Ezekiel Maloney1,2, A Luana Stanescu1,2, Francisco A Perez1,2, Ramesh S Iyer1,2, Randolph K Otto1,2, Sarah Leary3, Lotte Steuten4, Amanda I Phipps5, Dennis W W Shaw6,7. 1. Department of Radiology,, University of Washington,, Seattle, WA, USA. 2. Department of Radiology,, Seattle Children's Hospital,, 4800 Sand Point Way NE,, Seattle, WA, 98105, USA. 3. Cancer and Blood Disorders,, University of Washington, Seattle Children's Hospital,, Seattle, WA, USA. 4. Department of Pharmacy,, University of Washington, Fred Hutchinson Cancer Research Center,, Seattle, WA, USA. 5. Department of Epidemiology,, University of Washington School of Public Health,, Seattle, WA, USA. 6. Department of Radiology,, University of Washington,, Seattle, WA, USA. dennis.shaw@seattlechildrens.org. 7. Department of Radiology,, Seattle Children's Hospital,, 4800 Sand Point Way NE,, Seattle, WA, 98105, USA. dennis.shaw@seattlechildrens.org.
Abstract
BACKGROUND: Pediatric optic pathway gliomas are typically indolent but have a variable clinical course. Treatment is dictated by symptoms and changes on contrast-enhanced MRI examinations. Gadolinium retention in children has motivated parsimonious use of gadolinium-based contrast agents. OBJECTIVES: To determine surveillance MR factors that motivate changes in tumor-directed therapies and extrapolate cost-efficacy of a non-contrast follow-up protocol. MATERIALS AND METHODS: Using an imaging database search we identified children with isolated optic pathway gliomas and ≥3 follow-up contrast-enhanced MRIs. We reviewed medical records and imaging for: (1) coincident changes on contrast-enhanced MRI and tumor-directed therapy, (2) demographics and duration of follow-up, (3) motivations for intervention, (4) assessment of gadolinium-based contrast agents' utility and (5) health care utilization data. We assessed cost impact in terms of relative value unit (RVU) burden. RESULTS: We included 17 neurofibromatosis type 1 (NF1) and 21 non-NF1 patients who underwent a median 16.9 and 24.3 cumulative contrast-enhanced MR exams over 7.7 years and 8.1 years of follow-up, respectively. Eight children (one with NF1) had intervention based on contrast-enhanced MR findings alone. For these eight, increased tumor size was the only common feature, and it was apparent on non-contrast T2 sequences. For the median patient, a non-contrast follow-up protocol could result in 15.9 (NF1) and 23.3 (non-NF1) fewer gadolinium-based contrast agent administrations, and a 39% lower yearly RVU burden. CONCLUSION: Pediatric patients with isolated optic pathway gliomas undergo a large number of routine contrast-enhanced MR follow-up exams. Gadolinium might not be needed for these exams to inform management decisions. Secondary benefits of a non-contrast follow-up protocol include decreased cost and risk to the patient.
BACKGROUND: Pediatric optic pathway gliomas are typically indolent but have a variable clinical course. Treatment is dictated by symptoms and changes on contrast-enhanced MRI examinations. Gadolinium retention in children has motivated parsimonious use of gadolinium-based contrast agents. OBJECTIVES: To determine surveillance MR factors that motivate changes in tumor-directed therapies and extrapolate cost-efficacy of a non-contrast follow-up protocol. MATERIALS AND METHODS: Using an imaging database search we identified children with isolated optic pathway gliomas and ≥3 follow-up contrast-enhanced MRIs. We reviewed medical records and imaging for: (1) coincident changes on contrast-enhanced MRI and tumor-directed therapy, (2) demographics and duration of follow-up, (3) motivations for intervention, (4) assessment of gadolinium-based contrast agents' utility and (5) health care utilization data. We assessed cost impact in terms of relative value unit (RVU) burden. RESULTS: We included 17 neurofibromatosis type 1 (NF1) and 21 non-NF1patients who underwent a median 16.9 and 24.3 cumulative contrast-enhanced MR exams over 7.7 years and 8.1 years of follow-up, respectively. Eight children (one with NF1) had intervention based on contrast-enhanced MR findings alone. For these eight, increased tumor size was the only common feature, and it was apparent on non-contrast T2 sequences. For the median patient, a non-contrast follow-up protocol could result in 15.9 (NF1) and 23.3 (non-NF1) fewer gadolinium-based contrast agent administrations, and a 39% lower yearly RVU burden. CONCLUSION: Pediatric patients with isolated optic pathway gliomas undergo a large number of routine contrast-enhanced MR follow-up exams. Gadolinium might not be needed for these exams to inform management decisions. Secondary benefits of a non-contrast follow-up protocol include decreased cost and risk to the patient.
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