Challenges with the PRETEXT staging system: a SIOPEL Radiology Group position paper
Abstract 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.
Authors
- Hanna Hebelka (ORCID: https://orcid.org/0000-0001-5304-8241)
- Helen Woodley (ORCID: https://orcid.org/0000-0003-2742-3882)
- Seema Toso (ORCID: https://orcid.org/0000-0002-8244-5825)
- Céline Habre (ORCID: https://orcid.org/0000-0003-2853-4349)
- Stéphanie Franchi‐Abella (ORCID: https://orcid.org/0000-0002-3200-751X)
- Annamaria Deganello (ORCID: https://orcid.org/0000-0003-4868-9604)
- Anneloes E. Bohte (ORCID: https://orcid.org/0000-0001-6814-6952)
- Sílvia Costa Dias (ORCID: https://orcid.org/0000-0003-0862-6967)
- Erika Pace (ORCID: https://orcid.org/0000-0002-5057-0154)
- Annemieke Simone Littooij (ORCID: https://orcid.org/0000-0002-1839-0882)
- Charlotte de Lange (ORCID: https://orcid.org/0000-0002-5990-1781)
- Siri Margrete Hugo Lohne (ORCID: https://orcid.org/0009-0003-4193-9321)
- Greg Chambers (ORCID: https://orcid.org/0000-0003-2000-3201)
- Simon Prosser McGuirk (ORCID: https://orcid.org/0009-0009-8095-5512)
- Jip Frederik Prince
Institutions
- Oslo University Hospital (NO)
- Royal Marsden NHS Foundation Trust (GB)
- Institute of Cancer Research (GB)
- Universidade do Porto (PT)
- University of Oslo (NO)
- Université Paris-Saclay (FR)
- Leeds Teaching Hospitals NHS Trust (GB)
- Sahlgrenska University Hospital (SE)
- Amsterdam UMC Location University of Amsterdam (NL)
- Hospital de São João (PT)
- University Hospital of Geneva (CH)
- Royal Marsden Hospital (GB)
- Princess Máxima Center (NL)
- Amsterdam University Medical Centers (NL)
- King's College Hospital (GB)
- Birmingham Women’s and Children’s NHS Foundation Trust (GB)
- Wilhelmina Children's Hospital (NL)
- Bicêtre Hospital (FR)
- University of Gothenburg (SE)
Publication Details
- Journal
- Pediatric Radiology
- Published
- 2026-10-05
- DOI
- https://doi.org/10.1007/s00247-026-06786-w
- Primary Topic
- Pediatric Hepatobiliary Diseases and Treatments
- Type
- article
- Field-Weighted Citation Impact
- 0.00