Diagnostic accuracy of whole-body MRI versus standard imaging pathways for metastatic disease in newly diagnosed non-small-cell lung cancer: the prospective Streamline L trial

Streamline Investigators, Stuart A. Taylor*, Sue Mallett, Simon Ball, Sandy Beare, Gauraang Bhatnagar, Angshu Bhowmik, Peter Boavida, John Bridgewater, Caroline S. Clarke, Marian Duggan, Steve Ellis, Robert Glynne-Jones, Vicky Goh, Ashley M. Groves, Ayshea Hameeduddin, Sam M. Janes, Edward W. Johnston, Dow Mu Koh, Sara LockAnne Miles, Stephen Morris, Alison Morton, Neal Navani, Alfred Oliver, Terry O'Shaughnessy, Anwar R. Padhani, David Prezzi, Shonit Punwani, Laura Quinn, Hameed Rafiee, Krystyna Reczko, Andrea G. Rockall, Peter Russell, Harbir S. Sidhu, Nicola Strickland, Kathryn Tarver, Jonathan Teague, Steve Halligan, Ruth Evans, Khawaja Shahabuddin, Revanth Jannapureddy, Tina Mills-Baldock, Kishor Barhate, Zoltan Nagy, Sherif Raouf, Nathalie Rich, Tuck Kay Loke, Sofia Gourtsoyianni, Christian Kelly-Morland, Abel Jalloh

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

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Background: Whole-body magnetic resonance imaging (WB-MRI) could be an alternative to multi-modality staging of non-small-cell lung cancer (NSCLC), but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in NSCLC. Methods: The Streamline L trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed NSCLC that was potentially radically treatable on diagnostic chest CT (defined as stage IIIb or less). Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or histologies other than NSCLC. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs) and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN50436483, and is complete. Findings: Between Feb 26, 2013, and Sept 5, 2016, 976 patients were screened for eligibility. 353 patients were recruited, 187 of whom completed the trial; 52 (28%) had metastasis at baseline. Pathway sensitivity was 50% (95% CI 37–63) for WB-MRI and 54% (41–67) for standard pathways, a difference of 4% (−7 to 15, p=0·73). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (93% [88–96]) and standard pathways (95% [91–98], p=0·45). Agreement with the multidisciplinary team's final treatment decision was 98% for WB-MRI and 99% for the standard pathway. Time to complete staging was shorter for WB-MRI (13 days [12–14]) than for the standard pathway (19 days [17–21]); a 6-day (4–8) difference. The number of tests required was similar WB-MRI (one [1–1]) and standard pathways (one [1–2]). Mean per-patient costs were £317 (273–361) for WBI-MRI and £620 (574–666) for standard pathways. Interpretation: WB-MRI staging pathways have similar accuracy to standard pathways, and reduce the staging time and costs. Funding: UK National Institute for Health Research.

Original languageEnglish
Pages (from-to)523-532
Number of pages10
JournalThe Lancet Respiratory Medicine
Issue number6
Early online date9 May 2019
Publication statusPublished - 1 Jun 2019


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