51
|
Colorectal Carcinoma: Local Tumor Staging and Assessment of Lymph Node Metastasis by High-Resolution MR Imaging in Surgical Specimens. Int J Biomed Imaging 2010; 2009:659836. [PMID: 20150975 PMCID: PMC2817863 DOI: 10.1155/2009/659836] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 09/16/2009] [Indexed: 01/13/2023] Open
Abstract
Purpose. To assess the accuracy of high-resolution MR imaging as a means of evaluating mural invasion and lymph node metastasis by colorectal carcinoma in surgical specimens. Materials and Methods. High-resolution T1-weighted and T2-weighted MR images were obtained in 92 surgical specimens containing 96 colorectal carcinomas. Results. T2-weighted MR images clearly depicted the normal colorectal wall as consisting of seven layers. In 90 (94%) of the 96 carcinomas the depth of mural invasion depicted by MR imaging correlated well with the histopathologic stage. Nodal signal intensity on T2-weighted images (93%) and nodal border contour (93%) were more accurate than nodal size (89%) as indicators of lymph node metastasis, and MR imaging provided the highest accuracy (94%-96%) when they were combined. Conclusion. High-resolution MR imaging is a very accurate method for evaluating both mural invasion and lymph node metastasis by colorectal carcinoma in surgical specimens.
Collapse
|
52
|
Yeung JMC, Ferris NJ, Lynch AC, Heriot AG. Preoperative staging of rectal cancer. Future Oncol 2009; 5:1295-306. [DOI: 10.2217/fon.09.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Preoperative staging is now an essential factor in the multidisciplinary management of rectal cancer because tumor stage is the strongest predictive factor for recurrence. Preoperative staging of rectal cancer can be divided into either local or distant staging. Local staging incorporates the assessment of mural wall invasion, circumferential resection margin involvement, as well as the nodal status for metastasis. Distant staging assesses for evidence of metastatic disease. The aim of this review is to consider the indications and limitations of the current preoperative imaging modalities for rectal cancer staging including clinical examination, endorectal ultrasound, magnetic resonance imaging, computed tomography and positron emission tomography–computed tomography, with respect to local and distant disease.
Collapse
Affiliation(s)
- Justin MC Yeung
- Colorectal Fellow, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Nicholas J Ferris
- Consultant Radiologist, Department of Diagnostic Radiology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - A Craig Lynch
- Consultant Surgeon, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Alexander G Heriot
- Consultant Surgeon, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| |
Collapse
|
53
|
Sebag-Montefiore D, Radhakrishna G. Choosing between short-course preoperative radiotherapy and long-course chemoradiation therapy. CURRENT COLORECTAL CANCER REPORTS 2009. [DOI: 10.1007/s11888-009-0032-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
54
|
Established, emerging and future roles of PET/CT in the management of colorectal cancer. Clin Radiol 2009; 64:225-37. [DOI: 10.1016/j.crad.2008.08.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Revised: 08/05/2008] [Accepted: 08/07/2008] [Indexed: 12/27/2022]
|
55
|
Piippo U, Pääkkö E, Mäkinen M, Mäkelä J. Local staging of rectal cancer using the black lumen magnetic resonance imaging technique. Scand J Surg 2009; 97:237-42. [PMID: 18812273 DOI: 10.1177/145749690809700306] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS The treatment of rectal cancer is comprised of surgery and possible adjuvant therapy depending on the stage of the tumour. This prospective study evaluates the accuracy of magnetic resonance imaging (MRI) in the preoperative staging of rectal cancer using an endorectal and intravenous contrast. MATERIALS AND METHODS 37 consecutive patients with rectal cancer were imaged using a mixture of ferumoxsil and methylcellulose endorectally, and a gadolinium contrast intravenously. 33 tumours were resected and 4 tumours were considered unresectable during operation. The images were reviewed for local staging of the tumours. A tumour confined to the rectal wall was classified as a negative finding and a tumour invading through muscularis propria as a positive finding. The results were correlated with the histopathologic t stage (n = 33), or the clinical status (n = 4). RESULTS AND CONCLUSIONS of 37 cases, 20 (51 %) were true positive, and 11 (28%) were true negative. There were 3 false negative and 3 false positive cases. The sensitivity was 87%, specificity 79%, and diagnostic accuracy 84%. for the non-contrast images the figures were 78%, 79% and 78%, respectively. We consider black lumen magnetic resonance imaging to be a useful method for preoperative local staging of rectal cancer.
Collapse
Affiliation(s)
- U Piippo
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland.
| | | | | | | |
Collapse
|
56
|
Halefoglu AM, Yildirim S, Avlanmis O, Sakiz D, Baykan A. Endorectal ultrasonography versus phased-array magnetic resonance imaging for preoperative staging of rectal cancer. World J Gastroenterol 2008; 14:3504-10. [PMID: 18567078 PMCID: PMC2716612 DOI: 10.3748/wjg.14.3504] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the diagnostic accuracy of pelvic phased-array magnetic resonance imaging (MRI) and endorectal ultrasonography (ERUS) in the preoperative staging of rectal carcinoma.
METHODS: Thirty-four patients (15 males, 19 females) with ages ranging between 29 and 75 who have biopsy proven rectal tumor underwent both MRI and ERUS examinations before surgery. All patients were evaluated to determine the diagnostic accuracy of depth of transmural tumor invasion and lymph node metastases. Imaging results were correlated with histopathological findings regarded as the gold standard and both modalities were compared in terms of predicting preoperative local staging of rectal carcinoma.
RESULTS: The pathological T stage of the tumors was: pT1 in 1 patient, pT2 in 9 patients, pT3 in 21 patients and pT4 in 3 patients. The pathological N stage of the tumors was: pN0 in 19 patients, pN1 in 9 patients and pN2 in 6 patients. The accuracy of T staging for MRI was 89.70% (27 out of 34). The sensitivity was 79.41% and the specificity was 93.14%. The accuracy of T staging for ERUS was 85.29% (24 out of 34). The sensitivity was 70.59% and the specificity was 90.20%. Detection of lymph node metastases using phased-array MRI gave an accuracy of 74.50% (21 out of 34). The sensitivity and specificity was found to be 61.76% and 80.88%, respectively. By using ERUS in the detection of lymph node metastases, an accuracy of 76.47% (18 out of 34) was obtained. The sensitivity and specificity were found to be 52.94% and 84.31%, respectively.
CONCLUSION: ERUS and phased-array MRI are complementary methods in the accurate preoperative staging of rectal cancer. In conclusion, we can state that phased-array MRI was observed to be slightly superior in determining the depth of transmural invasion (T stage) and has same value in detecting lymph node metastases (N stage) as compared to ERUS.
Collapse
|
57
|
Evidence and research in rectal cancer. Radiother Oncol 2008; 87:449-74. [PMID: 18534701 DOI: 10.1016/j.radonc.2008.05.022] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 05/14/2008] [Accepted: 05/15/2008] [Indexed: 12/20/2022]
Abstract
The main evidences of epidemiology, diagnostic imaging, pathology, surgery, radiotherapy, chemotherapy and follow-up are reviewed to optimize the routine treatment of rectal cancer according to a multidisciplinary approach. This paper reports on the knowledge shared between different specialists involved in the design and management of the multidisciplinary ESTRO Teaching Course on Rectal Cancer. The scenario of ongoing research is also addressed. In this time of changing treatments, it clearly appears that a common standard for large heterogeneous patient groups have to be substituted by more individualised therapies based on clinical-pathological features and very soon on molecular and genetic markers. Only trained multidisciplinary teams can face this new challenge and tailor the treatments according to the best scientific evidence for each patient.
Collapse
|
58
|
Kulkarni T, Gollins S, Maw A, Hobson P, Byrne R, Widdowson D. Magnetic resonance imaging in rectal cancer downstaged using neoadjuvant chemoradiation: accuracy of prediction of tumour stage and circumferential resection margin status. Colorectal Dis 2008; 10:479-89. [PMID: 18318754 DOI: 10.1111/j.1463-1318.2007.01451.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim was to examine the accuracy of magnetic resonance imaging (MRI) in predicting circumferential resection margin (CRM) involvement, T- and N-stage in patients with locally advanced carcinoma of the rectum, who had undergone long-course downstaging chemoradiation (CRT). METHOD Patients with rectal cancer were selected for long-course downstaging CRT if their tumour was considered to threaten (< or = 1 mm) or involve the CRM on MRI. Eighty such patients had a repeat MRI at a median of 6 weeks post-CRT followed by surgical excision soon thereafter. The findings on the post-CRT MRI were compared with histological examination of the surgical specimen. RESULTS For CRM involvement, post-CRT restaging MRI had an accuracy of 81% (65/80) a sensitivity of 54% (7/13), a specificity of 87% (58/67), a positive predictive value of 44% (7/16) and a negative predictive value of 91% (58/64). Accuracy for T- and N-staging was 43% (34/80) and 78% (62/80), respectively. 38% of T-stages were overstaged and 20% understaged. 4% of N-stages were overstaged and 19% understaged. The 13 patients with histological positive CRM had worse clinical outcomes than the 67 patients with negative CRM in terms of disease-free survival (relative risk of reduced DFS 4.6, P = 0.001) and overall survival (relative risk of death 3.6, P = 0.016). CONCLUSION Magnetic resonance imaging has good specificity and negative predictive value for predicting an uninvolved CRM post downstaging CRT in locally advanced rectal cancer although sensitivity and positive predictive value for an involved CRM were unsatisfactory. The shortcomings of MRI stem from poor differentiation of viable tumour from posttreatment changes and inability to identify small nodal and tumour deposits. Clinical correlates in this group of patients have confirmed the importance of achieving a clear CRM at surgery.
Collapse
Affiliation(s)
- T Kulkarni
- Department of Surgery, Glan Clwyd Hospital, Bodelwyddan, Denbighshire, UK
| | | | | | | | | | | |
Collapse
|
59
|
Anthonioz-Lescop C, Aubé C, Luet D, Lermite E, Burtin P, Ridereau-Zins C. [MR-endoscopic US correlation for loco-regional staging of rectal carcinoma]. ACTA ACUST UNITED AC 2008; 88:1865-72. [PMID: 18235347 DOI: 10.1016/s0221-0363(07)78364-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION To correlate findings at high-resolution MR and endoscopic US (EUS) for preoperative loco-regional staging of rectal carcinoma. PATIENTS AND METHODS Fifty-two patients with rectal carcinoma underwent high-resolution MR imaging. Only 43 of these patients underwent EUS due to technical limitations and stenosing carcinomas. Morphological imaging features and TNM staging were evaluated for both imaging modalities. The degree of correlation and accuracy were calculated for both. RESULTS The correlation between MR and EUS was good for tumor length and thickness (r=0.7 and 0.61) for for nodal (N) staging (k=0.53). Correlation was good for T1 and T2 stages (k=0.51) and T3 stage (k=0.43) and very poor for stage 4 (k= -0.09), because no T4 lesion was detected at EUS. 81.8% of patients where T stage was over-estimated on MRI and 100% of patients where T stage was over-estimated on EUS had received preoperative radiation therapy. Therefore, results should be interpreted with caution. The predictive evaluation of tumor resectability (absence of perirectal fascia invasion) with a circumferential margin on MR> or =5 mm was 93%. CONCLUSION Correlation between MR and EUS was moderate for T staging, because of limitations of EUS for large tumors. Results confirm that high-resolution MRI is useful for loco-regional staging of rectal carcinoma, especially for large tumors. EUS should be limited to the valuation of superficial tumors of the rectum.
Collapse
Affiliation(s)
- C Anthonioz-Lescop
- Département de Radiologie, Centre hospitalo-universitaire, 4 rue Larrey, Angers Cedex 09
| | | | | | | | | | | |
Collapse
|
60
|
Penna C. [Rectal adenocarcinoma: appropriate pretherapeutic explorations by tumor type]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2008; 32:S126-S132. [PMID: 18467051 DOI: 10.1016/j.gcb.2008.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- C Penna
- Fédération des spécialités digestives, hôpital Ambroise-Paré, AP-HP, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France.
| |
Collapse
|
61
|
Guillem JG, Díaz-González JA, Minsky BD, Valentini V, Jeong SY, Rodriguez-Bigas MA, Coco C, Leon R, Hernandez-Lizoain JL, Aristu JJ, Riedel ER, Nitti D, Wong WD, Pucciarelli S. cT3N0 rectal cancer: potential overtreatment with preoperative chemoradiotherapy is warranted. J Clin Oncol 2008; 26:368-73. [PMID: 18202411 DOI: 10.1200/jco.2007.13.5434] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Although combined-modality therapy (CMT) is the preferred treatment for T3 and/or lymph node (LN)-positive rectal cancer, the German rectal cancer study published in 2004 demonstrated that 18% of patients deemed suitable for preoperative CMT by endorectal ultrasound (ERUS) may be overstaged. Because data also suggest that LN-negative rectal cancer after total mesorectal excision may not require radiotherapy, it is reasonable to consider omitting radiotherapy for the cT3N0 subset. We therefore determined the accuracy of pre-CMT ERUS or magnetic resonance imaging (MRI) staging, to explore the validity of a nonpreoperative CMT approach for cT3N0 disease. PATIENTS AND METHODS One hundred eighty-eight ERUS-/MRI-staged T3N0 rectal cancer patients received preoperative CMT (fluorouracil based and 45-50.4 Gy) followed by radical resection. Rates of pathologic complete response (pCR) and mesorectal LN involvement were determined. RESULTS Tumors were located a median of 5 cm from the anal verge. Sphincter-preserving surgery was performed in 143 patients (76%). Overall pCR was 20%, and 41 patients (22%) had pathologically positive mesorectal LNs. The incidence of positive LNs significantly increased with T stage: ypT0, 3%; ypT1, 7%; ypT2, 20%; ypT3-4, 36% (P = .001). CONCLUSION The accuracy of preoperative ERUS/MRI for staging mid to distal cT3N0 rectal cancer is limited because 22% of patients have undetected mesorectal LN involvement despite CMT. Therefore, ERUS-/MRI-staged T3N0 rectal cancer patients should continue to receive preoperative CMT. Although 18% may be overstaged and therefore overtreated, our data suggest that an even larger number would be understaged and require postoperative CMT, which is associated with significantly inferior local control, higher toxicity, and worse functional outcome.
Collapse
Affiliation(s)
- José G Guillem
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
62
|
LeBlanc JK. Imaging and management of rectal cancer. ACTA ACUST UNITED AC 2008; 4:665-76. [PMID: 18043676 DOI: 10.1038/ncpgasthep0977] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Accepted: 08/31/2007] [Indexed: 02/06/2023]
Abstract
Local staging and management of rectal cancer has evolved during the past decade. Imaging modalities used for staging rectal cancer include CT, endoscopic ultrasound, pelvic phased-array coil MRI, endorectal MRI, and PET. Each modality has its strengths and limitations. Evidence supports the use of both endoscopic ultrasound and CT in staging rectal cancer. MRI is the only reliable tool for determining the status of the circumferential resection margin, which is important for the assessment of the risk of local recurrence.
Collapse
Affiliation(s)
- Julia K LeBlanc
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN 46202, USA.
| |
Collapse
|
63
|
Preoperative 3T MR imaging of rectal cancer: local staging accuracy using a two-dimensional and three-dimensional T2-weighted turbo spin echo sequence. Eur J Radiol 2007; 65:66-71. [PMID: 18164156 DOI: 10.1016/j.ejrad.2007.11.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Accepted: 11/15/2007] [Indexed: 01/11/2023]
Abstract
PURPOSE The purpose of our study was to evaluate the image quality and diagnostic performance of two-dimensional (D) turbo spin echo (TSE) and 3D T2-weighted TSE MR imaging in local staging of rectal cancer at 3T. MATERIALS AND METHODS 3T phased-array MR imaging was performed in 36 consecutive patients with biopsy-proven rectal cancer. High-resolution 2D TSE images in three planes and 3D TSE images of the rectum were obtained. Two independent observers performed an image quality assessment using eight image quality characteristics. All 2D and 3D datasets were evaluated separately. MR images were prospectively evaluated by two experienced radiologists in consensus with regard to local disease. Total mesorectal excision was used as the standard of reference. The sensitivity, specificity, positive and negative predictive value, and overall accuracy were calculated. Areas under the receiver operating characteristic (ROC) curve (AUC) were determined. RESULTS Twenty-two patients who underwent a total mesorectal excision were enrolled in this study. Significantly more motion artifacts were present with 3D TSE imaging (P=0.04). The overall sensitivity, specificity, and accuracy of muscularis propria invasion in rectal cancer using 2D T2-weighted images were 100%, 66%, and 95%, respectively. There was a statistical significant greater AUC using 2D T2-weighted images compared to 3D T2-weighted MR images (P=0.04). The ROC curves describing the results of the interpretation of 2D and 3D T2-weighted datasets regarding perirectal tissue invasion showed no statistical significant difference (P=0.41). CONCLUSIONS In this study, high local staging accuracies with 3T 2D T2-weighted MR imaging were demonstrated. 3D T2-weighted MR imaging cannot replace 2D MR imaging for local staging of rectal cancer. However, 3D MR imaging can be used for visualization of the complex pelvic anatomy for treatment planning purposes.
Collapse
|
64
|
Vandenbroucke F, Dujardin M, Ilsen B, Craggs B, Op de Beeck B, de Mey J. Indications for body MRI Part II: retroperitoneum, intestines and pelvis. Eur J Radiol 2007; 65:222-7. [PMID: 18096342 DOI: 10.1016/j.ejrad.2007.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Accepted: 11/07/2007] [Indexed: 11/16/2022]
Abstract
In this article an overview is given of the present knowledge of whole body MRI, MRI of the retroperitoneum, intestines and pelvis. Recommendations are based on current literature and clinical applications in daily routine focusing on efficacy rather than cost considerations. The contribution and complementary role of MRI relative to those of its competing modalities was the most important endpoint assessed. Perfusion and functional information, as well as specific contrast agents in the area of the pelvis are still considered research indications.
Collapse
Affiliation(s)
- F Vandenbroucke
- Department of Radiology, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|
65
|
Yamada I, Okabe S, Enomoto M, Sugihara K, Yoshino N, Tetsumura A, Kumagai J, Shibuya H. Colorectal carcinoma: in vitro evaluation with high-spatial-resolution 3D constructive interference in steady-state MR imaging. Radiology 2007; 246:444-53. [PMID: 18094265 DOI: 10.1148/radiol.2462070128] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To retrospectively assess the accuracy of high-spatial-resolution three-dimensional (3D) constructive interference in steady-state (CISS) magnetic resonance (MR) imaging in the evaluation of mural invasion of colorectal carcinoma by using prospectively obtained in vitro images, with histopathologic analysis as the reference standard. MATERIALS AND METHODS Institutional review board approval was obtained for the prospective and retrospective components of this study, with informed consent for the former and waiver of informed consent for the latter. Surgical specimens were obtained in 92 patients (61 men, 31 women; mean age, 65 years) and contained 96 colorectal carcinomas. Specimens were examined with a 1.5-T MR system and a 4-cm-diameter loop coil. High-spatial-resolution 3D CISS MR images were obtained with 80 x 80-mm field of view, 512 x 512 matrix, and 0.7-mm section thickness, which resulted in a 0.017-mm(3) voxel size. The 3D data sets were postprocessed with surface-rendering software to generate virtual MR endoscopic images. The 3D CISS MR images were compared with histopathologic findings, and virtual MR endoscopic images were compared with macroscopic findings at surgery. Statistical analysis was performed with Spearman rank correlation. RESULTS In 92 (96%) colorectal carcinomas, the depth of mural invasion depicted by 3D CISS MR imaging correlated well with the histopathologic stage, although the stage assigned with 3D CISS MR imaging was higher than that assigned with histopathologic analysis in four (4%) carcinomas (r = 0.976, P < .001). Sensitivity, specificity, and accuracy were 100%, 94%-96%, and 98%-100%, respectively. In 91 (95%) carcinomas, virtual MR endoscopy clearly depicted the macroscopic type of carcinoma, including gross configuration and tumor ulceration (r = 0.916, P < .001). CONCLUSION High-spatial-resolution 3D CISS MR imaging has high diagnostic accuracy in the in vitro evaluation of mural invasion and macroscopic features of colorectal carcinomas.
Collapse
Affiliation(s)
- Ichiro Yamada
- Department of Diagnostic Radiology and Oncology, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | | | | | | | | | | | | | | |
Collapse
|
66
|
Abstract
At present, several modalities exist for the preoperative staging of rectal lesions, including computed tomography (CT), body coil or endorectal coil magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS) done by rigid or flexible probes, and positron emission tomography (PET). Staging accuracy for CT ranges from 53% to 94% for T-stage accuracy and from 54% to 70% for N-stage accuracy. Improved CT accuracy is observed at higher disease stages. Body coil MRI has shown T- and N-stage accuracy ranging from 59% to 95% and 39% to 95%, respectively. Endorectal coil MRI has shown improved T- and N-stage accuracy, with rates of 66% to 91% and 72% to 79%, respectively. The development of phased-array MRI, combining high spatial resolution with a larger field of view, offers promise to improve on these rates. EUS, considered the current gold standard, has shown T-stage accuracy ranging from 75% to 95%, with N-stage accuracy ranging from 65% to 80%. Flexible EUS probes have the advantage of being able to access and sample iliac nodes. Recent studies also suggest that three-dimensional EUS may provide greater accuracy than conventional two-dimensional EUS. Limited studies exist on the use of PET in primary tumor staging. PET may upstage disease in 8% to 24% of patients and has also been used in posttreatment restaging and surveillance. Postradiation edema, necrosis, and fibrosis seem to decrease restaging accuracy in all modalities. This article reviews the current literature about the staging accuracy of the various modalities and suggests a staging algorithm for rectal cancer.
Collapse
Affiliation(s)
- V Raman Muthusamy
- H H Chao Comprehensive Digestive Disease Center, Chao Family Comprehensive Cancer Center, Department of Medicine, University of California, Irvine Medical Center, Orange, CA 92868, USA
| | | |
Collapse
|
67
|
Bipat S, Zwinderman AH, Bossuyt PMM, Stoker J. Multivariate random-effects approach: for meta-analysis of cancer staging studies. Acad Radiol 2007; 14:974-84. [PMID: 17659244 DOI: 10.1016/j.acra.2007.05.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/08/2007] [Accepted: 05/08/2007] [Indexed: 12/12/2022]
Abstract
RATIONALE AND OBJECTIVES Meta-analyses of diagnostic accuracy studies produce summary estimates of sensitivity and specificity. Cancer staging relies on staging systems and meta-analysis is often performed after dichotomization of the staging results. For each dichotomization, summary estimates of sensitivity and specificity can be calculated by repeated bivariate random-effects analyses. In this process, staging information is lost and under- and overstaging can not be adequately expressed. MATERIALS AND METHODS We propose a new multivariate random-effects approach, which is an extension of the bivariate random-effects approach. To illustrate the principles and outcomes of both approaches, we used data from a meta-analysisevaluating endoluminal ultrasonography in staging of rectal cancer. In the multivariate approach, results on correct staging and under- and overstaging were calculated. In addition, the results from this analysis were used to calculate sensitivity and specificity estimates for each dichotomization and these estimates were compared with the results of the repeated bivariate analyses. RESULTS By the multivariate analysis, results on correct staging and under- and overstaging were obtained. The sensitivity and specificity estimates for the dichotomizations, calculated from the results of this multivariate approach, were also comparable with the sensitivity and specificity estimates obtained by the repeated bivariate analyses. CONCLUSIONS The multivariate random-effects approach can be a useful meta-analytic method for summarizing cancer staging data presented in diagnostic accuracy studies.
Collapse
Affiliation(s)
- Shandra Bipat
- Department of Radiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
68
|
Daniels IR, Fisher SE, Heald RJ, Moran BJ. Accurate staging, selective preoperative therapy and optimal surgery improves outcome in rectal cancer: a review of the recent evidence. Colorectal Dis 2007; 9:290-301. [PMID: 17432979 DOI: 10.1111/j.1463-1318.2006.01116.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The current optimal management of locally advanced rectal cancer has evolved from surgical excision followed by postoperative therapy in patients with involved margins, to an increasing use of a preoperative strategy to 'down-stage and/or down-size' the tumour. This treatment strategy is based on the relationship of the tumour to the mesorectal fascia, the optimal surgical circumferential resection margin that can be achieved by total mesorectal excision. We have reviewed the recent evidence for this strategy. METHOD An electronic literature search using PubMed identified articles on the subject of rectal cancer between January 2000 and December 2005. The search was limited to English language publications with secondary references obtained from key articles. Articles published in high impact factor journals formed the basis of the review, together with articles related to national programmes on the management of rectal cancer. This does lead to a selection bias, particularly as the articles identified had a European bias. CONCLUSION The UK NHS Cancer Plan has outlined the basis for the multidisciplinary team (MDT) management of rectal cancer. Advances in preoperative assessment through accurate staging and the recognition of the importance of the relationship of the tumour to the mesorectal fascia has allowed the selection of patients for a preoperative strategy to down-size/down-stage the tumour if this fascial layer is involved or threatened. Improvements in the quality of surgical resection through the acceptance of the principle of total mesorectal excision have ensured that optimal surgery remains the cornerstone to successful treatment. Further refinements of the MDT process strive to improve outcome. Accurate radiological staging, optimal surgery and detailed histopathological assessment together with consideration of a preoperative neoadjuvant strategy should now form the basis for current treatment and future research in rectal cancer.
Collapse
Affiliation(s)
- I R Daniels
- Pelican Cancer Foundation, North Hampshire Hospital, Basingstoke RG24 9NA, UK
| | | | | | | |
Collapse
|
69
|
Abstract
With improvements in therapy for colorectal cancer, accurate imaging has taken on an increased significance. Preoperative diagnosis of metastatic disease helps identify patients who could undergo combined resection or might benefit from systemic therapy before surgery. Accurate imaging of rectal cancer is critical in evaluating locally advanced disease treatable by combined modality therapy, including chemoradiation and surgery. Postoperative imaging enhances identification of recurrent disease that might be amenable to salvage surgery.
Collapse
Affiliation(s)
- Carl R Schmidt
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
| | | | | |
Collapse
|
70
|
Yamashita S, Masui T, Katayama M, Sato K, Yoshizawa N, Seo H, Sakahara H. T2-weighted MRI of rectosigmoid carcinoma: comparison of respiratory-triggered fast spin-echo, breathhold fast-recovery fast spin-echo, and breathhold single-shot fast spin-echo sequences. J Magn Reson Imaging 2007; 25:511-6. [PMID: 17326094 DOI: 10.1002/jmri.20827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To compare the abilities of T2-weighted (T2W) imaging using respiratory-triggered fast spin-echo (RT-FSE), breathhold fast-recovery FSE (BH-FRFSE), and BH single-shot FSE (BH-SSFSE) sequences without an endorectal coil to detect rectosigmoid carcinomas. MATERIALS AND METHODS Forty patients (stage: pT0, 1; pTis-2, 15; pT3-4, 24) were included in the study. All examinations were performed on a 1.5T magnet with a phased-array coil and the patients were studied in the prone position with per-anal air injection. Qualitative and quantitative evaluations were performed. RESULTS Motion artifact was the most prominent with the RT-FSE sequence, and the least prominent with the BH-SSFSE sequence. Scores for depiction of the rectal wall layer, tumor recognition, and overall image quality were the highest with the BH-FRFSE sequence. On the basis of a receiver operating characteristic (ROC) analysis, the detection rate of tumor invasion through the rectal wall was higher with the BH-FRFSE sequence (Az = 0.9077) than with the RT-FSE (Az = 0.7762, p < 0.05) or BH-SSFSE (Az = 0.8602) sequence. Tumor-to-fat contrast was highest with the BH-FRFSE sequence (P < 0.017). CONCLUSION The BH-FRFSE sequence may be the first choice for rectosigmoid T2W imaging in the prone position with per-anal air injection for patients who can hold their breath stably.
Collapse
Affiliation(s)
- Shuhei Yamashita
- Department of Radiology, Seirei Hamamatsu General Hospital, Shizuoka, Japan.
| | | | | | | | | | | | | |
Collapse
|
71
|
Torkzad MR, Lindholm J, Martling A, Cedermark B, Glimelius B, Blomqvist L. MRI after preoperative radiotherapy for rectal cancer; correlation with histopathology and the role of volumetry. Eur Radiol 2007; 17:1566-73. [PMID: 17265052 DOI: 10.1007/s00330-006-0518-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Revised: 10/02/2006] [Accepted: 10/24/2006] [Indexed: 12/15/2022]
Abstract
The objective is to assess if tumor size after radiotherapy in patients with rectal cancer can be assessed by a second magnetic resonance imaging (MRI), after radiotherapy prior to surgery and to correlate changes observed on MRI with findings at histopathology at surgery. Twenty-five patients with MRI before and after radiotherapy were included. Variables studied were changes in tumor size, T-staging and distance to the circumferential resection margin (CRM). RVs was measured as tumor volume at surgery (Vs) divided by tumor volume at the initial MRI (Vi) in percent. RVm was defined as the tumor volume at the second MRI (Vm) divided by Vi in percent. The ypT-stage was the same or more favorable than the initial MRI T-stage in 24 of 25 patients. The second MRI was not more accurately predictive than the initial MRI for ypT-staging or distance to CRM (p > 0.05). Vm correlated significantly to Vs, as did RVs to RVm, although the former was always smaller than the latter. Vm and RVm correlated well with ypT-stage (p < 0.001). Volumetry seems to correlate with ypT-stage after preoperative radiotherapy for resectable rectal cancer. The value of a second MRI after radiotherapy for assessment of distance to CRM and ypT-staging is, however, not apparent.
Collapse
Affiliation(s)
- Michael R Torkzad
- Radiology Department Solna, Karolinska University Hospital & Karolinska Institutet, SE-17176 Stockholm, Sweden.
| | | | | | | | | | | |
Collapse
|
72
|
Torkzad MR, Hansson KA, Lindholm J, Martling A, Blomqvist L. Significance of mesorectal volume in staging of rectal cancer with magnetic resonance imaging and the assessment of involvement of the mesorectal fascia. Eur Radiol 2006; 17:1694-9. [PMID: 17186247 DOI: 10.1007/s00330-006-0521-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 09/11/2006] [Accepted: 11/03/2006] [Indexed: 01/11/2023]
Abstract
The aim was to study the influence of mesorectal volume, as estimated by magnetic resonance imaging (MRI), that is to be removed during total mesorectal excision (TME), on the accuracy of the first preoperative MRI of rectal cancer compared to histopathology, and its correlation to locoregional prognostic factors. A total of 267 rectal cancer patients from a multinational study (MERCURY or MRI equivalence study) had their mesorectal volume retrospectively estimated by researchers without knowledge of the assessments made by the radiologist or the pathologist. The evaluations made by the pathologist and the radiologist were then compared, including T- and N-staging, assessment of extent of extramural tumor invasion (the largest portion of the tumor beyond the muscularis propria or EMI) and distance to mesorectal fascia; the discrepancies in the results were correlated to the mesorectal volume. T- or N-staging accuracy by MRI and the difference between the EMI as measured by the pathologist and the radiologist were not dependent on individual mesorectal volume. There was no correlation between assessment of involvement of mesorectal fascia or local neighboring organs by MRI and histopathology with mesorectal volume. Mesorectal volume does not affect locoregional prognostic factors or the accuracy of local staging of rectal cancer.
Collapse
Affiliation(s)
- Michael R Torkzad
- Department of Diagnostic Radiology, Karolinska University Hospital, Solna, Stockholm, Sweden.
| | | | | | | | | |
Collapse
|
73
|
Abstract
Preoperative staging of rectal cancer can influence the choice of surgery and the use of neoadjuvant therapy. This review evaluates the use of endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI) in the local staging of rectal cancer. Staging for distant metastases is beyond the scope of this review. A MEDLINE search for published work in English between 1984-2004 was carried out by entering the key words of ERUS, MRI and preoperative imaging and rectal cancer. Initially, 867 articles were retrieved. Abstracts were reviewed and papers selected according to the inclusion criteria of a minimum of 50 patients and papers published in English. Papers focusing on preoperative chemoradiotherapy and distal metastases were excluded. Thirty-one papers were included in the systematic review. The examination techniques and images obtained are discussed and the respective accuracy is reviewed. ERUS and MRI have complementary roles in the assessment of tumour depth. Ultrasound has an overall accuracy of 82% (T1, 2, 40-100%; T3, 4, 25-100%) and is particularly useful for early localized rectal cancers. MRI has an accuracy of 76% (T1, 2, 29-80%; T3, 4, 0-100%) and is useful in more advanced disease by providing clearer definition of the mesorectum and mesorectal fascia. Both methods have similar accuracy in the assessment of nodal metastases. Ultrasound is more operator dependent and accuracies improve with experience, but it is more portable and accessible than MRI. Improvements in technology and increased operator experience have led to more accurate preoperative staging. ERUS and MRI are complementary and are most accurate for early localized cancers and more advanced cancers, respectively.
Collapse
Affiliation(s)
- Anita R Skandarajah
- Department of Colorectal Surgery, Royal Melbourne and Epworth Hospitals, Australia
| | | |
Collapse
|
74
|
Maretto I, Pomerri F, Pucciarelli S, Mescoli C, Belluco E, Burzi S, Rugge M, Muzzio PC, Nitti D. The potential of restaging in the prediction of pathologic response after preoperative chemoradiotherapy for rectal cancer. Ann Surg Oncol 2006; 14:455-61. [PMID: 17139456 DOI: 10.1245/s10434-006-9269-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Revised: 10/17/2006] [Accepted: 10/18/2006] [Indexed: 12/16/2022]
Abstract
BACKGROUND We performed this study to prospectively evaluate the postchemoradiotherapy performance of transrectal ultrasonography (TRUS), pelvic computed tomography (CT) scan and magnetic resonance imaging (MRI), and endoscopic biopsies for predicting the pathologic complete response of rectal cancer patients. METHODS Four weeks after completion of preoperative chemoradiotherapy, 46 consecutive patients with mid to low rectal cancer were prospectively evaluated by proctoscopy, TRUS, and pelvic CT scan and MRI. On the basis of T and N status, patients were classified as T0 or T1-4 and N-negative or N-positive. For each staging modality used, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. Findings were compared with the pathologic tumor-node-metastasis stage. RESULTS On histopathologic analysis, 12 patients had pT0 and 34 had pT1-4 lesions; out of 45 assessable patients, 9 were N-positive. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in predicting T status (T0 vs. T >or=1) were 77%, 33%, 74%, 36%, and 64%, respectively, for TRUS; 100%, 0%, 74%, not assessable, and 74% for CT; and 100%, 0%, 77%, not assessable, and 77% for MRI. The corresponding figures in predicting N status (N-negative vs. N-positive) were, respectively, 37%, 67%, 21%, 81%, and 61% for TRUS; 78%, 58%, 32%, 91%, and 62% for CT; and 33%, 74%, 25%, 81%, and 65% for MRI. CONCLUSIONS Current rectal cancer staging modalities after chemoradiotherapy allow good prediction of node-negative cases, although none of them is able to predict the pathologic complete response on the rectal wall.
Collapse
Affiliation(s)
- Isacco Maretto
- Department of Oncological and Surgical Sciences, Clinica Chirurgica II, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
75
|
Chun HK, Choi D, Kim MJ, Lee J, Yun SH, Kim SH, Lee SJ, Kim CK. Preoperative Staging of Rectal Cancer: Comparison of 3-T High-Field MRI and Endorectal Sonography. AJR Am J Roentgenol 2006; 187:1557-62. [PMID: 17114550 DOI: 10.2214/ajr.05.1234] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of this study was to compare phased-array 3-T MRI and endorectal sonography in the preoperative staging of rectal cancer. MATERIALS AND METHODS During an 8-month period, 24 patients with rectal cancer underwent both 3-T MRI performed with phased-array coils and 7.5- to 10-MHz endorectal sonography in the 3 weeks before surgical resection. Three radiologists independently reviewed the MR and endorectal sonographic images. The histopathologic findings in resected specimens were used to evaluate the sensitivities and specificities of these techniques for invasion of the muscularis propria and perirectal tissue and for lymph node involvement. Receiver operating characteristic (ROC) analysis was used to compare the diagnostic accuracies of the techniques. RESULTS For muscularis propria invasion, the mean sensitivities of both MRI and endorectal sonography were 100%, and the mean specificities were 66.7% and 61.1%, respectively. The differences in the mean sensitivities and specificities were not statistically significant (p > 0.05 in each case). For perirectal tissue invasion, MRI and endorectal sonography had comparable sensitivities and specificities (91.1% vs 100%, 92.6% vs 81.5%; p > 0.05 in each case). They also had similar sensitivities and specificities for lymph node involvement (63.6% vs 57.6%, 92.3% vs 82.1%; p > 0.05 in each case). ROC curves for muscularis propria invasion and lymph node involvement showed no differences in diagnostic accuracy. The mean area under the ROC curve for endorectal sonography (A(Z) = 0.996) for perirectal tissue invasion, however, showed higher accuracy than that of MRI (A(Z) = 0.938, p = 0.028). CONCLUSION The sensitivity, specificity, and accuracy of 3-T MRI were similar to those of endorectal sonography for muscularis propria invasion and lymph node involvement, but for perirectal tissue invasion, 3-T MRI was less accurate than endorectal sonography.
Collapse
Affiliation(s)
- Ho-Kyung Chun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | | | | | | | | | | | | |
Collapse
|
76
|
Iafrate F, Laghi A, Paolantonio P, Rengo M, Mercantini P, Ferri M, Ziparo V, Passariello R. Preoperative staging of rectal cancer with MR Imaging: correlation with surgical and histopathologic findings. Radiographics 2006; 26:701-14. [PMID: 16702449 DOI: 10.1148/rg.263055086] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Rectal cancer is a common malignancy that continues to have a highly variable outcome, with local pelvic recurrence after surgical resection usually leading to incurable disease. The success of tumor excision depends largely upon accurate tumor staging and appropriate surgical technique, although the results of recent surgical trials indicate that evaluation of the involvement of the mesorectal fat and mesorectal fascia is even more important than T staging for treatment planning. Magnetic resonance (MR) imaging is increasingly being used to evaluate tumor resectability in patients with rectal cancer and to determine which patients can be treated with surgery alone and which will require radiation therapy to promote tumor regression. High-spatial-resolution MR imaging has proved useful in clarifying the relationship between a tumor and the mesorectal fascia, which represents the circumferential resection margin at total mesorectal excision. Phased-array surface coil MR imaging in particular plays a vital role in the therapeutic management of rectal cancer. At present, phased-array MR imaging best fulfills the clinical requirements for preoperative staging of rectal cancer. However, preoperative evaluation of the other prognostic factor, nodal status, is still problematic, and further studies will be needed to better define the role of MR imaging in this context.
Collapse
Affiliation(s)
- Franco Iafrate
- Department of Radiological Sciences, University of Rome La Sapienza, Policlinico Umberto I, Viale Regina Elena 324, 00161 Rome, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
77
|
Tatli S, Mortele KJ, Breen EL, Bleday R, Silverman SG. Local staging of rectal cancer using combined pelvic phased-array and endorectal coil MRI. J Magn Reson Imaging 2006; 23:534-40. [PMID: 16523466 DOI: 10.1002/jmri.20533] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
PURPOSE To assess the accuracy of MRI, using a pelvic phased-array coil and an endorectal coil, for preoperative local staging of rectal cancer. MATERIALS AND METHODS Fifty-one patients (26 males and 25 females) with adenocarcinoma of the rectum underwent preoperative MRI and surgical resection of their tumors. Surgical pathology staging was compared to MRI staging (using the TNM classification) obtained both retrospectively by a reader blinded to surgical findings and prospectively (radiological reports). In addition, patients were stratified according to surgical treatment groups (stage I = T1-2/N0, stage II = T3/N0, stage III = Tx/N1-2). RESULTS At pathology, 36 of 51 (68%) tumors were classified as T0-T2, and 15 (32%) were classified as T3. Overall, the sensitivity and specificity of MRI readings for T3 staging were 93% and 86%, respectively (positive predictive value (PPV) = 74%, negative predictive value (NPV) = 97%, accuracy = 88%). MRI correctly predicted lymph node metastases in 11 of 13 patients with a sensitivity of 85% and specificity of 69% (PPV = 58%, NPV = 90%, accuracy = 74%). MRI correctly predicted surgical treatment groups in 33 of 39 (85%) patients. Interobserver agreement between the retrospective and prospective readings was excellent (kappa = 0.85) for prediction of T3 tumor and good (kappa = 0.80) for prediction of nodal involvement. CONCLUSION Combined endorectal and pelvic phased-array coil MRI can be used reliably to select which patients should receive preoperative chemoradiotherapy. It is highly predictive in terms of excluding T3 tumors, but still has limitations in predicting lymph node metastasis.
Collapse
Affiliation(s)
- Servet Tatli
- Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
| | | | | | | | | |
Collapse
|
78
|
Abstract
Surgery is a primary modality for the treatment of patients with colorectal cancer. Before any surgical therapy, patients diagnosed with colorectal cancer require an evaluation. This preoperative evaluation can be used to assess the patient's risk associated with surgery, plan the surgical resection, and stage the patient's cancer. Staging of the cancer preoperatively is primarily of concern in rectal cancer patients. This article focuses on the elective surgical setting and the recommended preoperative evaluation of patients who have been diagnosed with colorectal cancer.
Collapse
Affiliation(s)
- James T McCormick
- Department of Surgery, The Western Pennsylvania Hospital, 4800 Friendship Avenue, Pittsburgh, PA 15224, USA
| | | |
Collapse
|
79
|
Kim CK, Kim SH, Chun HK, Lee WY, Yun SH, Song SY, Choi D, Lim HK, Kim MJ, Lee J, Lee SJ. Preoperative staging of rectal cancer: accuracy of 3-Tesla magnetic resonance imaging. Eur Radiol 2006; 16:972-80. [PMID: 16416276 DOI: 10.1007/s00330-005-0084-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 11/07/2005] [Accepted: 11/10/2005] [Indexed: 12/31/2022]
Abstract
The purpose of this study was to evaluate the accuracy of 3-Tesla magnetic resonance imaging (MRI) for the preoperative staging of rectal cancer. Thirty-five patients with a primary rectal cancer who underwent preoperative 3-T MRI using a phased-array coil and had a surgical resection were enrolled in the study group. Preoperatively, three experienced radiologists independently assessed the T and N staging. A confidence level scoring system was used to determine if there was any perirectal invasion, and receiver operating characteristic (ROC) curves were generated. The interobserver agreement was estimated using kappa statistics. The overall accuracy rate of T staging for rectal cancer was 92%. The diagnostic accuracy was 97% for T1, 89% for T2 and 91% for T3, respectively. The predictive accuracy for perirectal invasion by the three observers was high (Az>0.92). The interobserver agreement for T staging was moderate to substantial. The overall sensitivity, specificity, and accuracy for the detection of mesorectal nodal metastases were 80%, 98%, and 95%, respectively. In conclusion, preoperative 3-T MRI using a phase-array coil accurately indicates the depth of tumor invasion for rectal cancer with a low variability.
Collapse
Affiliation(s)
- Chan Kyo Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Seoul, 135-710, South Korea
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
80
|
Staging in colorectal cancer. EJC Suppl 2005. [DOI: 10.1016/s1359-6349(05)80296-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
81
|
|
82
|
Zammit M, Jenkins JT, Urie A, O'Dwyer PJ, Molloy RG. A technically difficult endorectal ultrasound is more likely to be inaccurate. Colorectal Dis 2005; 7:486-91. [PMID: 16108886 DOI: 10.1111/j.1463-1318.2005.00869.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Endorectal ultrasound (ERUS) is well established as an accurate modality for local staging of rectal tumours. The aim of this study was to identify reasons for inaccurate staging of tumours, and to assess whether difficulties encountered during scanning are likely to influence accuracy. PATIENTS AND METHODS ERUS was performed by a single operator using a 10 MHz rigid instrument. One hundred and seventeen patients that had both ERUS and surgery are included in this study (patients that had pre-operative radiotherapy were excluded). During ERUS, procedural conditions and limiting factors were recorded. Data was collected prospectively. RESULTS In 78 (66.7%) patients no technical difficulty was encountered during ERUS. In this group accuracy was 80% for T-stage and 77% for N-stage. Specific reasons for inaccuracy identified in this group were: inflammatory lymph nodes (from a tumour associated abscess and a colovesical fistula) and deep biopsy causing a submucosal defect with intramural haemorrhage in benign lesions (2 cases). In the remaining 39 (33.3%), the following problems were encountered: stenotic lesions (23), patient discomfort (8), poor bowel preparation (6), and scarring from previous surgery (2). In 11 patients from this group, the scan was considered inconclusive and no stage could be determined. For the other 28, the accuracy for T-stage was 68% and for N-stage 67%. CONCLUSION A technically difficult ERUS is likely to give an inconclusive or inaccurate result for both T-stage (P = 0.001) and N-stage (P = 0.003). In this situation a repeat scan may be considered (where appropriate). Alternatively, further assessment by MRI or flexible endoscopic ultrasound may be considered.
Collapse
Affiliation(s)
- M Zammit
- Department of Surgical Gastroenterology, Gartnavel General Hospital and Western Infirmary, Glasgow, UK
| | | | | | | | | |
Collapse
|
83
|
Guerrero V, Perretta S, Garcia-Aguilar J. Extended Abdominoperineal Resection. SEMINARS IN COLON AND RECTAL SURGERY 2005. [DOI: 10.1053/j.scrs.2005.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
84
|
Poon FW, McDonald A, Anderson JH, Duthie F, Rodger C, McCurrach G, McKee RF, Horgan PG, Foulis AK, Chong D, Finlay IG. Accuracy of thin section magnetic resonance using phased-array pelvic coil in predicting the T-staging of rectal cancer. Eur J Radiol 2005; 53:256-62. [PMID: 15664289 DOI: 10.1016/j.ejrad.2004.03.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2003] [Revised: 03/11/2004] [Accepted: 03/15/2004] [Indexed: 12/26/2022]
Abstract
Magnetic resonance (MR) imaging may contribute to staging rectal cancer and inform the decision regarding administration of pre-operative radiotherapy. The accuracy of MR has been debated. The aim of the present study was to determine the accuracy of thin section T2-weighted MR images in rectal cancer patients. MR results were compared with histological assessment of resection specimens. Over a 2-year period, 42 patients were studied. Histological staging was pT2 n = 13, pT3 n = 25 and pT4 n = 4. MR diagnostic accuracy was 74%. MR sensitivity and specificity was 62% and 79% for pT2 lesions, 84% and 59% for pT3 lesions and 50% and 76% for pT4 lesions. Estimation of tumour penetration by thin section MR imaging of rectal cancers using pelvic phased-array coil has moderate diagnostic accuracy. The limitations of MR should be acknowledged when selecting rectal cancer patients for pre-operative radiotherapy.
Collapse
Affiliation(s)
- F W Poon
- Department of Radiology, Royal Infirmary, Alexandra Parade, Glasgow, Scotland, UK.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
85
|
Koh DM, Brown G, Temple L, Blake H, Raja A, Toomey P, Bett N, Farhat S, Norman AR, Daniels I, Husband JE. Distribution of mesorectal lymph nodes in rectal cancer: in vivo MR imaging compared with histopathological examination. Initial observations. Eur Radiol 2005; 15:1650-7. [PMID: 15868124 DOI: 10.1007/s00330-005-2751-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2004] [Revised: 03/16/2005] [Accepted: 03/18/2005] [Indexed: 02/07/2023]
Abstract
The aim of this work was to determine the distribution of mesorectal lymph nodes using T2-weighted magnetic resonance (MR) imaging compared with histopathological findings in patients with rectal carcinoma. Sixteen patients with rectal carcinoma undergoing primary surgery without pre-operative neoadjuvant treatment were evaluated using 3-mm axial T2-weighted MR imaging. The position of each visible mesorectal node on imaging was localised by measuring its minimum distance from the mesorectal fascia (d(m)), its minimum distance from the rectal wall (d(r)) and its distance from the distal tumour margin (d(v)). Independent assessment of d(m), d(r) and d(v) was made at histopathological examination. Eighty-five mesorectal nodes on in vivo MR imaging were matched to histopathological findings. On imaging, 67/85 mesorectal nodes were found at the level of the tumour and 84/85 were identified at or within 5 cm proximal to the tumour. Only one out of 85 nodes was seen below the inferior tumour margin. The mean difference of d(m) and d(r) obtained on in vivo MR imaging and histopathological examination was 0.7 mm (95% confidence interval, CI, -0.12 to 1.42 mm) and -1.1 mm (95% CI -2.29 to 0.14 mm), respectively. Almost all mesorectal nodes visible on MR imaging were found at the level of tumour or within 5 cm proximal to the tumour. This has implications for the planning of MR imaging and the level of mesorectal transection at surgery.
Collapse
Affiliation(s)
- D M Koh
- Academic Department of Radiology, Cancer Research UK Magnetic Resonance Group, Institute of Cancer Research, Royal Marsden Hospital, Downs Road, Sutton, SM2 5PT, UK.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
86
|
Brown G, Daniels IR, Richardson C, Revell P, Peppercorn D, Bourne M. Techniques and trouble-shooting in high spatial resolution thin slice MRI for rectal cancer. Br J Radiol 2005; 78:245-51. [PMID: 15730990 DOI: 10.1259/bjr/33540239] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
MRI is increasingly advocated as an optimal method of staging rectal cancer. The technique enables depiction of the relationship of tumour to the mesorectal fascia and may thus identify tumours at risk of positive circumferential margin involvement at surgery. Depth of extramural spread may also be accurately measured and tumour deposits within the mesorectum are shown. It is important that a high spatial resolution technique is used in order to accurately depict these features and care should be taken in ensuring that images acquired cover the entire rectal tumour and mesorectum. This paper describes the technique of high spatial resolution rectal cancer imaging and the potential technical pitfalls in acquiring good quality images. Important factors to consider include: adequate scan duration to achieve high spatial resolution images with sufficient signal to noise ratio, careful positioning of the pelvic phased array coil, use of T2 weighted turbo spin-echo rather than T1 weighted imaging and careful planning of scans to ensure that images are obtained perpendicular to the rectal wall.
Collapse
Affiliation(s)
- G Brown
- Department of Radiology, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK
| | | | | | | | | | | |
Collapse
|
87
|
Chen CC, Lee RC, Lin JK, Wang LW, Yang SH. How accurate is magnetic resonance imaging in restaging rectal cancer in patients receiving preoperative combined chemoradiotherapy? Dis Colon Rectum 2005; 48:722-8. [PMID: 15747073 DOI: 10.1007/s10350-004-0851-1] [Citation(s) in RCA: 173] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Preoperative combined chemoradiotherapy is currently the main neoadjuvant therapy used to treat locally advanced middle and low rectal adenocarcinoma. A restaging work-up with magnetic resonance imaging was hoped to provide information about the effects related to combined chemoradiotherapy. The goal was to evaluate the correlation between pathologically verified tumor stages and clinical stages predicted by magnetic resonance imaging after combined chemoradiotherapy. METHODS Between August 2000 and June 2003, 50 patients with biopsy-proven middle and lower rectal adenocarcinoma, with initial stage T3-T4 or N+, M0, were recruited in this series. Pelvic magnetic resonance imaging was used to stage the tumor before and after combined chemoradiotherapy. A protocol of the standard external radiation dose and oral combined uracil and 5-fluorouracil plus leucovorin was used. The results of magnetic resonance imaging restaging after combined chemoradiotherapy were correlated with the pathologic staging. RESULTS The overall predictive accuracy in T stage was 52 percent, whereas overstaging and understaging occurred in 38 percent and 10 percent of patients, respectively. Most of the inaccurate T staging was a result of the overstaging of superficial tumors (T0-T2). In N stage, accurate staging was noted in 68 percent of all patients, whereas 24 percent were overstaged and 8 percent were understaged. CONCLUSION In restaging irradiated tumors, magnetic resonance imaging had the accuracy of 52 percent in T stage and 68 percent in N stage. Poor agreement between post-combined chemoradiotherapy magnetic resonance imaging and pathologic staging was observed in both T (k = 0.017) and N (k = 0.031) stages. Most of the inaccuracy in both T and N stages was caused by overstaging. The problem with magnetic resonance imaging was believed to be that it could not completely differentiate fibrosis from viable residual tumors.
Collapse
Affiliation(s)
- Chien-Chih Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | |
Collapse
|
88
|
Kim JH, Beets GL, Kim MJ, Kessels AGH, Beets-Tan RGH. High-resolution MR imaging for nodal staging in rectal cancer: are there any criteria in addition to the size? Eur J Radiol 2005; 52:78-83. [PMID: 15380850 DOI: 10.1016/j.ejrad.2003.12.005] [Citation(s) in RCA: 361] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2003] [Revised: 12/05/2003] [Accepted: 12/10/2003] [Indexed: 12/21/2022]
Abstract
PURPOSE MR staging of nodal metastases in patients with rectal cancer using criteria based on size, shape and signal intensity can be difficult, because > or =50% of the nodes are less than 5 mm in size. Therefore new MR criteria were evaluated to see whether it can improve the MR assessment of nodal metastases in rectal cancer patients. MATERIALS AND METHODS Ninety-nine patients with primary rectal carcinoma underwent 1.5 T high-resolution MRI with a quadrature phased array coil. Among them, 75 patients who had undergone total mesorectal excision were enrolled in this study. An MR radiologist, blinded for the histological results, randomly recorded the characteristics of each detectable node (LN); common criteria such as short-axis diameter, the ratio of long- to short-axis diameter, and signal intensity on each sequence; new criteria such as the margin (smooth, lobulated, spiculated, indistinct), a homogenous or mottled heterogeneous appearance, gross enhancement and its pattern, the venous encasement, and the dirty perirectal fat signal. RESULTS Among 75 patients, 22 (29%) were node-positive. All patients who did not have detectable LN on MR were node-free (n = 15). Presence of LNs > 4 mm was significantly higher in the node-positive group. Presence of LNs > 8 mm was seen only in the node-positive group. Presence of a spiculated border and an indistinct border shows sensitivities of 45 and 36%, and specificities of 100 and 100%, respectively. Presence of a mottled heterogeneic pattern shows a sensitivity of 50%, a specificity of 95%. The presence of these three features were strongly correlated with LN positivity (P < 0.001, respectively). Presence of a venous encasement (n = 4) and dirty perirectal fat signal (n = 3) were also significantly (P < 0.05, respectively) correlated with LN positivity. CONCLUSION In addition to size, new criteria such as a spiculated or indistinct border and a mottled heterogeneous appearance could be useful to predict regional lymph node involvement in patients with rectal cancer.
Collapse
Affiliation(s)
- Joo Hee Kim
- Radiology, University Hospital of Maastricht, Maastricht, The Netherlands.
| | | | | | | | | |
Collapse
|
89
|
Oberholzer K, Junginger T, Kreitner KF, Krummenauer F, Simiantonaki N, Trouet S, Thelen M. Local staging of rectal carcinoma and assessment of the circumferential resection margin with high-resolution MRI using an integrated parallel acquisition technique. J Magn Reson Imaging 2005; 22:101-8. [PMID: 15971183 DOI: 10.1002/jmri.20347] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
PURPOSE To assess the diagnostic accuracy of integrated parallel acquisition technique (iPAT) in local staging of rectal carcinoma in comparison to conventional high-resolution MRI. MATERIALS AND METHODS A total of 28 patients with a neoplasm of the rectum and 15 control patients underwent MRI of the pelvis. High-resolution images were acquired conventionally and with iPAT using a modified sensitivity encoding (mSENSE). Image quality, signal-to-noise and contrast-to-noise ratios (SNR, CNR), tumor extent, nodal status, and delineation of the circumferential resection margin (CRM) were compared. In 19 patients with a carcinoma, MR findings were correlated with the histopathological diagnosis. Tumor distance to the CRM was matched with resection specimen in 12 cases. RESULTS The comparison of both MR techniques revealed no clinically relevant differences in tumor staging and delineation of the CRM, though SNR and CNR were significantly lower in mSENSE images. Tumor stage was concordant in 17 of 19 cases compared to histopathology. In four of nine patients with T3 and T4 carcinomas, the histopathological resection margin was < or =2 mm, in five cases MRI predicted a margin of < or =2 mm. CONCLUSION The application of iPAT in local staging of rectal carcinoma is time-saving and does not degrade diagnostic accuracy. Tumor stage, nodal status, and the CRM can be assessed equally compared to conventional acquisition techniques.
Collapse
Affiliation(s)
- Katja Oberholzer
- Department of Radiology, Johannes Gutenberg-Universitiy Mainz, Mainz, Germany.
| | | | | | | | | | | | | |
Collapse
|
90
|
Lewis R, Flynn A, Dean ME, Melville A, Eastwood A, Booth A. Management of colorectal cancers. Qual Saf Health Care 2004; 13:400-4. [PMID: 15465947 PMCID: PMC1743890 DOI: 10.1136/qhc.13.5.400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The management of colorectal cancers, published in a recent issue of Effective Health Care, is reviewed.
Collapse
Affiliation(s)
- R Lewis
- Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK
| | | | | | | | | | | |
Collapse
|
91
|
Abstract
One concern after rectal cancer surgery is the high local recurrence rate. Randomized trials have shown that the best local control rate for rectal cancer patients as a group is achieved after a short course of radiation therapy followed by optimal surgery. It is debatable, however, whether all patients with rectal cancer should undergo preoperative radiation therapy. Preoperative identification of those most likely to benefit from neoadjuvant therapy is important. Therefore, the challenge for preoperative imaging in rectal cancer is to determine subgroups of patients with different risks for recurrence: those with superficial tumors, who can be treated with surgery alone; those with operable tumors and a wide circumferential resection margin, who can be treated with a short course of radiation therapy followed by total mesorectal excision; and those with advanced cancer and a close or involved resection margin, who require a long course of radiation therapy, with or without chemotherapy, and extensive surgery. So far, there is no consensus on the role of diagnostic imaging (endorectal ultrasonography, computed tomography, and magnetic resonance [MR] imaging) in the care of patients with primary rectal cancer. Preoperative staging has long relied on digital examination alone, which indicates that it has been difficult to achieve accuracy levels high enough for clinical decision making with preoperative imaging. In this review, the relevance of preoperative imaging in staging the local extent of primary rectal cancer will be discussed. Research on various imaging modalities, with an emphasis on MR, will be discussed under four main headings that address the most relevant aspects of local spread of rectal tumors: T stage, circumferential resection margin, locally advanced rectal cancer, and N stage.
Collapse
Affiliation(s)
- Regina G H Beets-Tan
- Department of Radiology, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
| | | |
Collapse
|
92
|
Bipat S, Glas AS, Slors FJM, Zwinderman AH, Bossuyt PMM, Stoker J. Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging--a meta-analysis. Radiology 2004; 232:773-83. [PMID: 15273331 DOI: 10.1148/radiol.2323031368] [Citation(s) in RCA: 717] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To perform a meta-analysis to compare endoluminal ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging in rectal cancer staging. MATERIALS AND METHODS Relevant articles published between 1985 and 2002 were included if more than 20 patients were studied, histopathologic findings were the reference standard, and data were presented for 2 x 2 tables; articles were excluded if data were reported elsewhere in more detail. Two reviewers independently extracted data on study characteristics and results. Bivariate random-effects approach was used to obtain summary estimates of sensitivity and specificity for invasion of muscularis propria, perirectal tissue, and adjacent organs and for lymph node involvement. Summary receiver operating characteristic (ROC) curves were fitted for perirectal tissue invasion and lymph node involvement. RESULTS Ninety articles fulfilled all inclusion criteria. For muscularis propria invasion, US and MR imaging had similar sensitivities; specificity of US (86% [95% confidence interval [CI]: 80, 90]) was significantly higher than that of MR imaging (69% [95% CI: 52, 82]) (P =.02). For perirectal tissue invasion, sensitivity of US (90% [95% CI: 88, 92]) was significantly higher than that of CT (79% [95% CI: 74, 84]) (P <.001) and MR imaging (82% [95% CI: 74, 87]) (P =.003); specificities were comparable. For adjacent organ invasion and lymph node involvement, estimates for US, CT, and MR imaging were comparable. Summary ROC curve for US of perirectal tissue invasion showed better diagnostic accuracy than that of CT and MR imaging. Summary ROC curves for lymph node involvement showed no differences in accuracy. CONCLUSION For local invasion, endoluminal US was most accurate and can be helpful in screening patients for available therapeutic strategies.
Collapse
Affiliation(s)
- Shandra Bipat
- Department of Radiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
93
|
Martling A, Holm T, Bremmer S, Lindholm J, Cedermark B, Blomqvist L. Prognostic value of preoperative magnetic resonance imaging of the pelvis in rectal cancer. Br J Surg 2003; 90:1422-8. [PMID: 14598425 DOI: 10.1002/bjs.4276] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite radiotherapy and improved surgical techniques, local recurrence rates after treatment of rectal cancer still vary between 3 and 30 per cent. Tumour involvement of the circumferential resection margin (CRM) predicts a high risk of local recurrence. Magnetic resonance imaging (MRI) allows accurate description of the tumour and its spread within the mesorectum. The aim of this study was to assess the prognostic impact of an involved CRM identified at preoperative MRI in patients with rectal cancer. METHODS Preoperative MRI was performed in 115 patients with rectal cancer between 1995 and 1999. The images were evaluated retrospectively. The shortest distance from the tumour to the CRM was measured, correlated with patient outcome and compared with histopathological findings. RESULTS The risk of any recurrence in patients with or without a tumour-involved margin on MRI was nine of 29 and nine of 57 respectively (P = 0.036). Overall survival at 5 years was 43 and 77 per cent (P = 0.012) respectively. Twenty-four of 30 patients who had an involved CRM on histopathology were correctly identified by MRI. CONCLUSION Patients with a potentially involved CRM identified by MRI had a significantly higher risk of recurrence and cancer-related death. Preoperative MRI may be of prognostic value in rectal cancer and may be used to select patients for neoadjuvant radiochemotherapy and/or more radical surgery.
Collapse
Affiliation(s)
- A Martling
- Department of Surgery, Karolinska Hospital, Stockholm, Sweden
| | | | | | | | | | | |
Collapse
|
94
|
Nesbakken A, Løvig T, Lunde OC, Nygaard K. Staging of rectal carcinoma with transrectal ultrasonography. Scand J Surg 2003; 92:125-9. [PMID: 12841552 DOI: 10.1177/145749690309200203] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Transrectal ultrasonography (TRUS) has proven useful for loco-regional staging of rectal carcinoma in specialised centres, but the investigation is not widely used. The aim of this study was to audit the introduction of TRUS performed by surgeons without previous experience with ultrasonography. MATERIAL AND METHODS All patients admitted with rectal carcinoma in the period 1996-2002 entered this prospective, comparative study. TRUS with a stiff endorectal probe was performed preoperatively in 118 consecutive patients, 91 of whom subsequently had rectal resection without preoperative radiotherapy (PRT), and seven who had rectal resection after PRT. Twenty patients did not have resection. The main outcome measures was the feasibility of TRUS in staging of rectal cancer, and the accuracy of T- and N-staging, comparing TRUS with the histopathological examination of resected specimens. RESULTS TRUS was successful in 81/91 patients who underwent rectal resection without PRT. The accuracy of T-staging was 74% overall; 40% in five pT1 tumours, 81% in 26 pT2 tumours, 80% in 45 pT3 tumours and 25% in four pT4-tumours. With regard to perirectal tissue invasion, the sensitivity and specificity of TRUS was 82% and 84%, respectively, and the positive and negative predictive values were 89% and 71%, respectively. The accuracy of TRUS for N-staging was 65%. The sensitivity for detection of lymph node metastases was 41% and the specificity 68%. TRUS was unsuccessful in 21/118 patients, in 12/98 who had rectal resection, and in 9/ 20 who did not have resection, because of stenosis or high location of the tumour precluding correct placing of the probe. CONCLUSIONS TRUS is often unsuccessful in patients with advanced tumours, especially when the tumour is located in the upper rectum. The predictive values for perirectal tumour invasion were acceptable, but the sensitivity for detection of lymph node metastases was low. These results were obtained by surgeons without previous experience with ultrasonographic examinations.
Collapse
Affiliation(s)
- A Nesbakken
- Department of Surgery, Aker University Hospital, Oslo, Norway.
| | | | | | | |
Collapse
|
95
|
Torkzad M, Lindholm J, Martling A, Blomqvist L. Retrospective measurement of different size parameters of non-radiated rectal cancer on MR images and pathology slides and their comparison. Eur Radiol 2003; 13:2271-7. [PMID: 12740710 DOI: 10.1007/s00330-003-1898-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2002] [Revised: 12/13/2002] [Accepted: 02/17/2003] [Indexed: 01/24/2023]
Abstract
There are no non-invasive methods to assess the real tumor size in rectal cancer prior to surgery, especially following radio/chemotherapy. Magnetic resonance imaging is gaining increasing acceptance as the primary modality at many centers for evaluation of pelvic malignancies including rectal cancers. The aim of this study was to evaluate if the tumor size as assessed by stereological or metric means on MRI correlates to the corresponding pathologic findings. To our knowledge, no such previous work has been reported in the literature. From the Cancer Register Center, 18 patients in the age range of 39-90 years with rectal cancer who had complete preoperative MR with subsequent giant section pathological examinations of the resected bowel were included. The tumor size was measured on MR and histopathologic specimen using both a stereologic and a metric mode. The measured parameters included the maximum transverse area occupied by the tumor, thickness, width, and the length of tumor and the volume of the tumor measured in two different fashions by the product of area and length (al) or the product of thickness, width, and length (twl). The depth of tumor infiltration (T) and presence of local lymph node metastases (N) were also separately evaluated on the histopathologic specimen. There were 1, 4, 12, and 1 patients with tumor stages T1, T2, T3, and T4, respectively. The mean thickness, width, length, area, and volumes, al and twl, were 1.62, 2.8, and 4.78 cm, and 4.72 cm2, 26.29 cm3, and 20.07 cm3, respectively. Regression curves were drawn for above-mentioned parameters. They showed some correlation with square correlation coefficient measuring between 0.38 and 0.82. The best correlation was seen for area (0.75) and volume measured by the product of area and length of the tumor (0.82). With the formula proposed from this material, we assume that rectal tumors can be measured on MR images using a metric model, especially area and the volume (the product of area and length), and then extrapolated to what we would expect from pathology, hence providing us with a tool where we could measure tumor response after neoadjuvant therapy.
Collapse
Affiliation(s)
- Michael Torkzad
- Department of Diagnostic Radiology (ADR), Karolinska Hospital, 17176 Stockholm, Sweden.
| | | | | | | |
Collapse
|
96
|
Abstract
Different stages of rectal cancer show differing degrees of risk for local recurrence. Paramount for the selection and differentiated treatment of the different risk groups is a reliable preoperative test that can distinguish between these subgroups. There is recent evidence suggesting that MRI can serve for this purpose, because it accurately predicts the circumferential resection margin. In this article the role of MRI in the preoperative management of rectal cancer patients will be discussed.
Collapse
Affiliation(s)
- R G H Beets-Tan
- Department of Radiology, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, the Netherlands.
| |
Collapse
|
97
|
Affiliation(s)
- P Hatfield
- Leeds Cancer Centre, Cookridge Hospital, Leeds, United Kingdom
| | | |
Collapse
|
98
|
Fuchsjäger MH, Maier AG, Schima W, Zebedin E, Herbst F, Mittlböck M, Wrba F, Lechner GL. Comparison of transrectal sonography and double-contrast MR imaging when staging rectal cancer. AJR Am J Roentgenol 2003; 181:421-7. [PMID: 12876020 DOI: 10.2214/ajr.181.2.1810421] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of this study was the prospective comparison of the diagnostic yield of transrectal sonography and double-contrast MR imaging for preoperative staging of rectal cancer. SUBJECTS AND METHODS. Thirty-nine rectal cancer patients (20 men, 19 women) underwent transrectal sonography performed with a 10-MHz endoanal probe and MR imaging (1.0 T or 1.5 T) using a whole-body coil. After rectal application of a superparamagnetic iron oxide MR contrast agent, T1- and T2-weighted images and gadolinium-enhanced double-contrast images were obtained. The results of examinations were compared with the histology of resected specimens. RESULTS Histopathology showed four stage T1, 11 stage T2, 18 stage T3, and six stage T4 tumors using the TNM staging system. Nodal metastases were seen in 16 patients. Transrectal sonography could not be performed in 11 patients because of the high location of the tumor. In the remaining 28 patients, the accuracy of transrectal sonography for T stage was 64% overall (patients not receiving radiation, 69%; patients receiving radiation, 60%) and 70% for N stage. In 39 patients, double-contrast MR imaging correctly identified the T stage with an accuracy of 64% overall (patients not receiving radiation, 75%; patients receiving radiation, 53%) and the N stage with an accuracy of 62%. The assessment of rectal wall penetration (Dukes' classification A versus B) revealed a sensitivity, specificity, and accuracy of 93%, 71%, and 82%, respectively, for transrectal sonography and 100%, 60%, and 85% for MR imaging. CONCLUSION If it is technically feasible, transrectal sonography is an accurate method for staging rectal cancer. In proximal or stenotic tumors, double-contrast MR imaging is the method of choice. Diagnostic accuracy of transrectal sonography and MR imaging is high for predicting bowel wall penetration.
Collapse
Affiliation(s)
- Michael H Fuchsjäger
- Department of Radiology, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | | | | | | | | | | | | | | |
Collapse
|
99
|
Abstract
The application of EUS has improved the way we evaluate and manage patients with rectal cancer. EUS has substantially greater sensitivity than CT in detecting advanced T stage tumors. Such improved sensitivity results in changes in preoperative therapy that would not otherwise have occurred without EUS. Although the addition of FNA provides little incremental effect on patient management, it carries the most potential for impacting management in those patients with early T stage disease, and its use should be considered in this subgroup of patients. Whether the accurate staging ability of EUS translates into improved outcomes in terms of reduced recurrence rates and ultimately prolonged survival remains uncertain. This will require further long-term outcome studies focusing on the endpoint of tumor recurrence and patient survival.
Collapse
Affiliation(s)
- Maurits J Wiersema
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | | |
Collapse
|
100
|
Affiliation(s)
- David A Schwartz
- Division of Gastroenterology and Hepatology, Vanderbilt University, Nashville, Tennessee,USA
| | | | | |
Collapse
|