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