Radiology Overreads of CT-sims

[dogjam]

We're considering having our radiology colleagues start to read our simulation CTs, mainly to ensure no major findings are missed. We're curious as to what the national standard is on this, if any. For those of you who have radiology read your sims, do you find it helpful overall? Or more annoying to suddenly become responsible for endless incidentalomas?

Thanks for any thoughts/advice!

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[medgator]

They can get paid for doing that? Seems unnecessary and possibly risky from multiple perspectives imo

 

[evilbooyaa]

I think having this be routine practice is detrimental. Be a radiation oncologist who has confidence in what you're doing. Evaluating CT Sims for extent of tumor and delineation of contouring limits is literally rad onc 101.

Also radiologists can't bill insurance for this I'm pretty sure, it would likely lead to a patient bill.

Also we've occasionally run into issues where they won't perform an official read (but they're OK to quickly eyeball it with you) because it's not all the diagnostic series that would assist in differentiating incidentaloma A from incidentaloma B.

 

[dogjam]

It wouldn't be for treatment planning purposes; it would be to avoid missing some finding that we could later be sued for. Basically the thinking is that we might not catch a concerning but subtle lung nodule on a breast sim, just as an example.

I believe there is some mechanism whereby radiology can bill for this.

 

[evilbooyaa]

How common is it to do a CT sim on somebody who has never had diagnostic imaging of that area? Outside of early stage breast that doesn't get a CT as part of their staging I can't think of one.

I personally think having radiology overreads of CT sim as a routine practice is silly and overkill, but see what your radiology group says. I imagine ours would stick with the "you didn't do a full diagnostic CT so we're not going to take on the liability of calling or not calling something" that we've heard occasionally.

 

[Palex80]

I have no idea what the US regulations are on billing for that.
We tried doing that in Germany & Switzerland and it didn't work. Billing for the report by the radiologist is charged together with actually having the CT performed by the radiologist, so you can't actually bill for the report extra. It's a package.
There was only the chance to charge a "second opinion" by the radiologist, but that would imply that a first opinion existed, which would imply that we (the radiation oncologist) would have to write that first report. Which we obviously never do.

I have been called quite a few times by colleagues from the radiology department, asking me to dig out some old CT done for planning in the past. Most of the times it is to check for lymph nodes in the pelvis or lung nodules.

 

[OTN]

It wouldn't work in the US. You have to have insurance authorization for both CT simulation and a diagnostic CT, and they can't be the same scan, or one won't be billed. Additionally, I echo the comments from other posters about us being able to read our own scans. I've picked up lots of stuff on the scan that wasn't directly related to what we were treating (early-stage lung cancers, breast cancers, CLL, etc), and I feel that falls right within our wheelhouse.

 

[Radiator20]

I share everyone's reservations about this idea. Practically speaking, also, do your CT sims populate to the diagnostic PACS where radiology could even see them? Ours don't. That lack of visibility also probably limits any (already negligible IMO) liability down the line. Even absent that, CT sim is just not a diagnostic-quality study designed to detect other pathology. If particularly worried, what about putting language to that effect in your consent?

 

[Gfunk6]

I vaguely remember seeing a paper published on this topic. If someone is more motivated then me then can search for it through the SDN archive. I think the conclusion that while a handful of actionable findings were noted, it was not enough to justify the time/expense of Rads reviewing every CT sim.

 

[Radonc11]

It wouldn't work in the US. You have to have insurance authorization for both CT simulation and a diagnostic CT, and they can't be the same scan, or one won't be billed. Additionally, I echo the comments from other posters about us being able to read our own scans. I've picked up lots of stuff on the scan that wasn't directly related to what we were treating (early-stage lung cancers, breast cancers, CLL, etc), and I feel that falls right within our wheelhouse.

There's virtually no risk of being sued for missing something subtle on a non-diagnostic study. In reality, I find things on my sim CT that leads to a diagnostic study ever so often or me having radiology amend a report.

2nd, A diagnostic study has two parts: Technical and professional. Your chances of generating both components on a Sim-CT is pretty much zero percent. This will not be paid for. Also no radiologist is going to be ok with doing a "read" on a non diagnostic study.

My Sims get pushed to PACS and I may curbside something interesting that was not previously known but it if really want to know anything about the sclv node that wasn't seen on the prior diagnostic CT I'm going to order a contrast CT (and you bet it'll need Auth unless it's Medicare) .

 

[Chartreuse Wombat]

I vaguely remember seeing a paper published on this topic. If someone is more motivated then me then can search for it through the SDN archive. I think the conclusion that while a handful of actionable findings were noted, it was not enough to justify the time/expense of Rads reviewing every CT sim.

Not sure if this is what you were referring to

https://www.practicalradonc.org/article/S1879-8500(10)00004-4/fulltext

 

[scarbrtj]

In the past, this would have been fraud: billing two entirely different CPT codes (CT sim, which is professional and technical, and diagnostic CT, which is professional at least and can be technical too obviously; without contrast, the CT sim must have direct supervision, but would be general supervision for just a diagnostic CT, but I digress...) for the same procedure. True "double billing."

Now you (we) are not able to bill CT simulations anymore most times (there is no code for "CT simulation" per se, only 77014-TC, e.g., and simulation codes like 77290, but again I digress...). So it would be technically allowable. I'm not a biller/coder but I play one on TV!

EDIT: If the radiologists get insurance co. blowback... everything must be pre-authorized nowadays... and are not paid, your project will die a rapid death.

 

[RadRadRad]

If worried about liability, why not just have phrase in your consent form stating that ct simulations are not for diagnosis only for radiation planning...

 

[Radiator20]

Two other points.

1. This policy would essentially transform negligible liability for rad onc into significant liability for diagnostic radiology (putting their name to a formal interpretation of a non-diagnostic quality study). Even absent billing issues, I can’t imagine they would appreciate that.
2. Diagnostic radiology does not over-read other non-diagnostic imaging obtained in the course of clinical care, eg, OR fluoro. This situation seems analogous.

 

[dogjam]

Thanks to all for the excellent input!

 

[SneakyBooger]

It wouldn't be for treatment planning purposes; it would be to avoid missing some finding that we could later be sued for. Basically the thinking is that we might not catch a concerning but subtle lung nodule on a breast sim, just as an example.

I believe there is some mechanism whereby radiology can bill for this.

Our group had diagnostic rad read them for a year, but the reports stated the same thing - "resolution too poor for diagnostic purposes" or something to that effect. So we stopped.

However, I did have one lovely very locally advanced breast ca (also a dear friend) patient who was found to have a lung nodule 6 months after XRT. (She remains dz free now 7 years out.) It was resected and found to be a carcinoid. In retrospect, it was there on the TP CT, but I didn't see it. I felt horrible. I have seen thousands of TP CT's for breast cancer in my lifetime. I recently diagnosed a rectourethral fistula on one for a rectal ca pt after resection and before the patient began adj XRT/Chemo (periprostatic soft tissue air and air in bladder) - the diagnostic rad missed it. I have seen things the diagnostic rad missed too many times to count - and vice versa I am sure. I am not disrespecting diagnostic rads - I have tremendous respect and appreciation for them. We are all human.

But I missed this one lung nodule. IMO, we are not diagnostic rads and don't go through the checklist of things to look for that they have drilled into their brain to see the things they see. When I look at CT's for planning breast ca I look at heart vol, lung vol, lump site, LN basins, etc. I may miss another lung nodule, but hope not.

I don't know the answer to your question, but understand and feel the same concern you have.

 

[RO28]

Our group had diagnostic rad read them for a year, but the reports stated the same thing - "resolution too poor for diagnostic purposes" or something to that effect. So we stopped.

However, I did have one lovely very locally advanced breast ca (also a dear friend) patient who was found to have a lung nodule 6 months after XRT. (She remains dz free now 7 years out.) It was resected and found to be a carcinoid. In retrospect, it was there on the TP CT, but I didn't see it. I felt horrible. I have seen thousands of TP CT's for breast cancer in my lifetime. I recently diagnosed a rectourethral fistula on one for a rectal ca pt after resection and before the patient began adj XRT/Chemo (periprostatic soft tissue air and air in bladder) - the diagnostic rad missed it. I have seen things the diagnostic rad missed too many times to count - and vice versa I am sure. I am not disrespecting diagnostic rads - I have tremendous respect and appreciation for them. We are all human.

But I missed this one lung nodule. IMO, we are not diagnostic rads and don't go through the checklist of things to look for that they have drilled into their brain to see the things they see. When I look at CT's for planning breast ca I look at heart vol, lung vol, lump site, LN basins, etc. I may miss another lung nodule, but hope not.

I don't know the answer to your question, but understand and feel the same concern you have.

I recently missed a node on a TP CT and feel horrible. Turns out the node started growing during therapy, patient felt a lump and now its coming out. When I went back to the TP CT there it was, not sure what I was thinking when I was doing the contours. I know we are all human and things get missed, but what is the consensus how to address this to the patient?

 

[BobbyHeenan]

I recently missed a node on a TP CT and feel horrible. Turns out the node started growing during therapy, patient felt a lump and now its coming out. When I went back to the TP CT there it was, not sure what I was thinking when I was doing the contours. I know we are all human and things get missed, but what is the consensus how to address this to the patient?

We’ve all made mistakes. I’ve done this too.

Ive done it on the other end too ...sent a patient back to breast rads for an axillary tail node biopsy because I swore her node was suspicious on tx planning CT just to be told by rads it was ok and when I demanded biopsy sure enough it was a normal intramammary node. Poor patient was freaked out. I put her through stress, more procedures, etc.

Learn from it and be more careful.

I’m not sure what best way to address this is. I’m not sure I’d really feel a need to comment on it unless patient asked specifically why you didn’t see it on CT sim.

I feel rads over reads on ct sim in general not a great idea. About once a month I do review a ct sim with rads, but routine over read not helpful.

 

[Burt Radnolds]

I recently missed a node on a TP CT and feel horrible. Turns out the node started growing during therapy, patient felt a lump and now its coming out. When I went back to the TP CT there it was, not sure what I was thinking when I was doing the contours. I know we are all human and things get missed, but what is the consensus how to address this to the patient?

Goes without saying but always be forthright with the patient. However I really don't think it's in anyone's best interest to go out of your way to roll yourself under the bus if this was a soft miss. Instilling doubt in a patients mind about the care they received will be psychologically damaging to them and perhaps put yourself at risk. If you do feel you made an egregious error and they are already acting funny wondering what happened, then I would involve your risk management team before doing anything else.

Was this node covered in an elective region and grow anyways? That's just bad biology and mostly absolves you.

I'm sorry you are in this situation, like you said we are all human and imperfect. Beating yourself up will get you nowhere, trust me I've been there and still end up there from time to time. When I uncover something I could have done better, I try my absolute best to spin in into a positive and figure out how I'll use it to help my future patients.

 

[deleted941485]

Goes without saying but always be forthright with the patient. However I really don't think it's in anyone's best interest to go out of your way to roll yourself under the bus if this was a soft miss. Instilling doubt in a patients mind about the care they received will be psychologically damaging to them and perhaps put yourself at risk. If you do feel you made an egregious error and they are already acting funny wondering what happened, then I would involve your risk management team before doing anything else.

Was this node covered in an elective region and grow anyways? That's just bad biology and mostly absolves you.

I'm sorry you are in this situation, like you said we are all human and imperfect. Beating yourself up will get you nowhere, trust me I've been there and still end up there from time to time. When I uncover something I could have done better, I try my absolute best to spin in into a positive and figure out how I'll use it to help my future patients.

Happens all the time, head and neck cases where there’s a node with no uptake and not commented upon anywhere. Sometimes you see them and sometimes you don’t

 

[Lamount]

One of the most important lessons I learned in med school was not to perform a test that isn’t medically indicated. I always ask radiology to review my sims with, WHEN I SEE SOMETHING CONCERNING AND UNEXPECTED. But if radiology is looking at planning scans when there was no indication for diagnostic imaging and there is no concern on the part of the rad onc, it is bound to lead to unnecessary biopsies and headaches.

 

[radoncgrad2019]

'Was this node covered in an elective region and grow anyways? That's just bad biology'

agree

 

[evilbooyaa]

I recently missed a node on a TP CT and feel horrible. Turns out the node started growing during therapy, patient felt a lump and now its coming out. When I went back to the TP CT there it was, not sure what I was thinking when I was doing the contours. I know we are all human and things get missed, but what is the consensus how to address this to the patient?

It happens. Many nodes are visible on a TP CT and it's always a judgment call about being suspicious but not over-reactionary to any lymph node you see. Assuming this was a breast LN, you tell them if they ask that it was there on your CT but at the time you didn't feel it was suspicious.

We've all made mistakes. My general goal is that if I make a mistake once, I correct behavior so that mistake does not happen again. There are mistakes I've picked up from myself, from the attendings I've been working with, from other cases that I've seen, that I vow to try to not make those same mistakes.

I re-review plans on anybody I treated who developed recurrence. Sure, it could've 'just' been cancer, but were my PTVs tight and it's a marginal miss? Or was it something like a 1A recurrence in a node negative oropharynx and I'm not going to change practice based on that?

 

[Mandelin Rain]

Those post lumpectomy breast sims often have a prominent/borderline axillary node. If it has a thin cortex and fatty hilum I usually just ignore it or at most try to capture in in the tangents.

I agree with re-reviewing plans of recurrences. Very instructive. Usually they come back dead center field, but I've had a few marginal ones where even if I was following standard contouring protocol, I have to live with not expanding a few more millimeters and the fact that it irreversibly impacted someone's life. Definitely makes you refocus when thinking about contours.

 

[RO28]

'Was this node covered in an elective region and grow anyways? That's just bad biology'

agree

yeah the node is in the treatment field, if I had seen it ahead of time I would have brought it to the attention of the surgeon to see if it would come out, but maybe the surgeon would have said treat anyways and I'll take it out after? I dunno, based on the pathology it is definitely bad biology. It just sucks either way.