenced the
diagnostic pathway and treatment decisions. Sole reliance
on ultrasound for Wilms staging risks missing signicant
abnormalities. The information gained from cross-sectional
imaging is likely to outweigh the risks due to radiation,
sedation, or general anaesthetic.
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