Challenges with the PRETEXT staging system: a SIOPEL Radiology Group position paper.

BACKGROUND

The PRETreatment EXTent of disease (PRETEXT) staging system is widely used in malignant pediatric liver tumors; however, significant challenges associated with this system remain.

OBJECTIVE

To describe challenges and limitations of the current PRETEXT system and propose potential strategies to mitigate them, from the European (SIOPEL) perspective.

METHODS

Expert insights from the SIOPEL Radiology Group, derived from both clinical and research experience, have been integrated into a position paper.

RESULTS

Key limitations include acquisition and inter-observer variability, definitional ambiguity for PRETEXT group and annotation factors, lack of structured reporting, gaps in surgical integration, and POST-Treatment EXTent of disease (POSTTEXT)-related pitfalls. Proposed strategies to address PRETEXT challenges include broader implementation of standardized imaging protocols and structured reporting, multidisciplinary integration, central review, definition refinement, and emerging technologies.

CONCLUSION

Addressing these challenges may improve diagnostic accuracy, risk stratification, and clinical decision-making in pediatric patients with malignant liver tumors.