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Diffusion weighted imaging improves diagnostic ability of MRI for determining complete response to neoadjuvant therapy in locally advanced rectal cancer. Eur J Radiol Open 2020; 7:100223. [PMID: 32140502 PMCID: PMC7044654 DOI: 10.1016/j.ejro.2020.100223] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/08/2020] [Accepted: 02/10/2020] [Indexed: 01/08/2023] Open
Abstract
The rate of pathological complete response (pCR) following NACRT was 14.7 %. Combination of morphology and DWI patterns was 89–96 % accurate in predicting pCR. Radiologists of varying experience agreed best with combined approach. Radiologists were more confident of their response using the combined approach.
Purpose To assess the diagnostic performance, interobserver agreement and confidence level for determining response to neoadjuvant chemoradiotherapy (NACRT) using morphology based MR-tumour regression grade (MR TRG), diffusion weighted imaging (DWI) patterns and their combination in patients with locally advanced rectal cancer. Methods This was a retrospective study including patients with locally advanced rectal cancer treated with NACRT and subsequent surgery. Two independent radiologists blinded to the histopathology reviewed staging and restaging MRI. Diagnostic performance of morphology based MR-TRG, DWI patterns and their combination for determining complete (CR) and incomplete (IR) response was assessed with pathological response as the reference. Likert’s scale was used to assess the radiologist’s level of confidence. Interobserver agreement was determined using Kappa statistics. Results The study included 251 patients (mean age of 47.9+/-14 (range 19–86) years, M:F = 164:87). Rate of pathological CR was 14.7 % (n = 37). Pattern based interpretation of DWI and combined approach (DWI + T2-HR) had superior diagnostic performance than morphology based assessment alone with area under curve (AUC) for T2HR, DWI and their combination being 0.531, 0.887, 0.874 respectively for observer 1 and 0.558, 0.653, 0.678 respectively for observer 2, p < 0.001. Interobserver agreement was substantial (k = 0.688) for combined approach, moderate (k = 0.402) for DWI patterns and fair (k = 0.265) for T2 HR MRI with both observers exhibiting highest level of confidence for determining response with the combined approach. Conclusion Complete response to neoadjuvant chemoradiotherapy can be determined with excellent accuracy, substantial interobserver agreement and high level of confidence by combined interpretation of DWI and T2 high resolution MRI.
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Key Words
- AJCC, American Joint Committee on Cancer
- AUC, area under the curve
- Complete response
- DWI, diffusion weighted imaging
- Diffusion weighted imaging
- IR, incomplete response
- LCCRT, neoadjuvant long course chemoradiotherapy
- MERCURY, Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study
- MR, TRG MR-tumour regression grade
- MRI
- NACRT, neoadjuvant chemoradiotherapy
- Neoadjuvant chemotherapy
- Rectal cancer
- T2-HR MRI, T2 high resolution MRI
- cCR, clinical complete response
- p-TRG, pathological tumour regression grade
- pCR, pathological complete response
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Tatsumoto S, Itoh T, Takahama J, Marugami N, Minamiguchi K, Tanaka T, Koyama F, Morita K, Kichikawa K. Accuracy of magnetic resonance imaging in predicting dentate line invasion in low rectal cancer. Jpn J Radiol 2020; 38:539-546. [PMID: 32100185 DOI: 10.1007/s11604-020-00933-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/12/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE To retrospectively assess the accuracy of magnetic resonance imaging (MRI) in predicting dentate line invasion in low rectal cancer. MATERIALS AND METHODS Eighty-one patients with primary rectal cancer were assessed by dynamic contrast-enhanced MRI. The location of the dentate line was assessed on MRI in 27 patients with upper-mid rectal cancer. Two observers independently evaluated the distance between the distal tumor edge and the MRI-defined dentate line in 54 patients with low rectal cancer, and the imaging and histological findings were compared. RESULTS The MRI-defined dentate line was 24.0 ± 3.8 mm above the anal verge in patients with upper-mid rectal cancer. The dentate line invasion status agreed with the histological findings in 49/54 (91%) patients (κ = 0.72 [95% CI 0.50-0.95]) for observer 1, and in 51/54 (94%) patients (κ = 0.83 [0.65-1.00]) for observer 2 in patients with low rectal cancer. Interobserver agreement was good (κ = 0.83 [0.65-1.00]). The MRI-derived distance between the distal tumor edge and the dentate line had significant correlation with the histological distance (r = 0.86 for reader 1 and 0.75 for observer 2). CONCLUSION MRI demonstrates high accuracy in predicting dentate line invasion in low rectal cancer.
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Affiliation(s)
- Shota Tatsumoto
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan.
| | - Takahiro Itoh
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan
| | - Junko Takahama
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan
| | - Nagaaki Marugami
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan
| | - Kiyoyuki Minamiguchi
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan
| | - Fumikazu Koyama
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan
| | - Kohei Morita
- Department of Diagnostic Pathology, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, 634-8522, Japan
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Gürses B, Altınmakas E, Böge M, Aygün MS, Bayram O, Balık E. Multiparametric MRI of rectal cancer-repeatability of quantitative data: a feasibility study. Diagn Interv Radiol 2020; 26:87-94. [PMID: 32071023 DOI: 10.5152/dir.2019.19127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE In this study, we aimed to analyze the repeatability of quantitative multiparametric rectal magnetic resonance imaging (MRI) parameters with different measurement techniques. METHODS All examinations were performed with 3 T MRI system. In addition to routine sequences for rectal cancer imaging protocol, small field-of-view diffusion-weighted imaging and perfusion sequences were acquired in each patient. Apparent diffusion coefficient (ADC) was used for diffusion analysis and ktrans was used for perfusion analysis. Three different methods were used in measurement of these parameters; measurements were performed twice by one radiologist for intraobserver and separately by three radiologists for interobserver variability analysis. ADC was measured by the lowest value, the value at maximum wall thickness, and freehand techniques. Ktrans was measured at the slice with maximum wall thickness, by freehand drawn region of interest (ROI), and at the dark red spot with maximum value. RESULTS A total of 30 patients with biopsy-proven rectal adenocarcinoma were included in the study. The mean values of the parameters measured by the first radiologist on the first and second measurements were as follows: mean lowest ADC, 721.31±147.18 mm2/s and 718.96±135.71 mm2/s; mean ADC value on the slice with maximum wall thickness, 829.90±144.24 mm2/s and 829.48±149.23 mm2/s; mean ADC value measured by freehand ROI on the slice with maximum wall thickness, 846.56±136.31 mm2/s and 848.23±144.15 mm2/s; mean ktrans value on the slice with maximum wall thickness, 0.219±0.080 and 0.214±0.074; mean ktrans by freehand ROI technique (including as much tumoral tissue as possible), 0.208±0.074 and 0.207±0.069; mean ktrans measured from the dark red foci, 0.308±0.109 and 0.311±0.105. Intraobserver agreement was very good among diffusion and perfusion parameters obtained with all three measurement techniques. Interobserver agreement was very good, except for one of the measurement techniques. As far as interobserver variability is considered, only ADC value measured on the slice with maximum wall thickness differed significantly. CONCLUSION Multiparametric MRI of rectum, using ADC as the diffusion and ktrans as the perfusion parameter is a repeatable technique. This technique may potentially be used in prediction and evaluation of neoadjuvant treatment response. New studies with larger patient groups are needed to validate the role of multiparametric MRI.
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Affiliation(s)
- Bengi Gürses
- Department of Radiology, Koç University School of Medicine, İstanbul, Turkey
| | - Emre Altınmakas
- Department of Radiology, Koç University School of Medicine, İstanbul, Turkey
| | - Medine Böge
- Department of Radiology, Koç University School of Medicine, İstanbul, Turkey
| | - M Serhat Aygün
- Department of Radiology, Koç University School of Medicine, İstanbul, Turkey
| | - Onur Bayram
- Department of General Surgery, Koç University School of Medicine, İstanbul, Turkey
| | - Emre Balık
- Department of General Surgery, Koç University School of Medicine, İstanbul, Turkey
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Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) joint consensus statement for MR imaging of placenta accreta spectrum disorders. Eur Radiol 2020; 30:2604-2615. [PMID: 32040730 DOI: 10.1007/s00330-019-06617-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/01/2019] [Accepted: 12/11/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES This study was conducted in order to establish the joint Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) guidelines on placenta accreta spectrum (PAS) disorders and propose strategies to standardize image acquisition, interpretation, and reporting for this condition with MRI. METHODS The published evidence-based data and the opinion of experts were combined using the RAND-UCLA Appropriateness Method and formed the basis for these consensus guidelines. The responses of the experts to questions regarding the details of patient preparation, MRI protocol, image interpretation, and reporting were collected, analyzed, and classified as "recommended" versus "not recommended" (if at least 80% consensus among experts) or uncertain (if less than 80% consensus among experts). RESULTS Consensus regarding image acquisition, interpretation, and reporting was determined using the RAND-UCLA Appropriateness Method. The use of a tailored MRI protocol and standardized report was recommended. CONCLUSIONS A standardized imaging protocol and reporting system ensures recognition of the salient features of PAS disorders. These consensus recommendations should be used as a guide for the evaluation of PAS disorders with MRI. KEY POINTS • MRI is a powerful adjunct to ultrasound and provides valuable information on the topography and depth of placental invasion. • Consensus statement proposed a common lexicon to allow for uniformity in MRI acquisition, interpretation, and reporting of PAS disorders. • Seven MRI features, namely intraplacental dark T2 bands, uterine/placental bulge, loss of low T2 retroplacental line, myometrial thinning/disruption, bladder wall interruption, focal exophytic placental mass, and abnormal vasculature of the placental bed, reached consensus and are categorized as "recommended" for diagnosing PAS disorders.
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405
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Zhang Q, van Houdt PJ, Lambregts DMJ, van Triest B, Kop MPM, Coolen BF, Strijkers GJ, van der Heide UA, Nederveen AJ. Locally advanced rectal cancer: 3D diffusion-prepared stimulated-echo turbo spin-echo versus 2D diffusion-weighted echo-planar imaging. Eur Radiol Exp 2020; 4:9. [PMID: 32030561 PMCID: PMC7005244 DOI: 10.1186/s41747-019-0138-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 11/20/2019] [Indexed: 11/10/2022] Open
Abstract
Background Diffusion-weighted imaging (DWI) has shown great value in rectal cancer imaging. However, traditional DWI with echo-planar imaging (DW-EPI) often suffers from geometrical distortions. We applied a three-dimensional diffusion-prepared stimulated-echo turbo spin-echo sequence (DPsti-TSE), allowing geometrically undistorted rectal DWI. We compared DPsti-TSE with DW-EPI for locally advanced rectal cancer DWI. Methods For 33 prior-to-treatment patients, DWI images of the rectum were acquired with DPsti-TSE and DW-EPI at 3 T using b-values of 200 and 1000 s/mm2. Two radiologists conducted a blinded scoring of the images considering nine aspects of image quality and anatomical quality. Tumour apparent diffusion coefficient (ADC) and distortions were compared quantitatively. Results DPsti-TSE scored significantly better than DW-EPI in rectum distortion (p = 0.005) and signal pileup (p = 0.001). DPsti-TSE had better tumour Dice similarity coefficient compared to DW-EPI (0.84 versus 0.80, p = 0.010). Tumour ADC values were higher for DPsti-TSE compared to DW-EPI (1.47 versus 0.86 × 10-3 mm2/s, p < 0.001). Radiologists scored DPsti-TSE significantly lower than DW-EPI on aspects of overall image quality (p = 0.001), sharpness (p < 0.001), quality of fat suppression (p < 0.001), tumour visibility (p = 0.009), tumour conspicuity (p = 0.010) and rectum wall visibility (p = 0.005). Conclusions DPsti-TSE provided geometrically less distorted rectal cancer diffusion-weighted images. However, the image quality of DW-EPI over DPsti-TSE was referred on the basis of several image quality criteria. A significant bias in tumour ADC values from DPsti-TSE was present. Further improvements of DPsti-TSE are needed until it can replace DW-EPI.
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Affiliation(s)
- Qinwei Zhang
- Amsterdam UMC, Radiology and Nuclear Medicine, University of Amsterdam, Room Z0-178, Meibergdreef 9, 1100 DD, Amsterdam, Netherlands.
| | - Petra J van Houdt
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Baukelien van Triest
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Marnix P M Kop
- Amsterdam UMC, Radiology and Nuclear Medicine, University of Amsterdam, Room Z0-178, Meibergdreef 9, 1100 DD, Amsterdam, Netherlands
| | - Bram F Coolen
- Amsterdam UMC, Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, the Netherlands
| | - Gustav J Strijkers
- Amsterdam UMC, Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, the Netherlands
| | - Uulke A van der Heide
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Aart J Nederveen
- Amsterdam UMC, Radiology and Nuclear Medicine, University of Amsterdam, Room Z0-178, Meibergdreef 9, 1100 DD, Amsterdam, Netherlands
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406
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Abstract
Template reporting increases key colon tumour descriptors. Template reporting was used for less than a third of the patients. High risk of underreporting.
Purpose The purpose of this study was to evaluate the effect of completeness of the radiological reports in primary local staging colon cancer when using a template. Methods The study used primary staging reports retrieved from the departments RIS/PACS. Five key tumour descriptors were evaluated within each report: tumour morphology (polypoid or annular), information on tumour breach of the colon wall (≥ T3), tumour out-growth in mm, nodal status and TNM in conclusion. The failure to provide a description of the presence or absence of a feature in a report counted as ‘not reported’. To allow comparisons between reporting styles, the template or free-text style of reporting was also recorded. Results During a two year period, a total of 666 patients CT reports were evaluated at the colorectal center multidisciplinary team (MDT) conference. In 200 of these reports a template was used. Information on tumour morphology (polypoid or annular) was present in 81% of the template reports vs 9% in free-text style. The figures in percentage for information on tumour breach of the colon wall (≥ T3) were 93% vs 48 %, tumour out-growth in mm: 51% vs 17%, nodal status: 99% vs 86% and TNM in conclusion: 98% vs 51%. P < 0.0001. Conclusion The present study provides additional support for the routine use of template reports to improve imaging reporting standards in colonic cancer.
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407
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Fornell-Perez R, Vivas-Escalona V, Aranda-Sanchez J, Gonzalez-Dominguez MC, Rubio-Garcia J, Aleman-Flores P, Lozano-Rodriguez A, Porcel-de-Peralta G, Loro-Ferrer JF. Primary and post-chemoradiotherapy MRI detection of extramural venous invasion in rectal cancer: the role of diffusion-weighted imaging. Radiol Med 2020; 125:522-530. [PMID: 32020526 DOI: 10.1007/s11547-020-01137-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the added value of diffusion-weighted imaging (DWI) to high-resolution T2-weighted sequences (HRT2w) in MRI detection of extramural venous infiltration (EMVI), according to the previous experience of radiologists. METHODS A cross-sectional study of a retrospective database including 1.5 T MRI records from 100 patients with biopsy-proven rectal cancer (2011-2016; 75 male/25 female, average 63 y/o), which included primary staging (54) and post-chemoradiotherapy follow-up MRIs (46). The reference standard was histology of surgical specimens. All cases were individually blindly reviewed by ten radiologists: three specialists in abdominal radiology, three specialized in different areas and four residents. In each case, the presence of EMVI was assessed twice: first, using just HRT2w; second, with DWI added to HRT2w. The results were pooled by experience, analyzing sensitivity, specificity, accuracy (area under ROC curve), likelihood ratios, predictive values and overstaging/understaging. RESULTS Addition of DWI improved diagnostic performance by specialists radiologists, particularly post-chemoradiotherapy (accuracy 0.74-0.84; positive likelihood ratio 3.9-9.1; overstaging 16-8%), less so at primary staging (specificity 76-87.2%; overstaging 21-11%). Non-specialist radiologists also improved, but only at primary staging (accuracy 0.59-0.63). Residents showed small changes, except for notably increased sensitivity in both primary staging (35.7-43%) and post-chemoradiotherapy (41.7-58.3%) staging, at the expense of increased overstaging. CONCLUSIONS The addition of DWI improved the diagnostic performance of EMVI by experienced radiologists, downgrading overstaging, especially in post-chemoradiotherapy follow-up. It resulted in fewer changes for inexperienced radiologists (enhanced primary staging) and residents (increased sensitivity).
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Affiliation(s)
- Roberto Fornell-Perez
- Departamento de Ciencias Clínicas, Facultad de Ciencias de la Salud, Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe, s/n. 35016, Las Palmas de Gran Canaria, Spain.
| | - Valentina Vivas-Escalona
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Joel Aranda-Sanchez
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - M Carmen Gonzalez-Dominguez
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Jano Rubio-Garcia
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Patricia Aleman-Flores
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Alvaro Lozano-Rodriguez
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Gabriela Porcel-de-Peralta
- Servicio de Radiodiagnóstico, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Juan Francisco Loro-Ferrer
- Departamento de Ciencias Clínicas, Facultad de Ciencias de la Salud, Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe, s/n. 35016, Las Palmas de Gran Canaria, Spain
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Bates DDB, Golia Pernicka JS, Fuqua JL, Paroder V, Petkovska I, Zheng J, Capanu M, Schilsky J, Gollub MJ. Diagnostic accuracy of b800 and b1500 DWI-MRI of the pelvis to detect residual rectal adenocarcinoma: a multi-reader study. Abdom Radiol (NY) 2020; 45:293-300. [PMID: 31690966 DOI: 10.1007/s00261-019-02283-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To compare the sensitivity, specificity and intra-observer and inter-observer agreement of pelvic magnetic resonance imaging (MRI) b800 and b1500 s/mm2 sequences in the detection of residual adenocarcinoma after neoadjuvant chemoradiation (CRT) for locally advanced rectal cancer (LARC). INTRODUCTION Detection of residual adenocarcinoma after neoadjuvant CRT for LARC has become increasingly important and relies on both MRI and endoscopic surveillance. Optimal MRI diffusion b values have yet to be established for this clinical purpose. METHODS From our MRI database between 2018 and 2019, we identified a cohort of 28 patients after exclusions who underwent MRI of the rectum before and after neoadjuvant chemoradiation with a protocol that included both b800 and b1500 s/mm2 diffusion sequences. Four radiologists experienced in rectal MRI interpreted the post-CRT MRI studies with either b800 DWI or b1500 DWI, and a minimum of 2 weeks later re-interpreted the same studies using the other b value sequence. Surgical pathology or endoscopic follow-up for 1 year without tumor re-growth was used as the reference standard. Descriptive statistics compared accuracy for each reader and for all readers combined between b values. Inter-observer agreement was assessed using kappa statistics. A p value of 0.05 or less was considered significant. RESULTS Within the cohort, 19/28 (67.9%) had residual tumor, while 9/28 (32.1%) had a complete response. Among four readers, one reader had increased sensitivity for detection of residual tumor at b1500 s/mm2 (0.737 vs. 0.526, p = 0.046). There was no significant difference between detection of residual tumor at b800 and at b1500 for the rest of the readers. With all readers combined, the pooled sensitivity was 0.724 at b1500 versus 0.605 at b800, but this was not significant (p = 0.119). There was no difference in agreement between readers at the two b value settings (67.8% at b800 vs. 72.0% at b1500), or for any combination of individual readers. CONCLUSION Aside from one reader demonstrating increased sensitivity, no significant difference in accuracy parameters or inter-observer agreement was found between MR using b800 and b1500 for the detection of residual tumor after neoadjuvant CRT for LARC. However, there was a suggestion of a trend towards increased sensitivity with b1500, and further studies using larger cohorts may be needed to further investigate this topic.
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410
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Diagnostic accuracy of b800 and b1500 DWI-MRI of the pelvis to detect residual rectal adenocarcinoma: a multi-reader study. Abdom Radiol (NY) 2020. [PMID: 31690966 DOI: 10.1007/s00261-019-02283-x.pmid:31690966;pmcid:pmc7386086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
PURPOSE To compare the sensitivity, specificity and intra-observer and inter-observer agreement of pelvic magnetic resonance imaging (MRI) b800 and b1500 s/mm2 sequences in the detection of residual adenocarcinoma after neoadjuvant chemoradiation (CRT) for locally advanced rectal cancer (LARC). INTRODUCTION Detection of residual adenocarcinoma after neoadjuvant CRT for LARC has become increasingly important and relies on both MRI and endoscopic surveillance. Optimal MRI diffusion b values have yet to be established for this clinical purpose. METHODS From our MRI database between 2018 and 2019, we identified a cohort of 28 patients after exclusions who underwent MRI of the rectum before and after neoadjuvant chemoradiation with a protocol that included both b800 and b1500 s/mm2 diffusion sequences. Four radiologists experienced in rectal MRI interpreted the post-CRT MRI studies with either b800 DWI or b1500 DWI, and a minimum of 2 weeks later re-interpreted the same studies using the other b value sequence. Surgical pathology or endoscopic follow-up for 1 year without tumor re-growth was used as the reference standard. Descriptive statistics compared accuracy for each reader and for all readers combined between b values. Inter-observer agreement was assessed using kappa statistics. A p value of 0.05 or less was considered significant. RESULTS Within the cohort, 19/28 (67.9%) had residual tumor, while 9/28 (32.1%) had a complete response. Among four readers, one reader had increased sensitivity for detection of residual tumor at b1500 s/mm2 (0.737 vs. 0.526, p = 0.046). There was no significant difference between detection of residual tumor at b800 and at b1500 for the rest of the readers. With all readers combined, the pooled sensitivity was 0.724 at b1500 versus 0.605 at b800, but this was not significant (p = 0.119). There was no difference in agreement between readers at the two b value settings (67.8% at b800 vs. 72.0% at b1500), or for any combination of individual readers. CONCLUSION Aside from one reader demonstrating increased sensitivity, no significant difference in accuracy parameters or inter-observer agreement was found between MR using b800 and b1500 for the detection of residual tumor after neoadjuvant CRT for LARC. However, there was a suggestion of a trend towards increased sensitivity with b1500, and further studies using larger cohorts may be needed to further investigate this topic.
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Arya S, Sen S, Engineer R, Saklani A, Pandey T. Imaging and Management of Rectal Cancer. Semin Ultrasound CT MR 2020; 41:183-206. [PMID: 32446431 DOI: 10.1053/j.sult.2020.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
High-resolution phased array external magnetic resonance imaging (MRI) is the first investigation of choice in rectal cancer for local staging, both in the primary and restaging situations. Use of MRI helps differentiate between those with good prognosis, which can be offered upfront surgery and the poor prognostic cases where treatment intensification is needed. MRI identified poor prognostic factors are threatened or involved mesorectal fascia, T3 tumors with >5 mm extramural spread, those with extramural vascular invasion, pelvic sidewall nodes and mucinous tumors. At restaging, use of MRI helps evaluate response and an MR tumor regression grading system is being evaluated. Complete response seen on clinical examination and endoscopy, needs confirmation on MRI using both T2-weighted and diffusion-weighted sequences to justify a "watch and wait" approach. In this subset of patients, MRI also plays a role in monitoring and detecting early regrowth. In those with partial response, MRI helps define surgical margins and can be used as a roadmap to decide between sphincter preserving surgeries and radical sphincter sacrificing surgeries; pelvic exenteration and pelvic sidewall lymph node dissection. Poor responders on MRI may benefit from adjuvant chemotherapy. Use of MRI thus helps in individualizing treatment in rectal cancer.
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Affiliation(s)
- Supreeta Arya
- Ex-Professor, Radiodiagnosis, Tata Memorial Centre, Mumbai, India; Member Expert Committee, National Cancer Grid, India.
| | - Saugata Sen
- Department of Radiology and Imaging Sciences, Tata Medical Center, Kolkata, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Avanish Saklani
- Department of Surgical Oncology, Robotic & Colorectal Surgery, Tata Memorial Hospital, Mumbai, India
| | - Tarun Pandey
- Department of Radiology and Orthopedics, University of Arkansas for Medical Sciences, Little Rock, AR
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Pandini RV, Pandini LC, Cotti GCC, Spinelli A, Anbar-Neto T, Pupo-Neto JA, Nahas SC. Surgical training in laparoscopic lateral pelvic lymph node dissection: description of an animal model - a video vignette. Colorectal Dis 2020; 22:108-112. [PMID: 31484217 DOI: 10.1111/codi.14843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 12/25/2022]
Affiliation(s)
- R V Pandini
- Colon and Rectum Surgery Department, University of Sao Paulo, Sao Paulo, Brazil.,Minimally Invasive Surgery Center in Araçatuba, Sao Paulo, Brazil
| | - L C Pandini
- Minimally Invasive Surgery Center in Araçatuba, Sao Paulo, Brazil.,FACERES Medical School in Sao Jose do Rio Preto, São Paulo, Brazil
| | - G C C Cotti
- São Paulo Cancer Institute, Sao Paulo, Brazil
| | - A Spinelli
- Division of Colon and Rectum Surgery, Humanitas Research Hospital, Humanitas University Rozzano Milano, Milan, Italy
| | - T Anbar-Neto
- Minimally Invasive Surgery Center in Araçatuba, Sao Paulo, Brazil.,FACERES Medical School in Sao Jose do Rio Preto, São Paulo, Brazil
| | - J A Pupo-Neto
- Minimally Invasive Surgery Center in Araçatuba, Sao Paulo, Brazil.,Colon and Rectum Surgery Department, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - S C Nahas
- Colon and Rectum Surgery Department, University of Sao Paulo, São Paulo, Brazil
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413
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Park JH, Seo N, Lim JS, Hahm J, Kim MJ. Feasibility of Simultaneous Multislice Acceleration Technique in Diffusion-Weighted Magnetic Resonance Imaging of the Rectum. Korean J Radiol 2020. [PMID: 31920031 DOI: 10.3348/kjr.2019.0406.pmid:31920031;pmcid:pmc6960306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
OBJECTIVE To assess the feasibility of simultaneous multislice-accelerated diffusion-weighted imaging (SMS-DWI) of the rectum in comparison with conventional DWI (C-DWI) in rectal cancer patients. MATERIALS AND METHODS This study included 65 patients with initially-diagnosed rectal cancer. All patients underwent C-DWI and SMS-DWI with acceleration factors of 2 and 3 (SMS2-DWI and SMS3-DWI, respectively) using a 3T scanner. Acquisition times of the three DWI sequences were measured. Image quality in the three DWI sequences was reviewed by two independent radiologists using a 4-point Likert scale and subsequently compared using the Friedman test. Apparent diffusion coefficient (ADC) values for rectal cancer and the normal rectal wall were compared among the three sequences using repeated measures analysis of variance. RESULTS Acquisition times using C-DWI, SMS2-DWI, and SMS3-DWI were 173 seconds, 107 seconds, (38.2% shorter than C-DWI), and 77 seconds (55.5% shorter than C-DWI), respectively. For all image quality parameters other than distortion (margin sharpness, artifact, lesion conspicuity, and overall image quality), C-DWI and SMS2-DWI yielded better results than did SMS3-DWI (Ps < 0.001), with no significant differences observed between C-DWI and SMS2-DWI (Ps ≥ 0.054). ADC values of rectal cancer (p = 0.943) and normal rectal wall (p = 0.360) were not significantly different among C-DWI, SMS2-DWI, and SMS3-DWI. CONCLUSION SMS-DWI using an acceleration factor of 2 is feasible for rectal MRI resulting in substantial reductions in acquisition time while maintaining diagnostic image quality and similar ADC values to those of C-DWI.
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Affiliation(s)
- Jae Hyon Park
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nieun Seo
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Joon Seok Lim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | | | - Myeong Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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414
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Lavryk OA, Manilich E, Valente MA, Miriam A, Gorgun E, Kalady MF, Shawki S, Delaney CP, Steele SR. Neoadjuvant chemoradiation improves oncologic outcomes in low and mid clinical T3N0 rectal cancers. Int J Colorectal Dis 2020; 35:77-84. [PMID: 31776698 DOI: 10.1007/s00384-019-03452-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Controversial data exists in the current literature in regard to the use of neoadjuvant chemoradiation (nCRT) in patients with clinical T3N0 (cT3N0) rectal cancers, specifically based on location and relation to peritoneal reflection. We aimed to analyze the impact of nCRT on oncologic outcomes among cT3N0 rectal cancers, depending on the tumor height from anal verge (AV). METHODS A retrospective analysis of patients with cT3N0 rectal cancers was included from a query of a prospectively maintained rectal cancer database from 1980 to 2016. Patients were divided into 3 groups based on the tumor height: low (1-5 cm from AV), mid (6-10 cm from AV), and upper (11-15 cm from AV). Patients were stratified by use of nCRT. MAIN OUTCOMES 5-year overall survival (OS), disease-free survival (DFS), cancer-specific survival (CSS), and local recurrence (LR) using Kaplan-Meier curves. RESULTS Five hundred ninety-two patients were included. Overall, 364 (61.4%) patients received nCRT and 228 (38.6%) patients did not. There were 251 (43%) patients with low, 302 (51%) with mid, and 39 (7%) with upper rectal cancer. Patients with low and mid rectal cancers received nCRT more frequently than those with upper rectal cancers (68.5% and 61.2% vs 43.6%, p = 0.007). The 5-year OS was 78% and 63%, DFS-88% and 73%, LR-1% and 8% in nCRT followed by resection vs. surgery alone (p < 0.001). In regard to cancer location after nCRT compared with surgery alone, low and mid cancers had better OS, DFS, and CSS, compared with upper ones. CONCLUSION nCRT prolongs survival among patients with rectal cancer below 10 cm from AV; however, it has no effect on 5-year oncologic survival of patients with upper rectal cancer located below peritoneal reflection.
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Affiliation(s)
- Olga A Lavryk
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | | | - Michael A Valente
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | | | - Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Matthew F Kalady
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Sherief Shawki
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA.,John Carroll University, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Cleveland, OH, 44195, USA.
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415
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Gupta NA, Mahajan S, Sumankumar A, Saklani A, Engineer R, Baheti AD. Impact of a standardized reporting format on the quality of MRI reports for rectal cancer staging. Indian J Radiol Imaging 2020; 30:7-12. [PMID: 32476744 PMCID: PMC7240900 DOI: 10.4103/ijri.ijri_308_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/26/2019] [Accepted: 01/09/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND AND AIMS Besides providing a surgical roadmap, rectal MRI plays a major role in treatment planning. We recently started using a structured template for reporting rectal cancer via MRI. We study the impact of using this template at our hospital in terms of number of essential imaging parameters described in the reports as compared to the pre-template free-text reports. METHODS A structured rectal MRI reporting template was created in consensus with members of the colorectal tumour board and was introduced in the department, which included 14 essential parameters to be mentioned in the reports. We conducted a retrospective analysis of rectal MRI reports of 100 cases with histologically proven rectal cancer, comprising 50 consecutive free-text reports before the template was introduced and 50 consecutive structured reports after its introduction, checking for the presence or absence of inclusion of the 14 parameters. An anonymous online feedback survey was conducted as well after the introduction of the template for the members of the colorectal tumour board. RESULTS Overall, the total number of parameters reported increased from a median value of 10 (range 6-13) to 14 (range 12-14). The common unreported parameters prior to template introduction included T staging, presence or absence of restricted diffusion, anterior peritoneal reflection (APR) involvement, and presence or absence of extramural vascular invasion; these were reported in 16%, 22%, 30% and 50% respectively. These improved to 98-100% reporting after template introduction. Maximum improvement was in T staging (16% to 98%) (P < 0.0001), restricted diffusion on DWI (from 22% to 100%) (P < 0.0001) and APR involvement (from 30% to 100%) (P < 0.0001). The most common unreported parameter after template introduction was the "tumoral T2 signal intensity" (unreported in 4% cases). The results of the survey were as follows: 100% felt a decreased need to talk to the radiologist to clarify the report, 81.8% felt an improvement in the quality of reporting as compared to free style reports, and 91% felt that the new template is easier to interpret. CONCLUSION The introduction of a structured template for rectal cancer significantly improved the quality of rectal MRI reports, along with the satisfaction of referring providers.
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Affiliation(s)
- Neeti A Gupta
- Department of Radio Diagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Shivani Mahajan
- Department of Radio Diagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - A Sumankumar
- Department of Radio Diagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Avanish Saklani
- Department of Colo-rectal Surgery, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Akshay D Baheti
- Department of Radio Diagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
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416
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Detering R, de Neree Tot Babberich MPM, Bos ACRK, Dekker JWT, Wouters MWJM, Bemelman WA, Beets-Tan RGH, Marijnen CAM, Hompes R, Tanis PJ. Nationwide analysis of hospital variation in preoperative radiotherapy use for rectal cancer following guideline revision. Eur J Surg Oncol 2019; 46:486-494. [PMID: 31882252 DOI: 10.1016/j.ejso.2019.12.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/02/2019] [Accepted: 12/17/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The revised Dutch colorectal cancer guideline (2014), led to an overall decrease in preoperative radiotherapy (RT) use. This study evaluates hospital variation in RT use for resectable rectal cancer and the influence of guideline revision, including the nationwide impact of changing RT application on short term outcomes. METHODS Data of surgically resected rectal cancer patients registered in the Dutch ColoRectal Audit were extracted between 2011 and 2017. Patients were divided into groups based on time of guideline revision (<2014 and ≥ 2014). Primary outcome was guideline adherence at hospital level regarding RT application, stratified for three stage groups. Secondary outcomes included positive circumferential resection (CRM+) and 30-day complicated postoperative course. RESULTS The groups consisted of 7364 and 12,057 patients, respectively. In total, 6772 patients did not receive RT (17.6% (<2014) vs. 45.7% (≥2014), p < 0.001). The largest increase of surgery alone was observed for cT1-2N0 stage rectal cancer (35.1% vs. 91.8%, p < 0.001), with a substantial decrease in hospital variation (IQR 22.2-50.0% vs. IQR 87.6-98.0%). For cT1-3N1MRF- stage rectal cancer, a substantial amount of hospital variation in short course RT remained after guideline revision (IQR 26.8-54.1% vs. IQR 26.2-50.0%). A significant decrease in CRM+ (5.8% vs. 4.2%, p < 0.001) and complicated course (22.5% vs. 18.5%, p < 0.001) was observed. CONCLUSIONS Radiotherapy for early-stage rectal cancer was uniformly abandoned after guideline revision, while substantial hospital variation remained for intermediate risk resectable rectal cancer in the Netherlands. The substantial nationwide decrease in the use of RT for rectal cancer treatment did not negatively impact CRM involvement.
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Affiliation(s)
- Robin Detering
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | | | - Amanda C R K Bos
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | | | - Michel W J M Wouters
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Center, Leiden, the Netherlands; Department of Radiotherapy, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
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417
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Tersteeg JJC, Crolla RMPH, Gobardhan PD, Kint PAM, Niers-Stobbe I, Boonman-de Winter L, Arnold DE, Rozema T, Schreinemakers JMJ. MRI-based guidelines for selective neoadjuvant treatment in rectal cancer: Does MRI adequately predict the indication for radiotherapy in daily practice in a large teaching hospital. Eur J Cancer Care (Engl) 2019; 29:e13190. [PMID: 31863608 DOI: 10.1111/ecc.13190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 08/01/2019] [Accepted: 10/14/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVES According to new Dutch guidelines for rectal cancer, MRI-defined tumour stage determines whether preoperative radiotherapy is indicated. Therefore, we sought to evaluate if preoperative MRI accurately predicts the indication for neoadjuvant treatment in rectal cancer cases in daily practice according to the new Dutch guidelines. METHODS Data for all rectal cancer patients who underwent mesorectal excision in our hospital, between January 2011 and January 2018 were collected retrospectively. We compared histopathologic outcome with tumour staging on preoperative MRI for patients who received no radiotherapy prior to resection or short-course radiotherapy directly followed by resection. RESULTS Of 223 patients treated according to the old guidelines, 94% received neoadjuvant therapy. Of 301 patients treated according to the new guidelines, only 49% did. Under the old guidelines, MRI predicted lymph node metastases with a sensitivity of 74.2% and a specificity of 52.6%. With the new guidelines, sensitivity was 47.5% and specificity was 77.3%. The new guidelines resulted in 45% more patients not being exposed to disadvantages of radiotherapy, but 13% of all patients were undertreated. CONCLUSIONS Concordance between clinical lymph node staging on preoperative MRI and histopathologic staging is limited, resulting in many rectal cancer patients not receiving adequate neoadjuvant therapy.
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Affiliation(s)
- Janneke J C Tersteeg
- Department of Oncological Surgery, Amphia Hospital, Breda, The Netherlands.,Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Paul D Gobardhan
- Department of Oncological Surgery, Amphia Hospital, Breda, The Netherlands
| | - Peter A M Kint
- Department of Radiology, Amphia Hospital, Breda, The Netherlands
| | | | | | | | - Tom Rozema
- Department of Radiation Oncology, Verbeeten Institute, Breda, The Netherlands
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418
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Ianuş A, Santiago I, Galzerano A, Montesinos P, Loução N, Sanchez-Gonzalez J, Alexander DC, Matos C, Shemesh N. Higher-order diffusion MRI characterization of mesorectal lymph nodes in rectal cancer. Magn Reson Med 2019; 84:348-364. [PMID: 31850546 DOI: 10.1002/mrm.28102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE Mesorectal lymph node staging plays an important role in treatment decision making. Here, we explore the benefit of higher-order diffusion MRI models accounting for non-Gaussian diffusion effects to classify mesorectal lymph nodes both 1) ex vivo at ultrahigh field correlated with histology and 2) in vivo in a clinical scanner upon patient staging. METHODS The preclinical investigation included 54 mesorectal lymph nodes, which were scanned at 16.4 T with an extensive diffusion MRI acquisition. Eight diffusion models were compared in terms of goodness of fit, lymph node classification ability, and histology correlation. In the clinical part of this study, 10 rectal cancer patients were scanned with diffusion MRI at 1.5 T, and 72 lymph nodes were analyzed with Apparent Diffusion Coefficient (ADC), Intravoxel Incoherent Motion (IVIM), Kurtosis, and IVIM-Kurtosis. RESULTS Compartment models including restricted and anisotropic diffusion improved the preclinical data fit, as well as the lymph node classification, compared to standard ADC. The comparison with histology revealed only moderate correlations, and the highest values were observed between diffusion anisotropy metrics and cell area fraction. In the clinical study, the diffusivity from IVIM-Kurtosis was the only metric showing significant differences between benign (0.80 ± 0.30 μm2 /ms) and malignant (1.02 ± 0.41 μm2 /ms, P = .03) nodes. IVIM-Kurtosis also yielded the largest area under the receiver operating characteristic curve (0.73) and significantly improved the node differentiation when added to the standard visual analysis by experts based on T2 -weighted imaging. CONCLUSION Higher-order diffusion MRI models perform better than standard ADC and may be of added value for mesorectal lymph node classification in rectal cancer patients.
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Affiliation(s)
- Andrada Ianuş
- Champalimaud Research, Champalimaud Centre for the Unknown, Lisbon, Portugal.,Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Ines Santiago
- Champalimaud Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal.,Nova Medical School, Lisbon, Portugal
| | - Antonio Galzerano
- Champalimaud Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | | | | | | | - Daniel C Alexander
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Celso Matos
- Champalimaud Research, Champalimaud Centre for the Unknown, Lisbon, Portugal.,Champalimaud Clinical Centre, Champalimaud Centre for the Unknown, Lisbon, Portugal
| | - Noam Shemesh
- Champalimaud Research, Champalimaud Centre for the Unknown, Lisbon, Portugal
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419
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Abstract
International guidelines dictate that magnetic resonance imaging (MRI) should be part of the primary standard work up of patients with rectal cancer because MRI can accurately identify the main risk factors for local recurrence and stratify patients into a differentiated treatment. The role of endoscopic ultrasound (EUS) is restricted to staging of superficial tumors because EUS is able to differentiate between T1 and T2 rectal cancer. Recent guidelines recommend the addition of diffusion-weighted (DWI) MRI to clinical and endoscopic assessment of response to preoperative radiochemotherapy (RCT). MRI is able to identify significant tumor regression which may alter the surgical approach.
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Affiliation(s)
- J Boot
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - F Gomez-Munoz
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Interventional Radiology, Hospital Clinic Universitari, Barcelona, Spain
| | - R G H Beets-Tan
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
- University of Southern Denmark, Odense, Denmark.
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420
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Monsellato I, Alongi F, Bertocchi E, Gori S, Ruffo G, Cassinotti E, Baldarti L, Boni L, Pernazza G, Pulighe F, De Nisco C, Perinotti R, Morpurgo E, Contardo T, Mammano E, Elmore U, Delpini R, Rosati R, Perna F, Coratti A, Menegatti B, Gentilli S, Baroffio P, Buccianti P, Balestri R, Ceccarelli C, Torri V, Cavaliere D, Solaini L, Ercolani G, Traverso E, Fusco V, Rossi M, Priora F, Numico G, Franzone P, Orecchia S. Standard (8 weeks) vs long (12 weeks) timing to minimally-invasive surgery after NeoAdjuvant Chemoradiotherapy for rectal cancer: a multicenter randomized controlled parallel group trial (TiMiSNAR). BMC Cancer 2019; 19:1215. [PMID: 31842784 PMCID: PMC6912945 DOI: 10.1186/s12885-019-6271-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 10/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The optimal timing of surgery in relation to chemoradiation is still controversial. Retrospective analysis has demonstrated in the recent decades that the regression of adenocarcinoma can be slow and not complete until after several months. More recently, increasing pathologic Complete Response rates have been demonstrated to be correlated with longer time interval. The purpose of the trial is to demonstrate if delayed timing of surgery after neoadjuvant chemoradiotherapy actually affects pathologic Complete Response and reflects on disease-free survival and overall survival rather than standard timing. METHODS The trial is a multicenter, prospective, randomized controlled, unblinded, parallel-group trial comparing standard and delayed surgery after neoadjuvant chemoradiotherapy for the curative treatment of rectal cancer. Three-hundred and forty patients will be randomized on an equal basis to either robotic-assisted/standard laparoscopic rectal cancer surgery after 8 weeks or robotic-assisted/standard laparoscopic rectal cancer surgery after 12 weeks. DISCUSSION To date, it is well-know that pathologic Complete Response is associated with excellent prognosis and an overall survival of 90%. In the Lyon trial the rate of pCR or near pathologic Complete Response increased from 10.3 to 26% and in retrospective studies the increase rate was about 23-30%. These results may be explained on the relationship between radiation therapy and tumor regression: DNA damage occurs during irradiation, but cellular lysis occurs within the next weeks. Study results, whether confirmed that performing surgery after 12 weeks from neoadjuvant treatment is advantageous from a technical and oncological point of view, may change the current pathway of the treatment in those patient suffering from rectal cancer. TRIAL REGISTRATION ClinicalTrials.gov NCT3465982.
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Affiliation(s)
- Igor Monsellato
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | | | | | | | - Elisa Cassinotti
- Department of Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Ludovica Baldarti
- Department of Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | | | | | | | | | - Emilio Morpurgo
- Ospedale Civile Pietro Cosma, Camposampiero/Ospedale Sant’Antonio, Padova, Italy
| | - Tania Contardo
- Ospedale Civile Pietro Cosma, Padova, Camposampiero Italy
| | - Enzo Mammano
- Ospedale Civile Pietro Cosma, Camposampiero/Ospedale Sant’Antonio, Padova, Italy
| | - Ugo Elmore
- Ospedale San raffaele IRCCS, Milan, Italy
| | | | | | - Federico Perna
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Coratti
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | - Sergio Gentilli
- Azienda Ospedaliero Universitaria Maggiore Della Carità, Novara, Italy
| | - Paolo Baroffio
- Azienda Ospedaliero Universitaria Maggiore Della Carità, Novara, Italy
| | | | | | | | - Valter Torri
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | | | | | | | - Elena Traverso
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Vittorio Fusco
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Maura Rossi
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Fabio Priora
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - G. Numico
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Paola Franzone
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sara Orecchia
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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421
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Predictive Value of Endoscopic Features for a Complete Response After Chemoradiotherapy for Rectal Cancer. Ann Surg 2019; 274:e541-e547. [PMID: 31851000 DOI: 10.1097/sla.0000000000003718] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE AND BACKGROUND Watch-and-wait approach in rectal cancer relies on the identification of a clinical complete response (CR) after neoadjuvant (chemo)radiotherapy. This is mainly performed by rectal examination, magnetic resonance imaging, and endoscopy. Endoscopy has been less well studied, and the objective of the study is to assess the diagnostic value of endoscopy and the predictive value of endoscopic features for the identification of CR. PATIENTS AND METHODS A total of 161 patients with primary rectal cancer undergoing flexible sigmoidoscopy for response assessment after neoadjuvant (chemo)radiotherapy between January 2012 and December 2015 at a single institution were evaluated retrospectively. Three independent readers scored endoscopic features and a confidence level score for a CR. Diagnostic performance of endoscopy and positive predictive value (PPV) of endoscopic features for a CR were calculated. If available, biopsy results were revealed to the reader and a change in confidence level was noted. Reference standard was histology after surgery, or long-term outcome in a watch-and-wait policy. RESULTS Median time to endoscopy was 9 (interquartile range 8-12) weeks. Area under the receiver operator characteristic curve, sensitivity, specificity, PPV, and negative predictive value for a CR were 0.80 to 0.84, 72% to 94%, 61% to 85%, 63% to 78% and 80% to 89%, respectively. A flat scar was the most predictive feature of a CR (PPV 70%-80%). The PPV of small flat ulcers and large flat ulcers were 40% to 50% and 29% to 33%, respectively. The addition of biopsy results led to a significant change in confidence level score in 4% to 13% of patients. CONCLUSIONS More than 70% of the patients with a luminal CR after neoadjuvant treatment for rectal cancer can be identified by endoscopy at ±9 weeks. Together with findings on digital rectal examination (DRE) and magnetic resonance imaging, specific endoscopic features can be used to select patients for an extended observation period to select for organ preservation.
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422
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Restaging Patients with Rectal Cancer Following Neoadjuvant Chemoradiation: A Systematic Review. World J Surg 2019; 44:973-979. [PMID: 31788724 DOI: 10.1007/s00268-019-05309-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND In the USA, most patients with clinical stage II/III rectal cancer receive neoadjuvant chemoradiation (chemo/XRT) over 5-6 weeks followed by a 6-10-week break before proctectomy. As chemotherapy is delivered at radio-sensitizing doses, there is essentially a 3-month window during which potential systemic disease is untreated. Evidence regarding the utility of restaging patients prior to proctectomy is limited. METHODS PubMed, Scopus, Web of Science, and the Cochrane Library were searched for studies evaluating the utility of restaging patients with rectal cancer after completion of long-course chemo/XRT, and reporting associated changes in management. Studies that were non-English, included <50 patients, or examining the diagnostic accuracy of imaging modalities were excluded. Study quality was evaluated using the modified Newcastle Ottawa Scale. RESULTS Eight studies were identified including a total of 1251 patients restaged between completion of chemo/XRT and proctectomy. All studies were retrospective. Restaging identified new metastatic disease in 72 (6.0%) patients, with 4 studies reporting specific sites: liver (n = 28), lung (n = 8), adrenal (n = 1), bone (n = 1), and multiple sites (n = 7). Overall progression (distant or local) was detected in 88 (7.0%) patients and resulted in a change in management in 77 (87.5%) of these patients. Tumor-related prognostic characteristics were inconsistently reported among studies, precluding meta-analysis. CONCLUSIONS Although restaging between completion of neoadjuvant chemo/XRT and proctectomy detects disease progression in only a small percentage of patients, findings alter the treatment plan in the vast majority of these patients. Multi-institutional collaboration with analysis of well-defined prognostic variables may better identify patients most likely to benefit from restaging.
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423
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Fu Y, Liu X, Yang Q, Sun J, Xie Y, Zhang Y, Zhang H. Radiomic features based on MRI for prediction of lymphovascular invasion in rectal cancer. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s42058-019-00016-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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424
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Abstract
In recent years, rectal MRI has become a central diagnostic tool in rectal cancer staging. Indeed, rectal MR has the ability to accurately evaluate a number of important findings that may impact patient management, including distance of the tumor to the mesorectal fascia, presence of extramural vascular invasion (EMVI), presence of lymph nodes, and involvement of the peritoneum/anterior peritoneal reflection. Many of these findings are difficult to assess in nonexpert hands. In this review, we present a practical approach for radiologists to provide high-quality interpretations at initial baseline exams, based on recent guidelines from the Society of Abdominal Radiology, Rectal and Anal Cancer Disease Focused Panel. Practical pearls and pitfalls are discussed, focusing on optimization of technique including, patient preparation and protocol recommendations, interpretation, and essentials of reporting.
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425
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Krdzalic J, Maas M, Gollub MJ, Beets-Tan RGH. Guidelines for MR imaging in rectal cancer: Europe versus United States. Abdom Radiol (NY) 2019; 44:3498-3507. [PMID: 31605186 DOI: 10.1007/s00261-019-02251-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The aim of this study was to compare and contrast recently published guidelines for staging and reporting of MR imaging in rectal cancer from the European Society of Gastrointestinal and Abdominal Radiology and the North American Society of Abdominal Radiology. These guidelines were assessed on the presence of consensus and disagreement. Items were compared by two reviewers, and items with agreement and disagreement between the guidelines were identified and are presented in the current paper. Differences between guidelines are discussed to offer insights in practice variations between both continents and among expert centers, which to some extent may explain the differences between guidelines.
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Affiliation(s)
- J Krdzalic
- Department of Radiology, Zuyderland Medical Center, PO Box 5500, 6130MB, Heerlen/Sittard, The Netherlands
| | - M Maas
- Department of Radiology, The Netherlands Cancer Institute, PO Box 90203, 1006BE, Amsterdam, The Netherlands.
| | - M J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - R G H Beets-Tan
- Department of Radiology, The Netherlands Cancer Institute, PO Box 90203, 1006BE, Amsterdam, The Netherlands
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426
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Ganeshan D, Nougaret S, Korngold E, Rauch GM, Moreno CC. Locally recurrent rectal cancer: what the radiologist should know. Abdom Radiol (NY) 2019; 44:3709-3725. [PMID: 30953096 DOI: 10.1007/s00261-019-02003-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite advances in surgical techniques and chemoradiation therapy, recurrent rectal cancer remains a cause of morbidity and mortality. After successful treatment of rectal cancer, patients are typically enrolled in a surveillance strategy that includes imaging as studies have shown improved prognosis when recurrent rectal cancer is detected during imaging surveillance versus based on development of symptoms. Additionally, patients who experience a complete clinical response with chemoradiation therapy may elect to enroll in a "watch-and-wait" strategy that includes imaging surveillance rather than surgical resection. Factors that increase the likelihood of recurrence, patterns of recurrence, and the imaging appearances of recurrent rectal cancer are reviewed with a focus on CT, PET CT, and MR imaging.
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Affiliation(s)
- Dhakshinamoorthy Ganeshan
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Stephanie Nougaret
- Montpellier Cancer Research Institute, IRCM, Montpellier Cancer Research Institute, 208 Ave des Apothicaires, 34295, Montpellier, France
- Department of Radiology, Montpellier Cancer Institute, INSERM, U1194, University of Montpellier, 208 Ave des Apothicaires, 34295, Montpellier, France
| | - Elena Korngold
- Department of Radiology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Gaiane M Rauch
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Courtney C Moreno
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road, NE, Atlanta, GA, 30322, USA.
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427
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Abstract
The imaging of rectal cancer has evolved noticeably over the past 2 decades, paralleling the advances in therapy. The methods for imaging rectal cancer are increasingly used in clinical practice with the purpose of helping to detect, characterize and stage rectal cancer. In this setting, MR imaging emerged as the most useful imaging method for primary staging of rectal cancer; the present review focuses on the role of MR imaging in this regard.
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428
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Gollub MJ, Lall C, Lalwani N, Rosenthal MH. Current controversy, confusion, and imprecision in the use and interpretation of rectal MRI. Abdom Radiol (NY) 2019; 44:3549-3558. [PMID: 31062058 DOI: 10.1007/s00261-019-01996-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There has been a rapid increase in the utilization of MRI in rectal cancer staging in the USA essentially replacing endorectal ultrasound and mimicking the trend in Europe seen in the 1990s and 2000s. Accompanying this trend, there is a demand, and recognized need, for greater precision and clarification of confusing, misunderstood and poorly understood concepts, facts, statements and nomenclature regarding rectal cancer and the use of pelvic MRI for diagnosis. As such, this Review, part evidence-based and part expert opinion, will attempt to elucidate and clarify several concepts the authors have encountered in 25 years of imaging rectal cancer, focusing on MRI.
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Affiliation(s)
- Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Chandana Lall
- Division of Abdominal and Body Imaging, Department of Radiology, University of Florida, Jacksonville, 32209, FL, USA
| | - Neeraj Lalwani
- Department of Radiology, Section of Abdominal Imaging, Wake Forest University and Baptist Medical Center, Winston Salem, 27103, NC, USA
| | - Michael H Rosenthal
- Harvard Medical School, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, 02215, MA, USA
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429
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Abstract
Anal canal cancer is a rare disease and squamous cell carcinoma is the most common histologic subtype. Traditionally, anal cancer is imaged with CT and PET/CT for purposes of TNM staging. With the increased popularity of MRI for rectal cancer evaluation, MRI has become increasingly utilized for local staging of anal cancer. In this review, we focus on the necessary information radiologists need to know to understand this rare and unique disease and to be familiar with staging of anal cancer on MRI.
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430
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Complete mesocolic excision and central vascular ligation for right colon cancer: an introduction for abdominal radiologists. Abdom Radiol (NY) 2019; 44:3518-3526. [PMID: 31049615 DOI: 10.1007/s00261-019-02037-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an overview of complete mesocolic excision, along with a review of the relevant vascular anatomy and locoregional staging concepts, for abdominal radiologists. RESULTS Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer has emerged as a technique that has growing interest in surgical oncology. Specific anatomic considerations and patterns of nodal spread have thus gained clinical significance, and should be familiar to abdominal radiologists. This review article provides an overview of CME with CVL, and discusses some of the important anatomic considerations in patients with colon cancer that are relevant to radiologists. CONCLUSION Knowledge of CME with CVL and the relevant anatomic and staging considerations is important for abdominal radiologists, as this surgical technique becomes increasingly utilized.
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431
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Primary and post-chemoradiotherapy staging using MRI in rectal cancer: the role of diffusion imaging in the assessment of perirectal infiltration. Abdom Radiol (NY) 2019; 44:3674-3682. [PMID: 31332499 DOI: 10.1007/s00261-019-02139-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE To analyze changes in MRI diagnostic accuracy in main rectal tumor (T) evaluation resulting from the use of diffusion-weighted imaging (DWI), according to the degree of experience of the radiologist. METHODS This is a cross-sectional study of a database including one hundred 1.5 T MRI records (2011-2016) from patients with biopsy-proven rectal cancer, including primary staging and post-chemoradiotherapy follow-up. All cases were individually blindedly reviewed by ten radiologists: three experienced in rectal cancer, three specialized in other areas, and four residents. Each case was assessed twice to detect perirectal infiltration: first, evaluating just high-resolution T2-weighted sequences (HRT2w); second, evaluation of DWI plus HRT2w sequences. Results were pooled by experience, calculating accuracy (area under ROC curve), sensitivity and specificity, predictive values, likelihood ratios, and overstaging/understaging. Histology of surgical specimens provided the reference standard. RESULTS DWI significantly improved specificity by experienced radiologists in primary staging (63.2% to 75.9%) and, to a lesser extent, positive likelihood ratio (2.06 to 2.87); minimal changes were observed post-chemoradiotherapy, with a slight decrease of accuracy (0.657 to 0.626). Inexperienced radiologists showed a similar pattern, but with slight enhancement post-chemoradiotherapy (accuracy 0.604 to 0.621). Residents experienced small changes, with increased sensitivity/decreased specificity in both primary (69% to 72%/67.2% to 64.7%) and post-chemoradiotherapy (68.1% to 73.6%/47.3% to 44.6%) staging. CONCLUSIONS Adding DWI to HRT2w significantly improved specificity for the detection of perirectal infiltration at primary staging by experienced radiologists and also by inexperienced ones, although to a lesser extent. In the post-neoadjuvant treatment subgroup, only minimal changes were observed.
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432
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Tumor detectability and conspicuity comparison of standard b1000 and ultrahigh b2000 diffusion-weighted imaging in rectal cancer. Abdom Radiol (NY) 2019; 44:3595-3605. [PMID: 31444557 DOI: 10.1007/s00261-019-02177-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To compare tumor detectability and conspicuity of standard b = 1000 s/mm2 (b1000) versus ultrahigh b = 2000 s/mm2 (b2000) diffusion-weighted imaging (DWI) in rectal cancer. METHODS Fifty-five patients for a total of 81 3T DWI-MR scans were retrospectively evaluated by two differently experienced readers. A comparison between b1000 and b2000 for tumor detectability and conspicuity was performed. The conspicuity was qualitatively and quantitatively assessed by using three-point scale and whole tumor volume manual delineation, respectively. Receiver-operating characteristic curve (ROC) with area under the curve (AUC) analysis provided diagnostic accuracy in tumor detectability of restaging MR scans. Qualitative scores and quantitative features including mean signal intensity, variance, 10th percentile and 90th percentile, were compared using the Wilcoxon test. Interobserver agreement (IOA) for qualitative and quantitative data was calculated using Cohen's Kappa and intraclass correlation coefficient (ICC) respectively. RESULTS Diagnostic accuracy was comparable between b1000 and b2000 for both readers (p > 0.05). Overall quality scores were significantly better for b2000 than b1000 (2.29 vs 1.65 Reader 1, p = 0.01; 2.18 vs 1.69 Reader 2, p = 0.04). IOA was equally good for both b values (k = 0.86 b1000, k = 0.86 b2000). Quantitative analysis revealed more uniform signal (measured in variance) of b2000 in both healthy surrounding tissue (p < 0.05) and tumor (p < 0.05), with less outliers (measured using 10th and 90th percentile). Additionally, b2000 offered lower mean signal intensity in tissue sorrounding the tumor (p < 0.05). Finally, ICC improved from 0.92 (b1000) to 0.97 (b2000). CONCLUSION Ultrahigh b value (b2000) may improve rectal cancer conspicuity and introbserver agreement maintaining comparable diagnostic accuracy to standard b1000.
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433
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Gollub MJ, Lall C, Lalwani N, Rosenthal MH. Current controversy, confusion, and imprecision in the use and interpretation of rectal MRI. Abdom Radiol (NY) 2019. [PMID: 31062058 DOI: 10.1007/s00261-019-01996-3.pmid:31062058;pmcid:pmc7365137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
There has been a rapid increase in the utilization of MRI in rectal cancer staging in the USA essentially replacing endorectal ultrasound and mimicking the trend in Europe seen in the 1990s and 2000s. Accompanying this trend, there is a demand, and recognized need, for greater precision and clarification of confusing, misunderstood and poorly understood concepts, facts, statements and nomenclature regarding rectal cancer and the use of pelvic MRI for diagnosis. As such, this Review, part evidence-based and part expert opinion, will attempt to elucidate and clarify several concepts the authors have encountered in 25 years of imaging rectal cancer, focusing on MRI.
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Affiliation(s)
- Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Chandana Lall
- Division of Abdominal and Body Imaging, Department of Radiology, University of Florida, Jacksonville, 32209, FL, USA
| | - Neeraj Lalwani
- Department of Radiology, Section of Abdominal Imaging, Wake Forest University and Baptist Medical Center, Winston Salem, 27103, NC, USA
| | - Michael H Rosenthal
- Harvard Medical School, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, 02215, MA, USA
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434
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Adopting Graduate Competencies in Opioid Prescribing for Massachusetts Physician Assistant Programs: A Statewide Public Health Response. J Physician Assist Educ 2019; 30:207-213. [PMID: 31664008 DOI: 10.1097/jpa.0000000000000276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Opioid addiction has become a national epidemic. Morbidity and mortality from prescription and synthetic opioid use and abuse have increased at an alarming rate in recent years. Ensuring that physician assistant (PA) graduates have the knowledge to become safe prescribers of medications, including opiates, is a goal of PA training programs. Achieving that goal requires fostering PA student competence regarding current issues in pain control, drug use and misuse, polypharmacy, diversion, self-medication, and substance use disorder. We present a public health approach to addressing that need. Our approach involved developing consensus among the 9 PA programs in Massachusetts concerning the adoption and implementation of statewide, graduate core competencies for the prevention and management of prescription drug misuse. The process implemented in Massachusetts could be used as a model in other states and might be relevant to addressing other public health crises. We present the adopted competencies as well as individual PA programs' curricular approaches.
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435
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Yu L, Wang L, Tan Y, Hu H, Shen L, Zheng S, Ding K, Zhang S, Yuan Y. Accuracy of Magnetic Resonance Imaging in Staging Rectal Cancer with Multidisciplinary Team: A Single-Center Experience. J Cancer 2019; 10:6594-6598. [PMID: 31777588 PMCID: PMC6856893 DOI: 10.7150/jca.32685] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 08/06/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose: To investigate the accuracy of magnetic resonance imaging (MRI) in preoperative staging diagnosis for rectal cancer with multidisciplinary team (MDT) discussion. Methods: The retrospective study included 377 patients of rectal cancer with preoperative MRI staging from February 2015 to April 2018, in which 137 patients (36 received MDT discussion) received neoadjuvant therapy, 240 did not (97 received MDT discussion) and direct surgery was given. With postoperative pathological stage as the standard, the accuracy of MRI in preoperative staging for rectal cancer with MDT discussion was compared with non-MDT. Results: For direct surgery group, 21 out 97 (21.6%) patients changed their therapy strategy due to the change of the stage assessment after MDT. The accuracy of MRI for the diagnosis of preoperative N stage with MDT was significantly higher than those without MDT (56.2% vs. 42.1%, P=0.021). And for those without lymph node metastasis, the accuracy of MRI was higher after MDT (61.2% vs. 37.8%, P=0.009). For neoadjuvant therapy group, 7 out of 36 (19.4%) patients altered their therapy after MDT because of the changed stage. MDT improved the accuracy of restaging N stage with MRI (70.0% vs. 33.3%, P=0.003). The accuracy of MRI in staging T stage seemed not improved after MDT in both groups. Conclusions: In conclusion, MDT discussion increased the accuracy of MRI in preoperative staging diagnosis for rectal cancer. This mode could give a more accurate clinical stage of patients, which was in favor of choosing a preferable therapy strategy.
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Affiliation(s)
- Linzhen Yu
- Department of Medical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Liuhong Wang
- Department of Radiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yinuo Tan
- Department of Medical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Hanguang Hu
- Department of Medical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Li Shen
- Department of Radiation Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Shu Zheng
- Department of Colorectal Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Kefeng Ding
- Department of Colorectal Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Suzhan Zhang
- Department of Colorectal Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Ying Yuan
- Department of Medical Oncology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.,Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education), the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
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436
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Dekker E, Tanis PJ, Vleugels JLA, Kasi PM, Wallace MB. Colorectal cancer. Lancet 2019; 394:1467-1480. [PMID: 31631858 DOI: 10.1016/s0140-6736(19)32319-0] [Citation(s) in RCA: 2297] [Impact Index Per Article: 459.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 07/19/2019] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
Several decades ago, colorectal cancer was infrequently diagnosed. Nowadays, it is the world's fourth most deadly cancer with almost 900 000 deaths annually. Besides an ageing population and dietary habits of high-income countries, unfavourable risk factors such as obesity, lack of physical exercise, and smoking increase the risk of colorectal cancer. Advancements in pathophysiological understanding have increased the array of treatment options for local and advanced disease leading to individual treatment plans. Treatments include endoscopic and surgical local excision, downstaging preoperative radiotherapy and systemic therapy, extensive surgery for locoregional and metastatic disease, local ablative therapies for metastases, and palliative chemotherapy, targeted therapy, and immunotherapy. Although these new treatment options have doubled overall survival for advanced disease to 3 years, survival is still best for those with non-metastasised disease. As the disease only becomes symptomatic at an advanced stage, worldwide organised screening programmes are being implemented, which aim to increase early detection and reduce morbidity and mortality from colorectal cancer.
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Affiliation(s)
- Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands.
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Jasper L A Vleugels
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands; Department of Internal Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Pashtoon M Kasi
- Department of Medical Oncology, University of Iowa, Iowa City, IA, USA
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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437
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Gursoy Coruh A, Peker E, Elhan A, Erden I, Erden A. Evaluation of Extramural Venous Invasion by Diffusion-Weighted Magnetic Resonance Imaging and Computed Tomography in Rectal Adenocarcinoma. Can Assoc Radiol J 2019; 70:457-465. [PMID: 31582328 DOI: 10.1016/j.carj.2019.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/30/2019] [Accepted: 06/09/2019] [Indexed: 02/07/2023] Open
Abstract
PURPOSE The aim of this study is to evaluate the diagnostic contribution of diffusion-weighted magnetic resonance imaging (MRI) and computed tomography (CT) to distinguish extramural venous invasion (EMVI) in rectal adenocarcinoma. MATERIALS AND METHODS Fifty-eight patients who had been diagnosed with rectal adenocarcinoma (30 patients with EMVI and 28 patients without EMVI) were enrolled in the study. Apparent diffusion coefficient (ADC) values of the tumour and the EMVI (+) vein, the lengths of the tumours were measured on MRI. The diameters of the superior rectal vein (SRV)-inferior mesenteric vein (IMV) and distant metastatic spread were evaluated on CT. The ability of these findings to detect EMVI was assessed using receiver operating characteristic (ROC) analysis. Pathology was accepted as the reference test for EMVI. RESULTS Mean diameters of the SRV (4.9 ± 0.9 mm vs 3.7 ± 0.8 mm) and IMV (6.9 ± 0.8 mm vs 5.4 ± 0.9 mm) were significantly larger (P < .001) and tumour ADC values were significantly lower (0.926 ± 0.281 × 10-3 mm2/s vs 1.026 ± 0.246 × 10-3 mm2/s; P = .032) in EMVI (+) patients. Diameters of 3.95 mm for the SRV (area under the curve [AUC] ± standard error [SE]: 0.851 ± 0.051, P < .001, sensitivity: 93.3%, specificity: 67.9%) and 5.95 mm for the IMV (AUC ± SE: 0.893 ± 0.040, P < .001, sensitivity: 93.3%, specificity: 71.4%) and an ADC value of 0.929 × 10-3 mm2/s (AUC ± SE: 0.664 ± 0.072, P = .032 sensitivity: 76.7%, specificity: 57.1%) were found to be cutoff values, determined by ROC analysis, for detection of EMVI. Distant metastases were significantly more prevalent in EMVI (+) patients (P < .001). CONCLUSION The measurement of ADC values and SRV-IMV diameters seems to have contribution for diagnosis of EMVI in rectal adenocarcinoma. EMVI (+) patients appear to have higher risks of distant metastases at diagnosis.
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Affiliation(s)
| | - Elif Peker
- Department of Radiology, School of Medicine, Ankara University, Ankara, Turkey
| | - Atilla Elhan
- Department of Biostatistics, School of Medicine, Ankara University, Ankara, Turkey
| | - Ilhan Erden
- Department of Radiology, School of Medicine, Ankara University, Ankara, Turkey
| | - Ayse Erden
- Department of Radiology, School of Medicine, Ankara University, Ankara, Turkey
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438
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Fornell-Perez R, Perez-Alonso E, Aleman-Flores P, Lozano-Rodriguez A, Loro-Ferrer JF. Nodal staging in the rectal cancer follow-up MRI after chemoradiotherapy: use of morphology, size, and diffusion criteria. Clin Radiol 2019; 75:100-107. [PMID: 31515052 DOI: 10.1016/j.crad.2019.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/08/2019] [Indexed: 02/07/2023]
Abstract
AIM To analyse changes in post-neoadjuvant follow-up magnetic resonance imaging (MRI) staging accuracy for malignant adenopathies in rectal cancer, by comparing size criteria with morphological criteria using high-resolution T2-weighted sequences, as well as variations when adding diffusion-weighted imaging. METHODS AND MATERIALS The present study was a cross-sectional study of a database including 46 1.5-T MRI examinations (2011-2016) from patients with biopsy-proven rectal cancer and chemoradiotherapy treatment before surgery. All cases were reviewed by three radiologists individually, who were blinded to any clinical information. The radiologists were experienced in rectal cancer (3-6 years) and evaluated the presence of malignant nodes in each patient. Malignancy was determined using morphological, size (5 mm), and diffusion criteria separately, as well as morphology plus diffusion. Each case was assessed four times: (1) evaluation of morphological criteria; (2) size criteria; (3) evaluation only using diffusion (b-values 50, 400, and 800); and (4) diffusion plus morphological criteria. Histological staging of surgical specimens was the reference standard. Statistical analysis included accuracy (area under the receiver operating characteristic [ROC] curve [AUC]), sensitivity, specificity, and positive/negative predictive values (PPV/NPV) for each radiologist, and group agreement (Fleiss' kappa). RESULTS Mean values using morphological criteria were: AUC 0.78, sensitivity 77.7%, specificity 73.8%, PPV 66.1%, NPV 85.2%. Using size criterion: AUC 0.75, sensitivity 62.9%, specificity 83.2%, PPV 74.1%, NPV 80%. Added diffusion yielded no improvement, and yielded worse results by itself. CONCLUSIONS Although morphological criteria showed better results in accuracy, sensitivity, and NPV, size criterion yielded the best specificity and PPV. Adding diffusion did not demonstrate a clear advantage over the criteria by themselves. Thus, mixed size-morphology criteria could have the greatest diagnostic value for follow-up N-staging.
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Affiliation(s)
- R Fornell-Perez
- Clinical Sciences Department, Faculty of Medicine, University of Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe, s/n, 35016, Las Palmas de Gran Canaria, Spain.
| | - E Perez-Alonso
- Clinical Sciences Department, Faculty of Medicine, University of Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe, s/n, 35016, Las Palmas de Gran Canaria, Spain; Department of General Surgery, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Spain
| | - P Aleman-Flores
- Department of Radiology, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Spain
| | - A Lozano-Rodriguez
- Department of Radiology, Complejo Hospitalario Universitario Insular Materno-Infantil, Av. Marítima, s/n, 35016, Las Palmas de Gran Canaria, Spain
| | - J F Loro-Ferrer
- Clinical Sciences Department, Faculty of Medicine, University of Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe, s/n, 35016, Las Palmas de Gran Canaria, Spain
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439
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Helmberger T. [Colorectal carcinoma : What kind of imaging do we need?]. Radiologe 2019; 59:785. [PMID: 31482270 DOI: 10.1007/s00117-019-00581-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- T Helmberger
- Institut für Radiologie, Neuroradiologie und minimal-invasive Therapie, Klinikum Bogenhausen, Englschalkinger Str. 77, 81925, München, Deutschland.
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440
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[Imaging of rectal cancer. German version]. Radiologe 2019; 59:799-803. [PMID: 31463539 DOI: 10.1007/s00117-019-0576-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
International guidelines dictate that magnetic resonance imaging (MRI) should be part of the primary standard work up of patients with rectal cancer because MRI can accurately identify the main risk factors for local recurrence and stratify patients into a differentiated treatment. The role of endoscopic ultrasound (EUS) is restricted to staging of superficial tumors because EUS is able to differentiate between T1 and T2 rectal cancer. Recent guidelines recommend the addition of diffusion-weighted (DWI) MRI to clinical and endoscopic assessment of response to preoperative radiochemotherapy (RCT). MRI is able to identify significant tumor regression which may alter the surgical approach.
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441
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Nougaret S, Castan F, de Forges H, Vargas HA, Gallix B, Gourgou S, Rouanet P. Early MRI predictors of disease-free survival in locally advanced rectal cancer from the GRECCAR 4 trial. Br J Surg 2019; 106:1530-1541. [PMID: 31436325 DOI: 10.1002/bjs.11233] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/05/2019] [Accepted: 04/14/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Tailored neoadjuvant treatment of locally advanced rectal cancer (LARC) may improve outcomes. The aim of this study was to determine early MRI prognostic parameters with which to stratify neoadjuvant treatment in patients with LARC. METHODS All patients from a prospective, phase II, multicentre randomized study (GRECCAR4; NCT01333709) were included, and underwent rectal MRI before treatment, 4 weeks after induction chemotherapy and after completion of chemoradiotherapy (CRT). Tumour volumetry, MRI tumour regression grade (mrTRG), T and N categories, circumferential resection margin (CRM) status and extramural vascular invasion identified by MRI (mrEMVI) were evaluated. RESULTS A total of 133 randomized patients were analysed. Median follow-up was 41·4 (95 per cent c.i. 36·6 to 45·2) months. Thirty-one patients (23·3 per cent) developed tumour recurrence. In univariable analysis, mrEMVI at baseline was the only prognostic factor associated with poorer outcome (P = 0·015). After induction chemotherapy, a larger tumour volume on MRI (P = 0·019), tumour volume regression of 60 per cent or less (P = 0·002), involvement of the CRM (P = 0·037), mrEMVI (P = 0·026) and a poor mrTRG (P = 0·023) were associated with poor outcome. After completion of CRT, the absence of complete response on MRI (P = 0·004), mrEMVI (P = 0·038) and a poor mrTRG (P = 0·005) were associated with shorter disease-free survival. A final multivariable model including all significant variables (baseline, after induction, after CRT) revealed that Eastern Cooperative Oncology Group performance status (P = 0·011), sphincter involvement (P = 0·009), mrEMVI at baseline (P = 0·002) and early tumour volume regression of 60 per cent or less after induction (P = 0·007) were associated with relapse. CONCLUSION Baseline and early post-treatment MRI parameters are associated with prognosis in LARC. Future preoperative treatment should stratify treatment according to baseline mrEMVI status and early tumour volume regression.
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Affiliation(s)
- S Nougaret
- Department of Radiology, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France.,Institut de Recherche en Cancérologie de Montpellier, Institut National de la Santé et de la Recherche Médicale, U1194, Montpellier, France
| | - F Castan
- Biometrics Unit, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - H de Forges
- Clinical Research Unit, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - H A Vargas
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - B Gallix
- Department of Radiology, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - S Gourgou
- Biometrics Unit, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France
| | - P Rouanet
- Department of Surgical Oncology, Institut du Cancer de Montpellier, University of Montpellier, Montpellier, France
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Long-term imaging characteristics of clinical complete responders during watch-and-wait for rectal cancer-an evaluation of over 1500 MRIs. Eur Radiol 2019; 30:272-280. [PMID: 31428827 DOI: 10.1007/s00330-019-06396-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/24/2019] [Accepted: 07/26/2019] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Rectal cancer patients with a clinical complete response after chemoradiotherapy (CRT) may be followed with a 'watch-and-wait' (W&W) approach as an alternative to surgery. MRI plays an important role in the follow-up of these patients, but basic knowledge on what to expect from the morphology of the irradiated tumour bed during follow-up is lacking, which can hamper image interpretation. The objective was to establish the spectrum of non-suspicious findings during long-term (> 2 years) follow-up in patients with a sustained clinical complete response undergoing W&W. METHODS A total of 1509 T2W MRIs of 164 sustained complete responders undergoing W&W were retrospectively evaluated. Morphology of the tumour bed was evaluated (2 independent readers) on the restaging MRI and on the various follow-up MRIs and classified as (a) no fibrosis, (b) minimal fibrosis, (c) full thickness fibrosis, or (d) irregular fibrosis. Any changes occurring during follow-up were documented. RESULTS A total of 104 patients (63%) showed minimal fibrosis, 38 (23%) full thickness fibrosis, 8 (5%) irregular fibrosis, and 14 (9%) no fibrosis. In 93% of patients, the morphology remained completely stable during follow-up; in 7%, a minor increase/decrease in fibrosis was observed. Interobserver agreement was excellent (κ 0.90). CONCLUSIONS Typically, the morphology as established at restaging remains completely unchanged. The majority of patients show fibrosis with the predominant pattern being a minimal fibrosis confined to the rectal wall. Complete absence of fibrosis occurs in only 1/10 cases. Once validated in independent cohorts, these findings may serve as a reference for radiologists involved in the clinical follow-up of W&W patients. KEY POINTS • In rectal cancer patients with a sustained complete response after chemoradiation, the rectal wall morphology as established on restaging MRI typically remains unchanged during long-term MRI follow-up. • The vast majority of complete responders show fibrosis with the predominant pattern being a minimal fibrotic remnant that remains confined to the rectal wall; complete absence of fibrosis occurs in only 10% of the cases. • Once validated in independent cohorts, the findings of this study may serve as a reference for radiologists involved in the clinical follow-up of rectal cancer patients undergoing watch-and-wait.
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443
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Kreis ME, Ruppert R, Kube R, Strassburg J, Lewin A, Baral J, Maurer CA, Sauer J, Winde G, Thomasmeyer R, Stelzner S, Bambauer C, Scheunemann S, Faedrich A, Junginger T, Hermanek P, Merkel S. MRI-Based Use of Neoadjuvant Chemoradiotherapy in Rectal Carcinoma: Surgical Quality and Histopathological Outcome of the OCUM Trial. Ann Surg Oncol 2019; 27:417-427. [PMID: 31414295 DOI: 10.1245/s10434-019-07696-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Preoperative magnetic resonance imaging (MRI) allows highly reliable imaging of the mesorectal fascia (mrMRF) and its relationship to the tumor. The prospective multicenter observational study OCUM uses these findings to indicate neoadjuvant chemoradiotherapy (nCRT) in rectal carcinoma. METHODS nCRT was indicated in patients with positive mrMRF (≤ 1 mm) in cT4 and cT3 carcinomas of the lower rectal third. RESULTS A total of 527 patients (60.2%) underwent primary total mesorectal excision, and 348 patients (39.8%) underwent long-term nCRT followed by surgery. The mrMRF was involved in 4.6% of the primary surgery group and 80.7% of the nCRT group. Rates of resections within the mesorectal plane (90.8%), sparing of pelvic nerves on both sides (97.8%), and number of regional lymph nodes (95.3% with ≥ 12 lymph nodes examined) are indicative of high-quality surgery. Resection was classified as R0 in 98.3%, the pathological circumferential resection margin (pCRM) was negative in 95.1%. Patients in the nCRT group had more advanced carcinomas with a significantly higher rate of abdominoperineal excision. Independent risk factors for pCRM positivity were advanced stage (T4), metastatic lymph nodes, resection in the muscularis propria plane, and location in the lower third. CONCLUSIONS The risk classification of rectal cancer patients by MRI seems to be highly reliable and allows the restriction of nCRT to approximately half of the patients with clinical stage II and III rectal carcinoma, provided there is a high-quality MRI diagnostic protocol, high-quality surgery, and standardized examination of the resected specimen.
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Affiliation(s)
- Martin E Kreis
- Department of Surgery, Campus Benjamin Franklin, Charité, University Medicine, Berlin, Germany
| | - Reinhard Ruppert
- Department of General and Visceral Surgery, Endocrine Surgery, and Coloproctology, Municipal Hospital of Munich-Neuperlach, Munich, Germany
| | - Rainer Kube
- Department of Surgery, Carl-Thiem-Klinik, Cottbus, Germany
| | - Joachim Strassburg
- Department of General and Visceral Surgery, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Andreas Lewin
- Department of General and Visceral Surgery, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Joerg Baral
- Department of General and Visceral Surgery, Municipal Hospital, Karlsruhe, Germany
| | - Christoph A Maurer
- Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland.,HIRSLANDEN Private Hospital Group, Clinic Beau-Site, Bern, Switzerland
| | - Joerg Sauer
- Department for General, Visceral and Minimal Invasive Surgery, Arnsberg, Germany
| | - Günther Winde
- Department for General and Visceral Surgery, Thoracic Surgery and Proctology University Medical Centre, Herford, Germany
| | - Rena Thomasmeyer
- Department for General, Visceral and Minimal Invasive Surgery, Municipal Hospital Wolfenbüttel, Wolfenbüttel, Germany
| | | | | | - Soenke Scheunemann
- Department for General and Visceral Surgery, Evangelisches Krankenhaus Lippstadt, Lippstadt, Germany
| | - Axel Faedrich
- Department for Genera- and Visceral Surgery, Brüderkrankenhaus St. Josef Paderborn, Paderborn, Germany
| | - Theodor Junginger
- Department of General and Abdominal Surgery, University Medical Centre at the Johannes Gutenberg-University, Mainz, Germany.
| | - Paul Hermanek
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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444
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Elliot AH, Blomqvist L, Sigurdsson A, Martling A, Johansson H, Glimelius B, Nilsson PJ. An audit of performance, interpretation, and influence of pretherapeutic MRI in rectal cancer: a Swedish population-based cohort study. Acta Radiol 2019; 60:955-961. [PMID: 30322292 DOI: 10.1177/0284185118806638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The performance of magnetic resonance imaging (MRI) interpretation and communication of findings and its implication on treatment decisions has not fully been explored in rectal cancer. Purpose To investigate in a region the adherence to MRI protocol standards and the relation between MRI interpretation and selection to preoperative therapy in rectal cancer. Material and Methods Data on consecutive patients who underwent elective rectal cancer surgery in the region from January to June 2010 were obtained from the National Colorectal Cancer Registry. Pretherapeutic MRI images were re-evaluated. Agreement between the original reports and the re-evaluation was compared using Cohen’s kappa coefficient. Results Among the 94 patients included, 81 (86%) had pretherapeutic MRI in accordance with defined imaging guidelines. In 34% of the original MR reports, data on extramural venous invasion (mrEMVI) and mrT category were not reported. Complete tumor staging was not possible because of missing data in 33 (35%) of the patients. The agreement between the original MR reports and the re-evaluation regarding tumor stage was moderate (κ = 0.48). For decided treatment compared to recommended preoperative treatment according to the re-evaluation, the agreement was fair (κ = 0.33). Conclusion Established MRI protocol standards were not universally applied. Missing data and inadequacies in original MRI reports resulted in moderate agreement between the original report and the re-evaluation indicating a risk of inappropriate treatment selection. The results call for further educational efforts in rectal cancer MRI acquisition and repeated audits of image protocol adherence and interpretation quality.
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Affiliation(s)
- Anders H Elliot
- 1 Department of Molecular Medicine and Surgery, Karolinska Institutet, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Lennart Blomqvist
- 2 Department of Molecular Medicine and Surgery, Karolinska Institutet, Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anna Martling
- 1 Department of Molecular Medicine and Surgery, Karolinska Institutet, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Hemming Johansson
- 4 Karolinska Institutet, Department of Oncology-Pathology (OnkPat), Karolinska University Hospital, Stockholm, Sweden
| | - Bengt Glimelius
- 5 Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Per J Nilsson
- 1 Department of Molecular Medicine and Surgery, Karolinska Institutet, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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445
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Brown PJ, Hyland R, Quyn AJ, West NP, Sebag-Montefiore D, Jayne D, Sagar P, Tolan DJ. Current concepts in imaging for local staging of advanced rectal cancer. Clin Radiol 2019; 74:623-636. [PMID: 31036310 DOI: 10.1016/j.crad.2019.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/22/2019] [Indexed: 12/20/2022]
Abstract
Imaging of rectal cancer has an increasingly pivotal role in the diagnosis, staging, and treatment stratification of patients with the disease. This is particularly true for advanced rectal cancers where magnetic resonance imaging (MRI) findings provide essential information that can change treatment. In this review we describe the rationale for the current imaging standards in advanced rectal cancer for both morphological and functional imaging on the baseline staging and reassessment studies. In addition the clinical implications and future methods by which radiologists may improve these are outlined relative to TNM8.
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Affiliation(s)
- P J Brown
- Department of Clinical Radiology, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK.
| | - R Hyland
- Department of Clinical Radiology, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - A J Quyn
- Department of General Surgery, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - N P West
- Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, Welcome Trust Brenner Building, St James's University Hospital, Leeds, LS9 7TF, UK
| | - D Sebag-Montefiore
- Department of Clinical Oncology, Bexley Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - D Jayne
- Department of General Surgery, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - P Sagar
- Department of General Surgery, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - D J Tolan
- Department of Clinical Radiology, Lincoln Wing, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
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446
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Chan BPH, Patel R, Mbuagbaw L, Thabane L, Yaghoobi M. EUS versus magnetic resonance imaging in staging rectal adenocarcinoma: a diagnostic test accuracy meta-analysis. Gastrointest Endosc 2019; 90:196-203.e1. [PMID: 31004599 DOI: 10.1016/j.gie.2019.04.217] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 04/04/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS EUS and magnetic resonance imaging (MRI) are both used for locoregional staging of rectal cancer, which determines treatment options. There is a lack of consensus on the best modality for locoregional staging, with studies supporting both EUS and MRI. In this study, we performed the first diagnostic test accuracy meta-analysis to compare the diagnostic accuracy, sensitivity, and specificity of EUS and MRI in the staging of rectal cancer. METHODS A comprehensive electronic literature search up to June 2018 was performed to identify prospective cohort studies directly comparing the accuracy of EUS with MRI in staging nonmetastatic rectal cancer with surgical pathology as the reference standard. Quality of the included studies was measured by using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. A bivariate hierarchical model was used to perform the meta-analysis of diagnostic test accuracy according to the Cochrane approved methodology. Summary receiver operating characteristics were developed, and the area under the curve was calculated for overall and individual T and N staging, for EUS, MRI, and head-to-head comparison. RESULTS Six of 2475 studies including 234 patients were eligible. Pooled sensitivity and specificity in T staging were .79 (95% confidence interval [CI], .72-.85) and .89 (95% CI, .84-.93) for EUS and .79 (95% CI, .72-.85) and .85 (95% CI, .79-.90) for MRI, respectively. Pooled sensitivity and specificity in N staging were .81 (95% CI, .71-.89) and .88 (95% CI, .80-.94) for EUS and .83 (95% CI, .73-.90), and .90 (95% CI, .82-.95) for MRI, respectively. In area under the curve head-to-head analysis, EUS was superior to MRI in overall T staging (P < .05). EUS outperformed MRI in overall T, overall N, T1, and T3 staging (P < .01), after excluding studies using an endorectal coil for MRI. MRI was superior to EUS in T2 staging (P = .01) in both analyses. CONCLUSIONS EUS and MRI both provide reasonable diagnostic accuracy in the staging of nonmetastatic rectal cancer. EUS was superior to MRI in overall T staging and overall T and N staging after adjusting for MRI technology. Practitioners should be aware of advantages and disadvantages of both modalities and choose appropriate methods while considering diagnostic accuracy of each test and institutional practices and limitations.
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Affiliation(s)
- Brian P H Chan
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Raxitkumar Patel
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Gastrointestinal Health Technology Assessment Group, The Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
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447
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Rutegård MK, Båtsman M, Axelsson J, Brynolfsson P, Brännström F, Rutegård J, Ljuslinder I, Blomqvist L, Palmqvist R, Rutegård M, Riklund K. PET/MRI and PET/CT hybrid imaging of rectal cancer - description and initial observations from the RECTOPET (REctal Cancer trial on PET/MRI/CT) study. Cancer Imaging 2019; 19:52. [PMID: 31337428 PMCID: PMC6651930 DOI: 10.1186/s40644-019-0237-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/09/2019] [Indexed: 12/24/2022] Open
Abstract
Purpose The role of hybrid imaging using 18F-fluoro-2-deoxy-D-glucose positron-emission tomography (FDG-PET), computed tomography (CT) and magnetic resonance imaging (MRI) to improve preoperative evaluation of rectal cancer is largely unknown. To investigate this, the RECTOPET (REctal Cancer Trial on PET/MRI/CT) study has been launched with the aim to assess staging and restaging of primary rectal cancer. This report presents the study workflow and the initial experiences of the impact of PET/CT on staging and management of the first patients included in the RECTOPET study. Methods This prospective cohort study, initiated in September 2016, is actively recruiting patients from Region Västerbotten in Sweden. This pilot study includes patients recruited and followed up until December 2017. All patients had a biopsy-verified rectal adenocarcinoma and underwent a minimum of one preoperative FDG-PET/CT and FDG-PET/MRI examination. These patients were referred to the colorectal cancer multidisciplinary team meeting at Umeå University Hospital. All available data were evaluated when making management recommendations. The clinical course was noted and changes consequent to PET imaging were described; surgical specimens underwent dedicated MRI for anatomical matching between imaging and histopathology. Results Twenty-four patients have so far been included in the study. Four patients were deemed unresectable, while 19 patients underwent or were scheduled for surgery; one patient was enrolled in a watch-and-wait programme after restaging. Consequent to taking part in the study, two patients were upstaged to M1 disease: one patient was diagnosed with a solitary hepatic metastasis detected using PET/CT and underwent metastasectomy prior to rectal cancer surgery, while one patient with a small, but metabolically active, lung nodulus experienced no change of management. PET/MRI did not contribute to any recorded change in patient management. Conclusions The RECTOPET study investigating the role of PET/CT and PET/MRI for preoperative staging of primary rectal cancer patients will provide novel data that clarify the value of adding hybrid to conventional imaging, and the role of PET/CT versus PET/MRI. Trial registration NCT03846882.
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Affiliation(s)
- Miriam K Rutegård
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, SE-901 85, Umeå, Sweden.
| | - Malin Båtsman
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | - Jan Axelsson
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, SE-901 85, Umeå, Sweden
| | - Patrik Brynolfsson
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, SE-901 85, Umeå, Sweden
| | - Fredrik Brännström
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Jörgen Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Ingrid Ljuslinder
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Lennart Blomqvist
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, SE-901 85, Umeå, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Imaging and Physiology, Karolinska University Hospital, Solna, Sweden
| | - Richard Palmqvist
- Department of Medical Biosciences, Pathology, Umeå University, Umeå, Sweden
| | - Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.,Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Katrine Riklund
- Department of Radiation Sciences, Diagnostic Radiology, Umeå University, SE-901 85, Umeå, Sweden
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448
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Νikolouzakis ΤΚ, Mariolis-Sapsakos T, Triantopoulou C, De Bree E, Xynos E, Chrysos E, Tsiaoussis J. Detailed and applied anatomy for improved rectal cancer treatment. Ann Gastroenterol 2019; 32:431-440. [PMID: 31474788 PMCID: PMC6686088 DOI: 10.20524/aog.2019.0407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/25/2019] [Indexed: 12/12/2022] Open
Abstract
Rectal anatomy is one of the most challenging concepts of visceral anatomy, even though currently there are more than 23,000 papers indexed in PubMed regarding this topic. Nonetheless, even though there is a plethora of information meant to assist clinicians to achieve a better practice, there is no universal understanding of its complexity. This in turn increases the morbidity rates due to iatrogenic causes, as mistakes that could be avoided are repeated. For this reason, this review attempts to gather current knowledge regarding the detailed anatomy of the rectum and to organize and present it in a manner that focuses on its clinical implications, not only for the colorectal surgeon, but most importantly for all colorectal cancer-related specialties.
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Affiliation(s)
- Τaxiarchis Κonstantinos Νikolouzakis
- Laboratory of Anatomy-Histology-Embryology, Medical School of Heraklion, University of Crete (Taxiarchis Konstantinos Nikolouzakis, John Tsiaoussis)
| | - Theodoros Mariolis-Sapsakos
- Surgical Department, National and Kapodistrian University of Athens, Agioi Anargyroi General and Oncologic Hospital of Kifisia, Athens (Theodoros Mariolis-Sapsakos)
| | | | - Eelco De Bree
- Department of Surgical Oncology, Medical School of Crete University Hospital, Heraklion, Crete (Eelco De Bree)
| | - Evaghelos Xynos
- Colorectal Surgery, Creta Interclinic, Heraklion, Crete (Evaghelos Xynos)
| | - Emmanuel Chrysos
- Department of General Surgery, University Hospital of Heraklion, Crete (Emmanuel Chrysos), Greece
| | - John Tsiaoussis
- Laboratory of Anatomy-Histology-Embryology, Medical School of Heraklion, University of Crete (Taxiarchis Konstantinos Nikolouzakis, John Tsiaoussis)
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449
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Rectal cancer: can T2WI histogram of the primary tumor help predict the existence of lymph node metastasis? Eur Radiol 2019; 29:6469-6476. [PMID: 31278581 DOI: 10.1007/s00330-019-06328-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/03/2019] [Accepted: 06/13/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To explore if there is a correlation between T2WI histogram features of the primary tumor and the existence of regional lymph node (LN) metastasis in rectal cancer. METHODS Eighty-eight patients with pathologically proven rectal adenocarcinoma, who received direct surgical resection and underwent preoperative rectal MRIs, were enrolled retrospectively. Based on pathological analysis of surgical specimen, patients were classified into negative LN (LN-) and positive LN (LN+) groups. The degree of differentiation and pathological T stage were recorded. Clinical T stage, tumor location, and maximum diameter of tumor were evaluated of each patient. Whole-tumor texture analysis was independently performed by two radiologists on axial T2WI, including skewness, kurtosis, energy, and entropy. RESULTS The interobserver agreement was overall good for texture analysis between two radiologists, with intraclass correlation coefficients (ICCs) ranging from 0.626 to 0.826. The LN- group had a significantly higher skewness (p < 0.001), kurtosis (p < 0.001), and energy (p = 0.004) than the LN+ group, and a lower entropy (p = 0.028). These four parameters showed moderate to good diagnostic power in predicting LN metastasis with respective AUC of 0.750, 0.733, 0.669, and 0.648. In addition, they were both correlated with LN metastasis (rs = - 0.413, - 0.385, - 0.28, and 0.245, respectively). The multivariate analysis showed that lower skewness was an independent risk factor of LN metastasis (odds ratio, OR = 9.832; 95%CI, 1.171-56.295; p = 0.01). CONCLUSIONS Signal intensity histogram parameters of primary tumor on T2WI were associated with regional LN status in rectal cancer, which may help improve the prediction of nodal stage. KEY POINTS • Histogram parameters of tumor on T2WI may help to reduce uncertainty when assessing LN status in rectal cancer. • Histogram parameters of tumor on T2WI showed a significant difference between different regional LN status groups in rectal cancer. • Skewness was an independent risk factor of regional LN metastasis in rectal cancer.
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450
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Fusco R, Granata V, Rega D, Russo C, Pace U, Pecori B, Tatangelo F, Botti G, Izzo F, Cascella M, Avallone A, Delrio P, Petrillo A. Morphological and functional features prognostic factor of magnetic resonance imaging in locally advanced rectal cancer. Acta Radiol 2019; 60:815-825. [PMID: 30286607 DOI: 10.1177/0284185118803783] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Roberta Fusco
- Division of Radiology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Vincenza Granata
- Division of Radiology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Daniela Rega
- Division of Gastrointestinal Surgical Oncology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Carolina Russo
- Division of Radiology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Ugo Pace
- Division of Gastrointestinal Surgical Oncology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Biagio Pecori
- Divion of Radiotherapy, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Fabiana Tatangelo
- Division of Diagnostic Pathology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Gerardo Botti
- Division of Diagnostic Pathology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Francesco Izzo
- Division of Hepatobiliary Surgical Oncology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Marco Cascella
- Division of Anesthesia, Endoscopy and Cardiology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Antonio Avallone
- Division of Gastrointestinal Medical Oncology, “Istituto Nazionale Tumori Fondazione Giovanni Pascale – IRCCS,” Naples, Italy
| | - Paolo Delrio
- Division of Gastrointestinal Surgical Oncology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
| | - Antonella Petrillo
- Division of Radiology, “Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale,” Naples, Italy
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