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Crafa F, Vanella S, Catalano OA, Pomykala KL, Baiamonte M. Role of one-step nucleic acid amplification in colorectal cancer lymph node metastases detection. World J Gastroenterol 2022; 28:4019-4043. [PMID: 36157105 PMCID: PMC9403438 DOI: 10.3748/wjg.v28.i30.4019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 06/03/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023] Open
Abstract
Current histopathological staging procedures in colorectal cancer (CRC) depend on midline division of the lymph nodes (LNs) with one section of hematoxylin and eosin staining. Cancer cells outside this transection line may be missed, which could lead to understaging of Union for International Cancer Control Stage II high-risk patients. The one-step nucleic acid amplification (OSNA) assay has emerged as a rapid molecular diagnostic tool for LN metastases detection. It is a molecular technique that can analyze the entire LN tissue using a reverse-transcriptase loop-mediated isothermal amplification reaction to detect tumor-specific cytokeratin 19 mRNA. Our findings suggest that the OSNA assay has a high diagnostic accuracy in detecting metastatic LNs in CRC and a high negative predictive value. OSNA is a standardized, observer-independent technique, which may lead to more accurate staging. It has been suggested that in stage II CRC, the upstaging can reach 25% and these patients can access postoperative adjuvant chemotherapy. Moreover, intraoperative OSNA sentinel node evaluation may allow early CRC to be treated with organ-preserving surgery, while in more advanced-stage disease, a tailored lymphadenectomy can be performed considering the presence of aberrant lymphatic drainage and skip metastases.
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Affiliation(s)
- Francesco Crafa
- Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
| | - Serafino Vanella
- Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
| | - Onofrio A Catalano
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Kelsey L Pomykala
- Department of Nuclear Medicine, Department of Radiological Sciences, David Geffen School of Medicine at University of California, Los Angeles, University Hospital Essen, University of Duisburg-Essen, Essen 45141, Germany
| | - Mario Baiamonte
- Division of General and Surgical Oncology, St. Giuseppe Moscati Hospital, Center of National Excellence and High Specialty, Avellino 83100, Italy
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2
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Liu H, Zhao Y, Yang F, Lou X, Wu F, Li H, Xing X, Peng T, Menze B, Huang J, Zhang S, Han A, Yao J, Fan X. Preoperative Prediction of Lymph Node Metastasis in Colorectal Cancer with Deep Learning. BME FRONTIERS 2022; 2022:9860179. [PMID: 37850180 PMCID: PMC10521754 DOI: 10.34133/2022/9860179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/08/2022] [Indexed: 10/19/2023] Open
Abstract
Objective. To develop an artificial intelligence method predicting lymph node metastasis (LNM) for patients with colorectal cancer (CRC). Impact Statement. A novel interpretable multimodal AI-based method to predict LNM for CRC patients by integrating information of pathological images and serum tumor-specific biomarkers. Introduction. Preoperative diagnosis of LNM is essential in treatment planning for CRC patients. Existing radiology imaging and genomic tests approaches are either unreliable or too costly. Methods. A total of 1338 patients were recruited, where 1128 patients from one centre were included as the discovery cohort and 210 patients from other two centres were involved as the external validation cohort. We developed a Multimodal Multiple Instance Learning (MMIL) model to learn latent features from pathological images and then jointly integrated the clinical biomarker features for predicting LNM status. The heatmaps of the obtained MMIL model were generated for model interpretation. Results. The MMIL model outperformed preoperative radiology-imaging diagnosis and yielded high area under the curve (AUCs) of 0.926, 0.878, 0.809, and 0.857 for patients with stage T1, T2, T3, and T4 CRC, on the discovery cohort. On the external cohort, it obtained AUCs of 0.855, 0.832, 0.691, and 0.792, respectively (T1-T4), which indicates its prediction accuracy and potential adaptability among multiple centres. Conclusion. The MMIL model showed the potential in the early diagnosis of LNM by referring to pathological images and tumor-specific biomarkers, which is easily accessed in different institutes. We revealed the histomorphologic features determining the LNM prediction indicating the model ability to learn informative latent features.
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Affiliation(s)
- Hailing Liu
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Yu Zhao
- AI Lab, Tencent, Shenzhen 518057China
- Department of Computer Science, Technical University of Munich, Munich 85748, Germany
| | - Fan Yang
- AI Lab, Tencent, Shenzhen 518057China
| | - Xiaoying Lou
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Feng Wu
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
| | - Hang Li
- AI Lab, Tencent, Shenzhen 518057China
- Department of Computer Science, Xiamen University, Xiamen 361005, China
| | - Xiaohan Xing
- AI Lab, Tencent, Shenzhen 518057China
- Department of Electronic Engineering, The Chinese University of Hong Kong, Hong Kong 999077, China
| | - Tingying Peng
- Institute of Computational Biology, Helmholtz Zentrum München, Neuherberg 85764, Germany
- Helmholtz AI, Helmholtz Zentrum München, Neuherberg 85764, Germany
| | - Bjoern Menze
- Department of Computer Science, Technical University of Munich, Munich 85748, Germany
- Department of Quantitative Biomedicine, University of Zurich, Zurich 8091, Switzerland
| | | | - Shujun Zhang
- Department of Pathology, The Fourth Hospital of Harbin Medical University, Harbin 150001, China
| | - Anjia Han
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | | | - Xinjuan Fan
- Department of Pathology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
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3
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Ogawa S, Itabashi M, Inoue Y, Ohki T, Bamba Y, Koshino K, Nakagawa R, Tani K, Aihara H, Kondo H, Yamaguchi S, Yamamoto M. Lateral pelvic lymph nodes for rectal cancer: A review of diagnosis and management. World J Gastrointest Oncol 2021; 13:1412-1424. [PMID: 34721774 PMCID: PMC8529924 DOI: 10.4251/wjgo.v13.i10.1412] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/21/2021] [Accepted: 08/24/2021] [Indexed: 02/06/2023] Open
Abstract
The current status and future prospects for diagnosis and treatment of lateral pelvic lymph node (LPLN) metastasis of rectal cancer are described in this review. Magnetic resonance imaging (MRI) is recommended for the diagnosis of LPLN metastasis. A LPLN-positive status on MRI is a strong risk factor for metastasis, and evaluation by MRI is important for deciding treatment strategy. LPLN dissection (LPLD) has an advantage of reducing recurrence in the lateral pelvis but also has a disadvantage of complications; therefore, LPLD may not be appropriate for cases that are less likely to have LPLN metastasis. Radiation therapy (RT) and chemoradiation therapy (CRT) have limited effects in cases with suspected LPLN metastasis, but a combination of preoperative CRT and LPLD may improve the treatment outcome. Thus, RT and CRT plus selective LPLD may be a rational strategy to omit unnecessary LPLD and produce a favorable treatment outcome.
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Affiliation(s)
- Shimpei Ogawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Michio Itabashi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Yuji Inoue
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Takeshi Ohki
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Yoshiko Bamba
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Kurodo Koshino
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Ryosuke Nakagawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Kimitaka Tani
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Hisako Aihara
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Hiroka Kondo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Shigeki Yamaguchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
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Turgeon MK, Gamboa AC, Keilson JM, Maniko J, Maguire L, Hrebinko K, Holder-Murray J, Wiseman JT, Abdel-Misih S, Hamdan S, Hawkins AT, Bauer P, Silviera M, Maithel SK, Balch GC. Radiological assessment of persistent retroperitoneal and lateral pelvic lymph nodes after neoadjuvant therapy for rectal cancer: An analysis of the United States Rectal Cancer Consortium. J Surg Oncol 2021; 124:818-828. [PMID: 34270097 DOI: 10.1002/jso.26600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/19/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Management of retroperitoneal and lateral pelvic lymph nodes (RLPN) in rectal cancer remains unclear. With total neoadjuvant therapy (TNT), more patients have radiologic complete clinical response (rCR). We sought to evaluate the impact of radiographic persistent RLPN after neoadjuvant therapy on survival. MATERIALS AND METHODS Patients with rectal adenocarcinoma with isolated RLPN metastasis, who received neoadjuvant therapy before surgery were included from the United States Rectal Cancer Consortium database. Primary outcomes were recurrence-free survival (RFS) and overall survival (OS). RESULTS Of 77 patients, all received neoadjuvant therapy, with 35 (46%) receiving TNT. Posttreatment, 33 (43%) had rCR while 44 (57%) had radiographic persistent RLPN. Median number of radiographic positive RLPN was 1 (IQR 1-2). Receipt of TNT was associated with radiographic RLPN rCR (OR 4.77, 95% CI 1.81-12.60, p < .01). However, there was no difference in RFS and OS between patients who achieved rCR or with persistent RLPN (all p > .05). CONCLUSIONS Radiographic persistence of RLPN was not associated with worse survival in well-selected patients and may not be a reliable indicator of pathological response. TNT may be the preferred management strategy to select patients given its association with rCR. Radiographic persistence of RLPN after preoperative therapy should not necessarily preclude surgery.
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Affiliation(s)
- Michael K Turgeon
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Adriana C Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jessica M Keilson
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jeffrey Maniko
- Department of Surgery, Division of Colorectal Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Lillias Maguire
- Department of Surgery, Division of Colorectal Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Katherine Hrebinko
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jennifer Holder-Murray
- Department of Surgery, Division of Colon and Rectal Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jason T Wiseman
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Sherif Abdel-Misih
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Saif Hamdan
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Philip Bauer
- Department of Surgery, Section of Colon & Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew Silviera
- Department of Surgery, Section of Colon & Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Glen C Balch
- Department of Surgery, Division of Colon & Rectal Surgery, Emory University, Atlanta, Georgia, USA
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5
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Zhang X, Fan J, Zhang L, Wang J, Wang M, Zhu J. Association Between Three-Dimensional Transrectal Ultrasound Findings and Tumor Response to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer: An Observational Study. Front Oncol 2021; 11:648839. [PMID: 34178635 PMCID: PMC8223675 DOI: 10.3389/fonc.2021.648839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/06/2021] [Indexed: 11/25/2022] Open
Abstract
Background There is a significant demand for the development of non-surgical methods for the evaluation of complete response to tumor therapy. Predicting ability and image quality of routine imaging has not been satisfactory. To avoid the deficiencies, we assessed the capability of three-dimensional transrectal ultrasound in predicting the response to neoadjuvant chemoradiotherapy in rectal cancer patients. Methods The inclusion criteria were patients with locally advanced rectal adenocarcinoma, receiving capecitabine-based neoadjuvant chemoradiotherapy, distance from anal verge (≤6 cm), clinical stage T3-4 and/or N+ without evidence of distant metastasis, and restaging ycT0-3a (T3a <5 mm) after the end of neoadjuvant chemoradiotherapy. Three-dimensional transrectal ultrasound was performed 7 weeks after neoadjuvant chemoradiotherapy to discern the patients with complete response from the others. Eight main parameters were obtained from three-dimensional transrectal ultrasound: thickness of muscularis on the residual side, thickness of contralateral muscularis, angle of residual arc, regularity of the shape, integrity of the mucosal layer, blurring of the margin, internal echo, and posterior echo. The association between tumor response and three-dimensional transrectal ultrasound parameters was analyzed, and a model was developed by logistic regression. Results Between 2014 and 2019, 101 patients were recruited; 72 cases received total mesorectal excision, and 29 cases underwent watch-and-wait. Among the three-dimensional transrectal ultrasound parameters, the adjusted-thickness of the muscularis (P<0.01), angle of the residual arc (P<0.01), and regularity of the residual shape (P<0.01) were strongly associated with tumor response. In the dataset with total mesorectal excision cases (TME dataset), the residual adjusted-thickness (odds ratio [OR]=4.88, 95% confidence interval [CI]=1.44–16.6, P=0.01) and regularity of the residual shape (OR=5.00, 95% CI=1.13–22.2, P=0.03) were kept in the final logistic model. The area under the curve of the logistic model was 0.84. Among these parameters, residual adjusted-thickness correlated significantly with tumor response. Additionally, we observed similar results in the whole population of 101 cases (whole dataset) and in the cross-validation. Conclusion Three-dimensional transrectal ultrasound model is a valuable method for predicting tumor response in rectal cancer patients undergoing neoadjuvant chemoradiotherapy, which should be included as a factor for evaluating clinical complete response. Trial Registration This trial was registered with ClinicalTrials.gov, number NCT02605265. Registered 9 November 2015 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT02605265
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Affiliation(s)
- Xun Zhang
- Department of Ultrasound Diagnosis, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jin Fan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lijie Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jingwen Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Minghe Wang
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ji Zhu
- Department of Abdominal Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China.,Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
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6
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O'Connell E, Galvin R, McNamara DA, Burke JP. The utility of preoperative radiological evaluation of early rectal neoplasia: a systematic review and meta-analysis. Colorectal Dis 2020; 22:1076-1084. [PMID: 32052545 DOI: 10.1111/codi.15015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 02/05/2020] [Indexed: 12/12/2022]
Abstract
AIM The diagnostic role for preoperative imaging of clinically benign rectal adenomas is unclear. The objective of this systematic review and meta-analysis was to examine the diagnostic accuracy of preoperative imaging in distinguishing benign adenomas from rectal cancer. METHOD A systematic search was performed for all studies published that correlated staging of clinically benign rectal adenomas with endorectal ultrasound (ERUS) or MRI and histology. Imaging was compared with postoperative histology and data on the numbers of true positives, false positives, true negatives and false negatives were extracted. Summary estimates of sensitivity and specificity with 95% CIs were calculated using a bivariate random effects model. The QUADAS2 tool was used to determine the methodological quality of included studies. RESULTS Eleven studies describing 1511 patients were retrieved. A total of 1134 patients underwent local excision and 377 had a formal proctectomy. A benign rectal adenoma was diagnosed in 840 and 214 had a T1 rectal cancer. For confirming benign adenomas, the pooled sensitivity of ERUS was 0.81 (95% CI 0.69-0.89) and specificity was 0.85 (95% CI 0.68-0.93). For detecting occult T1 tumours, the pooled sensitivity of ERUS was 0.50 (95% CI 0.33-0.66) and specificity was 0.89 (95% CI 0.82-0.94). Quantitative analysis of MRI could not be performed due to insufficient studies. CONCLUSION This study demonstrates the limited accuracy of preoperative ERUS in distinguishing benign adenomas from T1 rectal cancer. Preoperative imaging must be interpreted with caution to prevent over-staging and unnecessary proctectomy. We propose that clinically benign lesions may undergo local excision, with subsequent management based on final histology.
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Affiliation(s)
- E O'Connell
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - R Galvin
- School of Allied Health, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - D A McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.,Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - J P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.,Royal College of Surgeons in Ireland, Dublin 2, Ireland
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7
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Aiming for the Vessel in Investigation of Perivascular Space to Stage Gastrointestinal Malignancies. Clin Gastroenterol Hepatol 2019; 17:2437-2438. [PMID: 31265806 DOI: 10.1016/j.cgh.2019.05.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 05/29/2019] [Indexed: 02/07/2023]
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8
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Juchems MS, Wessling J. [Rational staging and follow-up of colorectal cancer : Do guidelines provide further help?]. Radiologe 2019; 59:820-827. [PMID: 31455978 DOI: 10.1007/s00117-019-0578-6] [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] [Indexed: 12/14/2022]
Abstract
CLINICAL/METHODICAL ISSUE Colorectal cancer is one of the most common malignant tumors. Preoperative imaging is crucial in rectal cancer as patients can only receive optimal treatment when accurate staging is performed. The N‑staging is often difficult with the available options and must be called into question as a staging parameter. STANDARD RADIOLOGICAL METHODS Endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) are particularly suitable for local staging. Multiparametric MRI with diffusion imaging is indispensable for tumor follow-up. METHODICAL INNOVATIONS The assessment of infiltration of the mesorectal fascia is best accomplished using high-resolution MRI. In addition, extramural vascular infiltration (EMVI) has become established as another important prognostic factor. After neoadjuvant therapy and restaging of locally advanced rectal cancer, the identification and validation of prognostically relevant image parameters are prioritized. Multiparametric MRI of the rectum including diffusion imaging as well as the application of radiological and pathological scores (MR-TRG) are becoming increasingly more important in this context. ASSESSMENT For the radiologist it is important to become familiar with indicators of the resectability of rectal cancer and to be able to reliably read prognostically relevant imaging parameters in the tumor follow-up. PRACTICAL RECOMMENDATIONS For the practical application, the establishment of a fixed MRI protocol is essential. In addition to a guideline-compliant TNM classification, the radiologist must provide the clinician with information on infiltration of the mesorectal fascia and extramural vascular infiltration. The MR-TRGs are becoming increasingly more important in tumor follow-up.
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Affiliation(s)
- M S Juchems
- Diagnostische und Interventionelle Radiologie, Klinikum Konstanz, Mainaustr. 35, 78464, Konstanz, Deutschland.
| | - J Wessling
- Zentrum für Radiologie, Neuroradiologie und Nuklearmedizin, Clemenshospital Münster, Münster, Deutschland
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Dodaro CA, Calogero A, Tammaro V, Pellegrino T, Lionetti R, Campanile S, Menkulazi M, Ciccozzi M, Iannicelli AM, Giallauria F, Sagnelli C. Colorectal Cancer in the Elderly Patient: The Role of Neo-adjuvant Therapy. Open Med (Wars) 2019; 14:607-612. [PMID: 31428685 PMCID: PMC6698051 DOI: 10.1515/med-2019-0068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023] Open
Abstract
Background Neoadjuvant chemoradiotherapy has a significant role in downstaging cancer. It improves the local control of the disease and can make conservative resection of rectal cancer possible. Methods We enrolled 114 patients with subperitoneal rectal cancer who underwent neoadjuvant chemoradio-therapy and radical excision with total mesorectal excision (TME). The primary endpoint was oncological outcomes and the secondary endpoint was surgical outcomes.We evaluate the experience of a multidisciplinary team and the role of neoadjuvant chemoradiotherapy in integrated treatment of cancer of the subperitoneal rectum. Results Surgical procedures performed were abdominal perineal resection in 4 cases (3.5%), anterior resection in 89 cases (78%), Hartmann’s procedure in 5 cases (4.4%), and ultralow resection with coloanal anastomosis and diverting stoma in 16 patients (14%). Local recurrence occurred in 6 patients (5.2%), the overall survival was 71.9% at 5 years and disease-free survival was about 60%. Conclusions The effect of pathological downstaging amounted to 58.8%, including cPR. The pathologic complete remission occurred in 8.8% of cases. The outcomes of neoadjuvant therapy can be achieved when this treatment is associated with correct surgical technique with TME and the prognosis is defined by an anatomopathological examination performed according to Quirke’s protocol.
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Affiliation(s)
- Concetta Anna Dodaro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Armando Calogero
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Vincenzo Tammaro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Tommaso Pellegrino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Silvia Campanile
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Marsela Menkulazi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Massimo Ciccozzi
- Medical Statistics and Molecular Epidemiology Unit, Campus Bio-Medico University, Rome, Italy
| | - Anna Maria Iannicelli
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Francesco Giallauria
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Caterina Sagnelli
- Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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10
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Parvataneni S, Varela L, Vemuri-Reddy SM. Advance Rectal Cancer in a Young Patient: Should Screening Start Early? Cureus 2019; 11:e5195. [PMID: 31565601 PMCID: PMC6758997 DOI: 10.7759/cureus.5195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Colorectal cancer is the third most common non-cutaneous malignancy in the United States, and the second most common cause of cancer-related deaths. Colorectal cancer is a broad term to include both colon and rectal cancer. Rectal cancer is commonly seen in age more the 50 years and often present with rectal bleeding. In this article, we will be discussing about a young female patient who presented with somatic pain as an initial symptom for metastatic rectal adenocarcinoma.
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Affiliation(s)
| | - Lionel Varela
- Family Medicine, Geisinger Health System, Lewistown, USA
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11
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Locally Advanced Rectal Cancer Evaluation by Magnetic Resonance Imaging after Neoadjuvant Therapy on Decision Making: Cancer Center Experience and Literature Review. J Gastrointest Cancer 2019; 51:254-259. [PMID: 31054106 DOI: 10.1007/s12029-019-00246-5] [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
PURPOSE An accurate clinical and radiological staging is the pyramid of treatment decisions in locally advanced rectal cancer (LARC). Guidelines recommended neoadjuvant chemoradiation therapy (CRT) followed by surgical resection for fit patients with LARC. Determining the aggressiveness of intervention while avoiding needless morbidity according to patient risk remains an unmet pre-operative decision-making need. With newer magnetic resonance imaging (MRI) techniques and image acquisition available at our Cancer Center, we seek to retrospectively review the correlation between pre- and post-CRT MRI response to the surgical pathological stage in order to aide multidisciplinary team decision making. METHODS Our Cancer Center Rectal Cancer Registry between 2011 and 2015 included 57 patients with LARC, 20 completed standard CRT with surgery, and of those 10 had repeated MRI after CRT. RESULTS Our retrospective case series revealed that 90% of the patients had a downstage tumor response on surgical specimen compared to radiological evaluation after CRT, and furthermore, all patients who were re-staged with MRI prior to surgery correlated with the gold standard pathological stage (p = 0.02). CONCLUSIONS Post-CRT MRI could potentially aide decision making to further avoid 20% of patients with a complete pathological response from a morbid surgery, whereas 10% of patients with an upstaged disease state may require a more aggressive neoadjuvant or planned surgical intervention. We concluded that future multidisciplinary oncology care treatment decision making would benefit from a repeat MRI after neoadjuvant CRT of LARC.
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12
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Bae SU, Won KS, Song BI, Jeong WK, Baek SK, Kim HW. Accuracy of F-18 FDG PET/CT with optimal cut-offs of maximum standardized uptake value according to size for diagnosis of regional lymph node metastasis in patients with rectal cancer. Cancer Imaging 2018; 18:32. [PMID: 30217167 PMCID: PMC6137872 DOI: 10.1186/s40644-018-0165-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/30/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The low sensitivity of F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for the evaluation of metastatic lymph nodes (LNs) is mainly due to the partial volume effect in patients with rectal cancer. This retrospective study evaluated the diagnostic accuracy of F-18 FDG PET/CT with optimal cut-off values of the maximum standardized uptake value (SUVmax), according to LN size, for the evaluation of regional LN in rectal cancer patients. METHODS This study included 176 patients with rectal cancer who underwent F-18 FDG PET/CT for initial staging. Patients were classified based on the long-axis diameter of the regional LN on CT images as small (≤ 7 mm; n = 118) and large (> 7 mm; n = 58) LN groups. The optimal cut-off value of SUVmax was determined for each group, using receiver operating characteristic curve analysis. Areas under the curve (AUC) were compared by C-statistics using two methods: the cut-off value of SUVmax optimized according to LN size, and a fixed SUVmax cut-off value of 2.5. RESULTS The optimal cut-off values of SUVmax for the small and large LN groups were 1.1, and 2.1, respectively. The sensitivity, specificity, and accuracy of F-18 FDG PET/CT using the optimal cut-off values were 90.6, 70.9, and 76.3% in the small LN group, and 68.6, 78.3, and 72.4% in the large LN group. The sensitivity, specificity, and accuracy of F-18 FDG PET/CT using the fixed cut-off value were 18.8, 100, and 78.0% in the small LN group, and 51.4, 87.0, and 65.5% in the large LN group. The AUC was significantly higher using the optimal cut-off values than the fixed cut-off value (0.808 vs. 0.594, p = 0.005) in the small LN group, but not in the large LN group (0.734 vs. 0.692, p = 0.429). CONCLUSIONS Application of the lower cut-off value of SUVmax improves the diagnostic performance of F-18 FDG PET/CT for the evaluation of small regional LNs in patients with rectal cancer.
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Affiliation(s)
- Sung Uk Bae
- Department of Surgery, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Kyoung Sook Won
- Department of Nuclear Medicine, Keimyung University Dongsan Medical Center, 56 Dalseong-ro, Jung-gu, Daegu, 41931, Republic of Korea
| | - Bong-Il Song
- Department of Nuclear Medicine, Keimyung University Dongsan Medical Center, 56 Dalseong-ro, Jung-gu, Daegu, 41931, Republic of Korea
| | - Woon Kyung Jeong
- Department of Surgery, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Seong Kyu Baek
- Department of Surgery, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Hae Won Kim
- Department of Nuclear Medicine, Keimyung University Dongsan Medical Center, 56 Dalseong-ro, Jung-gu, Daegu, 41931, Republic of Korea.
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Rowen RK, Kelly J, Motl J, Monson JR. Transanal transabdominal TME: how far can we push it? MINERVA CHIR 2018; 73:579-591. [PMID: 30019878 DOI: 10.23736/s0026-4733.18.07827-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over many decades, advances in surgical technology, such as the use of the electrocautery Bovie, development of minimally invasive and advanced endoscopic platforms and the ability to create and maintain pneumorectum have propelled surgical techniques forward to today, with development of the transanal total mesorectal excision TME (taTME) for en bloc resection of rectal cancers. The transanal platform offers, for now, a viable alternative to perform safe and oncologically sound TME, especially favorable in cases of low rectal lesions in a narrow pelvis post neoadjuvant treatment. The aspiration of the colorectal community remains to continue to push the operative boundaries whilst maintaining safe oncological principals with the best possible functional outcomes for patients. In this article we review this evolving technique and focus on future directions.
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Affiliation(s)
| | - Justin Kelly
- Surgical Health Outcomes Consortium, Orlando, FL, USA
| | - Jill Motl
- Surgical Health Outcomes Consortium, Orlando, FL, USA
| | - John R Monson
- Surgical Health Outcomes Consortium, Orlando, FL, USA -
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Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer. Int J Colorectal Dis 2017; 32:1631-1637. [PMID: 28762190 DOI: 10.1007/s00384-017-2873-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to identify the size criteria of lateral lymph node metastasis in lower rectal cancer both in patients who underwent preoperative CRT and those who did not. METHODS This study enrolled 150 patients who underwent resection for primary lower rectal adenocarcinoma with lateral lymph node dissection between 2013 and 2015. Patients were divided into two groups: the CRT group, treated with preoperative chemoradiotherapy before surgery, and the non-CRT group, treated with surgery alone. The short-axis diameter of each dissected lateral lymph node was measured. Receiver-operating characteristic curves were generated to reveal the optimal cutoff values for determining lateral lymph node metastasis in both groups. RESULTS In the non-CRT group (n = 131), the ROC curve demonstrated that the optimal cutoff value for determining metastasis was 6.0 mm, with a sensitivity of 78.5% and specificity of 82.9%, and the AUC was 0.845. In comparison, in the CRT group (n = 19), the optimal cutoff value was 5.0 mm, with a sensitivity of 71.4% and specificity of 85.3% and an AUC of 0.836. CONCLUSION The cutoff size for determining lateral lymph node metastasis was smaller in the CRT group than in the non-CRT group.
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Prediction of lateral pelvic lymph node metastasis from lower rectal cancer using magnetic resonance imaging and risk factors for metastasis: Multicenter study of the Lymph Node Committee of the Japanese Society for Cancer of the Colon and Rectum. Int J Colorectal Dis 2017; 32:1479-1487. [PMID: 28762189 DOI: 10.1007/s00384-017-2874-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The goal of the study was to examine prediction of lateral pelvic lymph node (LPLN) metastasis from lower rectal cancer using a logistic model including risk factors for LPLN metastasis and magnetic resonance imaging (MRI) clinical LPLN (cLPLN) status, compared to prediction based on MRI alone. METHODS The subjects were 272 patients with lower rectal cancer who underwent MRI prior to mesorectal excision combined with LPLN dissection (LPLD) at six institutes. No patients received neoadjuvant therapy. Prediction models for right and left pathological LPLN (pLPLN) metastasis were developed using cLPLN status, histopathological grade, and perirectal lymph node (PRLN) status. For evaluation, data for patients with left LPLD were substituted into the right-side equation and vice versa. RESULTS Left LPLN metastasis was predicted using the right-side model with accuracy of 86.5%, sensitivity 56.4%, specificity 92.7%, positive predictive value (PPV) 61.1%, and negative predictive value (NPV) 91.2%, while these data using MRI cLPLN status alone were 80.4, 76.9, 81.2, 45.5, and 94.5%, respectively. Similarly, right LPLN metastasis was predicted using the left-side equation with accuracy of 83.8%, sensitivity 57.8%, specificity 90.4%, PPV 60.5%, and NPV 89.4%, and the equivalent data using MRI alone were 78.4, 68.9, 80.8, 47.7, and 91.1%, respectively. The AUCs for the right- and left-side equations were significantly higher than the equivalent AUCs for MRI cLPLN status alone. CONCLUSIONS A logistic model including risk factors for LPLN metastasis and MRI findings had significantly better performance for prediction of LPLN metastasis compared with a model based on MRI findings alone.
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Dosokey EMG, Brady JT, Neupane R, Jabir MA, Stein SL, Reynolds HL, Delaney CP, Steele SR. Do patients requiring a multivisceral resection for rectal cancer have worse oncologic outcomes than patients undergoing only abdominoperineal resection? Am J Surg 2017. [PMID: 28622838 DOI: 10.1016/j.amjsurg.2017.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Abdominoperineal Resection (APR) remains an important option for patients with advanced rectal cancer though some may require multivisceral resection (MVR) in addition to APR. We hypothesized that oncological outcomes would be worse with MVR. METHODS A retrospective review from 2006 to 2015 of 161 patients undergoing APR or MVR for rectal cancer, of whom 118 underwent curative APR or APR with MVR. Perioperative, oncologic and survival metrics were evaluated. RESULTS There were 82 patients who underwent APR and 36 who underwent MVR. Surgical approach and incidence of complications were similar (All P > 0.05). There was 1 local recurrence in each of the APR and MVR groups at a mean follow-up of 34 and 32 months, respectively. Distant recurrences occurred in 3 APR patients and 4 MVR patients. CONCLUSIONS APR and APR with MVR can be performed with comparable morbidity and oncologic outcomes.
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Affiliation(s)
- Eslam M G Dosokey
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Surgical Oncology, SECI, Assiut University, Assiut, Egypt
| | - Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Ruel Neupane
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Murad A Jabir
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Harry L Reynolds
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Conor P Delaney
- Digestive Disease and Surgical Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Scott R Steele
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
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Moreno CC, Sullivan PS, Mittal PK. MRI Evaluation of Rectal Cancer: Staging and Restaging. Curr Probl Diagn Radiol 2016; 46:234-241. [PMID: 28089690 DOI: 10.1067/j.cpradiol.2016.11.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 11/20/2016] [Accepted: 11/21/2016] [Indexed: 01/03/2023]
Abstract
Magnetic resonance imaging (MRI) plays an important role in the staging and restaging of rectal cancer. Multiplanar high-resolution (≤3-mm section thickness) T2-weighted images are the primary sequences used for rectal cancer staging. No preprocedural bowel cleansing regimen, intravenous contrast material, nor endorectal coil is necessary. MRI is highly accurate for differentiating T1-T2 disease from T3 and T4 disease, an important distinction as patients with T3 and T4 tumors typically undergo preoperative neoadjuvant chemoradiation before resection. At MRI, the muscularis propria appears as a thin black line encircling the outer wall of the rectum, and tumor extension through this line indicates T3 disease. Further tumor extension into adjacent organs indicates T4 disease. Endorectal ultrasound is generally preferred to differentiate T1 (submucosal involvement) from T2 (extension into but no disruption of muscularis propria) disease. MRI is also accurate in the assessment of tumor involvement of the mesorectal fascia. Tumor involvement of the mesorectal fascia increases the likelihood of recurrence following resection. MRI is less accurate for determination of lymph node status, though heterogeneous signal intensity and irregular margins are suggestive of node positive disease. Approximately 10%-30% of patients who undergo preoperative chemoradiation experience a complete pathologic response that is defined as no residual tumor found at histopathologic analysis of the resected specimen. The addition of diffusion-weighted images to T2-weighted images improves the accuracy of restaging examinations for determination of complete pathologic responders.
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Affiliation(s)
- Courtney C Moreno
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Patrick S Sullivan
- Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA
| | - Pardeep K Mittal
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA
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Ogawa S, Hida JI, Ike H, Kinugasa T, Ota M, Shinto E, Itabashi M, Kameoka S, Sugihara K. Selection of Lymph Node-Positive Cases Based on Perirectal and Lateral Pelvic Lymph Nodes Using Magnetic Resonance Imaging: Study of the Japanese Society for Cancer of the Colon and Rectum. Ann Surg Oncol 2015; 23:1187-94. [PMID: 26671038 DOI: 10.1245/s10434-015-5021-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE To investigate the optimum cutoff for lymph node size to identify cases positive for perirectal lymph node (PRLN) and lateral lymph node (LPLN) metastasis of lower rectal cancer on magnetic resonance imaging (MRI). METHODS The subjects were 449 patients who underwent preoperative MRI. Mesorectal excision was performed in all patients (combined with lateral pelvic lymph node [LN] dissection in 324) between 2004 and 2013 at 6 institutes. Cases were classified as cN positive and cN negative on the basis of the short axis of the largest LN being greater than or equal to a cutoff or less than a cutoff, respectively. PRLN and LPLN diagnoses using 5 and 10 mm cutoffs were compared with histologic diagnoses. Of the 449 patients, 55 received preoperative chemoradiotherapy. MRI was only performed after this therapy in all of these patients. RESULTS For PRLNs, 5 and 10 mm cutoffs gave area under the curve (AUC) values of 0.6364 and 0.5794, respectively. The 5 mm cutoff gave a significantly higher AUC value (P = 0.0152), with an accuracy of 63.7 %, sensitivity of 72.6 %, and specificity of 54.7 %. For right LPLNs, the respective AUC values were 0.7418 and 0.6326 (P = 0.0034), and the variables (5 mm cutoff) were 77.6, 68.6, and 79.7 %. For left LPLNs, AUC values were 0.7593 and 0.6559, respectively (P = 0.0057), and the variables (5 mm cutoff) were 79.3, 70.8, and 81.0 %. CONCLUSIONS Identification of LN-positive cases on the basis of PRLN and LPLN sizes was superior at a short-axis 5 mm cutoff. Size-based diagnosis of LN metastasis is simple and useful, but further investigation is needed to clarify whether it is superior to diagnosis based on morphology, such as shape, border, and signal intensity.
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Affiliation(s)
- Shimpei Ogawa
- Department of Surgery II, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.
| | - Jin-Ichi Hida
- Department of Surgery, Kindai University School of Medicine, Osaka-Sayama, Osaka, Japan.
| | - Hideyuki Ike
- Department of Surgery, Saiseikai Yokohama City Nanbu Hospital, Yokohama, Japan
| | - Tetsushi Kinugasa
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Mitsuyoshi Ota
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Eiji Shinto
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Michio Itabashi
- Department of Surgery II, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Shingo Kameoka
- Department of Surgery II, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kenichi Sugihara
- Department of Surgical Oncology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Marone P, Bellis MD, D’Angelo V, Delrio P, Passananti V, Girolamo ED, Rossi GB, Rega D, Tracey MC, Tempesta AM. Role of endoscopic ultrasonography in the loco-regional staging of patients with rectal cancer. World J Gastrointest Endosc 2015; 7:688-701. [PMID: 26140096 PMCID: PMC4482828 DOI: 10.4253/wjge.v7.i7.688] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 11/26/2014] [Accepted: 03/20/2015] [Indexed: 02/05/2023] Open
Abstract
The prognosis of rectal cancer (RC) is strictly related to both T and N stage of the disease at the time of diagnosis. RC staging is crucial for choosing the best multimodal therapy: patients with high risk locally advanced RC (LARC) undergo surgery after neoadjuvant chemotherapy and radiotherapy (NAT); those with low risk LARC are operated on after a preoperative short-course radiation therapy; finally, surgery alone is recommended only for early RC. Several imaging methods are used for staging patients with RC: computerized tomography, magnetic resonance imaging, positron emission tomography, and endoscopic ultrasound (EUS). EUS is highly accurate for the loco-regional staging of RC, since it is capable to evaluate precisely the mural infiltration of the tumor (T), especially in early RC. On the other hand, EUS is less accurate in restaging RC after NAT and before surgery. Finally, EUS is indicated for follow-up of patients operated on for RC, where there is a need for the surveillance of the anastomosis. The aim of this review is to highlight the impact of EUS on the management of patients with RC, evaluating its role in both preoperative staging and follow-up of patients after surgery.
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Fischer J, Hellmich G, Jackisch T, Puffer E, Zimmer J, Bleyl D, Kittner T, Witzigmann H, Stelzner S, Jörg Z, Bleyl D, Dorothea B, Kittner T, Thomas K, Witzigmann H, Helmut W, Stelzner S, Sigmar S. Outcome for stage II and III rectal and colon cancer equally good after treatment improvement over three decades. Int J Colorectal Dis 2015; 30:797-806. [PMID: 25922143 DOI: 10.1007/s00384-015-2219-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to investigate the outcome for stage II and III rectal cancer patients compared to stage II and III colonic cancer patients with regard to 5-year cause-specific survival (CSS), overall survival, and local and combined recurrence rates over time. METHODS This prospective cohort study identified 3,355 consecutive patients with adenocarcinoma of the colon or rectum and treated in our colorectal unit between 1981 and 2011, for investigation. The study was restricted to International Union Against Cancer (UICC) stages II and III. Postoperative mortality and histological incomplete resection were excluded, which left 995 patients with colonic cancer and 726 patients with rectal cancer for further analysis. RESULTS Five-year CSS rates improved for colonic cancer from 65.0% for patients treated between 1981 and 1986 to 88.1% for patients treated between 2007 and 2011. For rectal cancer patients, the respective 5-year CSS rates improved from 53.4% in the first observation period to 89.8% in the second one. The local recurrence rate for rectal cancer dropped from 34.2% in the years 1981-1986 to 2.1% in the years 2007-2011. In the last decade of observation, prognosis for rectal cancer was equal to that for colon cancer (CSS 88.6 vs. 86.7%, p = 0.409). CONCLUSION Survival of patients with colon and rectal cancer has continued to improve over the last three decades. After major changes in treatment strategy including introduction of total mesorectal excision and neoadjuvant (radio)chemotherapy, prognosis for stage II and III rectal cancer is at least as good as for stage II and III colonic cancer.
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Affiliation(s)
- Joern Fischer
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Dresden, Germany
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Kim IK, Kang J, Lim BJ, Sohn SK, Lee KY. The impact of lymph node size to predict nodal metastasis in patients with rectal cancer after preoperative chemoradiotherapy. Int J Colorectal Dis 2015; 30:459-64. [PMID: 25586204 DOI: 10.1007/s00384-014-2099-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE During restaging after preoperative chemoradiotherapy (CRT), the assessment of lymph node (LN) metastasis is vital for selecting further treatment strategies. This study aimed to evaluate the impact of LN size to predict LN metastasis in rectal cancer patients after preoperative CRT. METHODS A total of 30 consecutive patients who underwent preoperative CRT followed by curative resection of primary rectal cancer were selected as a study group (CRT group). As a control group (non-CRT group), 30 patients who underwent primary tumor resection were selected using a 1:1 case-match design. Matching criteria were gender, age, and clinical T stage. The size of each LN was measured from the surgical specimen. To clarify optimal cutoff values for node size according to the risk of detecting metastasis, receiving-operator characteristic (ROC) curves were generated. RESULTS In the non-CRT group, 39/474 LNs were confirmed to have metastasis. In the CRT group, 29/422 LNs showed metastasis. The median size of metastatic LNs was 6.0 mm in CRT group, which was significantly larger than 4.0 mm in the non-CRT group (p = 0.006). The optimal cutoff value for determining metastasis in the CRT group was 4.5 mm, compared to 3.5 mm in the non-CRT group. The accuracy of the cutoff value was much higher in the CRT group (CRT vs. non-CRT, 77.9 vs. 59.9%). CONCLUSIONS LN size is a strong indicator for prediction of regional LN metastasis in rectal cancer patients after preoperative CRT, compared to those without CRT.
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Affiliation(s)
- Im-Kyung Kim
- Department of Surgery, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, South Korea
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Sanders M, Vabi BW, Cole PA, Kulaylat MN. Local Excision of Early-Stage Rectal Cancer. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Wale A, Brown G. A practical review of the performance and interpretation of staging magnetic resonance imaging for rectal cancer. Top Magn Reson Imaging 2014; 23:213-223. [PMID: 25099560 DOI: 10.1097/rmr.0000000000000028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The purpose of this article was to outline key technical considerations in performing rectal magnetic resonance imaging (MRI) along with a practical, systematic approach to the interpretation of rectal MRI. CONCLUSIONS Following validation by the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study group, rectal MRI is mandatory for the local staging of rectal cancer in many countries. The systematic interpretation of high-quality, high-resolution T2-weighted images should form the basis for discussing the management of patients with rectal cancer, including aiding surgical planning and enabling the appropriate use of neoadjuvant therapy. In this article, we discuss the methods for obtaining high-quality rectal magnetic resonance images and a systematic approach for the accurate interpretation of these images.
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Affiliation(s)
- Anita Wale
- From the Department of Radiology, Royal Marsden Hospital, Surrey, United Kingdom
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Ghieda U, Hassanen O, Eltomey MA. MRI of rectal carcinoma: Preoperative staging and planning of sphincter-sparing surgery. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2014. [DOI: 10.1016/j.ejrnm.2013.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Damin DC, Lazzaron AR. Evolving treatment strategies for colorectal cancer: A critical review of current therapeutic options. World J Gastroenterol 2014; 20:877-887. [PMID: 24574762 PMCID: PMC3921541 DOI: 10.3748/wjg.v20.i4.877] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 11/22/2013] [Accepted: 01/06/2014] [Indexed: 02/06/2023] Open
Abstract
Management of rectal cancer has markedly evolved over the last two decades. New technologies of staging have allowed a more precise definition of tumor extension. Refinements in surgical concepts and techniques have resulted in higher rates of sphincter preservation and better functional outcome for patients with this malignancy. Although, preoperative chemoradiotherapy followed by total mesorectal excision has become the standard of care for locally advanced tumors, many controversial matters in management of rectal cancer still need to be defined. These include the feasibility of a non-surgical approach after a favorable response to neoadjuvant therapy, the ideal margins of surgical resection for sphincter preservation and the adequacy of minimally invasive techniques of tumor resection. In this article, after an extensive search in PubMed and Embase databases, we critically review the current strategies and the most debatable matters in treatment of rectal cancer.
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Tsung PC, Park JH, Kim YS, Kim SY, Park WW, Kim HT, Kim JN, Kang YK, Moon JS. Miniprobe endoscopic ultrasonography has limitations in determining the T stage in early colorectal cancer. Gut Liver 2013; 7:163-8. [PMID: 23560151 PMCID: PMC3607769 DOI: 10.5009/gnl.2013.7.2.163] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 06/06/2012] [Accepted: 06/06/2012] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Mini-probe endoscopic ultrasonography (mEUS) is a useful diagnostic tool for accurate assessment of tumor invasion. The aim of this study was to estimate the accuracy of mEUS in patients with early colorectal cancer (ECC). Methods Ninety lesions of ECC underwent mEUS for pre-treatment staging. We divided the lesions into either the mucosal group or the submucosal group according to the mEUS findings. The histological results of the specimens were compared with the mEUS findings. Results The overall accuracy for assessing the depth of tumor invasion (T stage) was 84.4% (76/90). The accuracy of mEUS was significantly lower for submucosal lesions compared to mucosal lesions (p=0.003) and it was lower for large tumors (≥2 cm) (p=0.034). The odds ratios of large tumors and submucosal tumors affecting the accuracy of T staging were 3.46 (95% confidence interval [CI], 1.05 to 11.39) and 6.25 (95% CI, 1.85 to 25.14), respectively. When submucosal tumors were combined with large size, the odds ratio was 14.67 (95% CI, 1.46 to 146.96). Conclusions The overall accuracy of T stage determination with mEUS was considerably high in patients with ECC; however, the accuracy decreased when tumor size was >2 cm or the tumor had invaded the submucosal layer.
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Affiliation(s)
- Pei Chuan Tsung
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
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White R, Ung KA, Mathlum M. Accuracy of magnetic resonance imaging in the pre-operative staging of rectal adenocarcinoma: Experience from a regional Australian cancer center. Asia Pac J Clin Oncol 2012; 9:318-23. [DOI: 10.1111/ajco.12033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Rohen White
- Radiation Oncology Department; Andrew Love Cancer Centre; Geelong Victoria Australia
| | - Kim Ann Ung
- Radiation Oncology Department; Andrew Love Cancer Centre; Geelong Victoria Australia
| | - Maitham Mathlum
- Radiation Oncology Department; Andrew Love Cancer Centre; Geelong Victoria Australia
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Isbert C, Germer CT. [Impact of endoscopy and endosonography on local staging of rectal carcinoma]. Chirurg 2012; 83:430-8. [PMID: 22573246 DOI: 10.1007/s00104-011-2203-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
For rectal carcinoma the decision between primary resection, neoadjuvant therapy and local excision depends on an accurate local staging. Local staging includes digital examination, rigid rectoscopy and endorectal ultrasound (EUS). The rectal digitation allows clinical staging according to the mobility of the tumor in relation to the rectal mucosa or the rectal wall. The rigid rectoscopy determines the aboral distance of the tumor from the dentate line or the anal verge. The endorectal ultrasound determines the pre-therapeutic UICC stage on the basis of evaluating the pretherapeutic T and N categories. Results of EUS should be discussed on the background of neoadjuvant therapy including response evaluation and in comparison with the results of magnetic resonance imaging. In addition, there is only little information available concerning evaluation of the circumferential resection margin by EUS. Technical improvements, such as the 3D-EUS, might be appropriate in the future to provide enhancement of EUS staging of rectal tumors.
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Affiliation(s)
- C Isbert
- Klinik & Poliklinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Zentrum Operative Medizin, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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Kuo LJ, Chiou JF, Tai CJ, Chang CC, Kung CH, Lin SE, Hung CS, Wang W, Tam KW, Lee HC, Liang HH, Chang YJ, Wei PL. Can we predict pathologic complete response before surgery for locally advanced rectal cancer treated with preoperative chemoradiation therapy? Int J Colorectal Dis 2012; 27:613-21. [PMID: 22080392 DOI: 10.1007/s00384-011-1348-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pathologic complete response has been proven to have oncological benefits for locally advanced rectal cancer treated with chemoradiation therapy. The aims of this study are to analyze and determine the factors to predict pathologic complete response for patients treated with preoperative neoadjuvant therapy. METHODS Patients with biopsy-proven, locally advanced rectal cancer were treated neoadjuvantly followed by radical surgical resection. Tumors were re-assessed after completing chemoradiation, including pelvic magnetic resonance images, colonoscopic examination, and re-biopsy. The results of examination were compared with the final pathologic status. RESULTS A retrospective chart review of 166 patients was conducted. Twenty-five patients (15.1%) had pathologic complete response after chemoradiation. The 5-year overall survival rates were better in the complete response group than the residual tumor group (91.1% vs. 70.8%; P = 0.047), and there were also significant differences in the 5-year disease-free survival rates between these two groups (91.1% vs. 70.2%; P = 0.027). The prediction rates for pathologic complete response by re-biopsy, magnetic resonance images, and colonoscopy were 21.4%, 33.3%, and 53.8%, respectively. In addition, when we further combine the results of colonoscopic findings and re-biopsy, the prediction rate for pathologic complete response reached 77.8% (P = 0.009). CONCLUSIONS Combining the results of the re-biopsy and post-treatment colonoscopic findings, we can achieve a good prediction rate for pathologic complete response. Post-treatment magnetic resonance images are not useful tools in predicting tumor clearance following chemoradiation.
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Affiliation(s)
- Li-Jen Kuo
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Ishida H, Hatano S, Ishiguro T, Kumamoto K, Ishibashi K, Haga N. Prediction of lateral lymph node metastasis in lower rectal cancer: analysis of paraffin-embedded sections. Jpn J Clin Oncol 2012; 42:485-90. [PMID: 22457325 DOI: 10.1093/jjco/hys041] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE In the surgical treatment for lower rectal cancer, preoperative selection of patients at high risk for lateral lymph node metastasis is important, since lateral lymph node dissection might impair genitourinary functions. We examined whether the status of lateral lymph node metastasis can be predicted from the lymph node size. METHODS The subjects were 533 (35 positive and 498 negative) lateral lymph nodes from 47 patients with lower rectal cancer who underwent curative resection with lateral lymph node dissection. The sizes of the lateral lymph nodes immediately after removal and those in paraffin-embedded sections were compared for 108 lateral lymph nodes from 13 patients. In addition, receiver-operating characteristic curves were generated for the 533 paraffin-embedded lateral lymph nodes from the 47 patients to determine the optimal cut-off size for discriminating between positive and negative lateral lymph nodes. RESULTS Irrespective of the presence/absence of metastasis and the long-/short-axis diameter, a positive relationship was noted between the sizes of the lateral lymph nodes measured immediately after removal and those measured on paraffin-embedded sections (P< 0.01). The area under the curve for the short-axis diameter differed little from that for the long-axis diameter (0.77 vs. 0.76, P =0.80). The optimal cut-off values of the short- and long-axis diameter extrapolated to the living body were 5.4 and 8.4 mm, respectively, with an accuracy of 72.8% for the short-axis diameter and 71.9% for the long-axis diameter. CONCLUSIONS Prediction of the status of lateral lymph node metastasis from the lymph node size (long-/short-axis diameter) may be a simple and reliable method. The optimal cut-off diameter should be validated in prospective imaging studies.
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Affiliation(s)
- Hideyuki Ishida
- Department of Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, Japan.
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Preoperative local staging of colosigmoideal cancer: air versus water multidetector-row CT colonography. Radiol Med 2012; 117:254-67. [PMID: 22271004 DOI: 10.1007/s11547-011-0782-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 10/04/2010] [Indexed: 12/22/2022]
Abstract
PURPOSE The authors sought to evaluate the diagnostic accuracy of multidetector-row computed tomography (MDCT) performed with two different hypodense endoluminal contrast agents for the preoperative staging of colosigmoideal cancer. MATERIALS AND METHODS Seventy consecutive patients with an endoscopically and histologically proven diagnosis of colosigmoideal cancer underwent MDCT examination. Thirty-five patients were evaluated with water MDCT colonography and the remaining 35 with air MDCT colonography. Patients were randomly assigned to the air or water groups for staging. Transverse images and multiplanar reconstructions (MPR) were retrospectively examined by two blinded expert radiologists in order to assess T and N parameters, and the results were compared with histological findings. RESULTS The overall diagnostic accuracy of MDCT was 68.6% for water and 62.8% for air colonography. In the evaluation of the T parameter, the accuracy values were 88.6% for water and 80% for air colonography. In staging of the N parameter, the accuracy values were 77.1% and 74.3% for water and air MDCT colonography, respectively. CONCLUSIONS MDCT examination can be proposed for the local staging of colosigmoideal cancer. Water is more accurate than air in evaluation of the T parameter, whereas the kind of endoluminal contrast material does not influence the definition of the N parameter.
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Identification of Regional Lymph Node Involvement of Colorectal Cancer by Serum SELDI Proteomic Patterns. Gastroenterol Res Pract 2011; 2011:784967. [PMID: 22253617 PMCID: PMC3255105 DOI: 10.1155/2011/784967] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 09/29/2011] [Indexed: 12/18/2022] Open
Abstract
Background. To explore the application of serum proteomic patterns for the preoperative detection of regional lymph node involvement of colorectal cancer (CRC). Methods. Serum samples were applied to immobilized metal affinity capture ProteinChip to generate mass spectra by Surface-Enhanced Laser Desorption/ionization Time-of-Flight Mass Spectrometry (SELDI-TOF-MS). Proteomic spectra of serum samples from 70 node-positive CRC patients and 75 age- and gender-matched node-negative CRC patients were employed as a training set, and a classification tree was generated by using Biomarker Pattern Software package. The validity of the classification tree was then challenged with a blind test set including another 65 CRC patients. Results. The software identified an average of 46 mass peaks/spectrum and 5 of the identified peaks at m/z 3,104, 3,781, 5,867, 7,970, and 9,290 were used to construct the classification tree. The classification tree separated effectively node-positive CRC patients from node-negative CRC patients, achieving a sensitivity of 94.29% and a specificity of 100.00%. The blind test challenged the model independently with a sensitivity of 91.43% a specificity of 96.67%. Conclusions. The results indicate that SELDI-TOF-MS can correctly distinguish node-positive CRC patients from node-negative ones and show great potential for preoperative screening for regional lymph node involvement of CRC.
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Segev Y, Goldberg Y, Lavie O, Keidar R, Sagie S, Biterrman A, Auslender R. Diagnosis of Lower Gastrointestinal Tumors by Transvaginal Sonography. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2011. [DOI: 10.1177/8756479311426776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Sonography plays a primary role in the diagnosis of gynecological diseases. A retrospective review of incidental findings report by transvaginal sonography (TVS) was performed to evaluate the ability of TVS to visualize rectosigmoid carcinoma. The authors performed a retrospective review of 450 women who were referred for TVS because of suspected gynecological indications to evaluate those with incidental findings. Of these, 15 with incidental findings were subsequently diagnosed with rectosigmoid carcinoma. The sonographic properties and clinical findings were systematically evaluated. TVS findings included solid nonhomogeneous lesions (mean diameter of 4 cm; range, 1.6–8 cm), distended rectal walls, and gas inside the gastrointestinal lumen in 53% ( n = 8) of the cases. Total wall invasion was suspected, and signs of edema were noticed in 60% ( n = 9) of the cases. All lesions seen by TVS were pathologically confirmed as carcinoma of gastrointestinal origin. Inspection of the rectosigmoid during a TVS examination has the ability to detect unsuspected rectosigmoid lesions.
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Affiliation(s)
- Yakir Segev
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
| | - Yael Goldberg
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
| | - Ofer Lavie
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
| | - Reuven Keidar
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
| | - Shlomi Sagie
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
| | - Arie Biterrman
- Department of General Surgery, Carmel Medical Center, Haifa, Israel
| | - Ron Auslender
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
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Gleeson FC, Clain JE, Rajan E, Topazian MD, Wang KK, Levy MJ. EUS-FNA assessment of extramesenteric lymph node status in primary rectal cancer. Gastrointest Endosc 2011; 74:897-905. [PMID: 21839439 DOI: 10.1016/j.gie.2011.05.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 05/21/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Preoperative staging is an essential factor in the multidisciplinary management of rectal cancer. The accuracy of imaging alone with CT, magnetic resonance imaging, or rigid endorectal US is poor. The addition of EUS-FNA may enhance extramesenteric lymph node metastases detection (M1 disease) and overall staging accuracy. OBJECTIVE To evaluate the frequency of extramesenteric lymph node visualization by EUS and the rate of extramesenteric lymph node metastases by FNA. Secondary goals were to evaluate the clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases, disease progression, and overall mortality. DESIGN Retrospective cohort study. SETTINGS Tertiary referral center. RESULTS Forty-one of 316 patients (13%) with primary rectal cancer over a 6-year period had M1 disease by EUS-FNA. Significant clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases included the serum carcinoembryonic antigen level, tumor length 4 cm and longer, annularity 50% or more, sessile morphology, and lymph node size. The sensitivity and specificity of CT for extramesenteric lymph node metastases were 44% and 89%, respectively. Twenty-three of 316 rectal cancer endosonographic procedures (7.3%) were up-staged by FNA, which established extramesenteric lymph node metastases. Over a 4-year follow-up, disease progression and overall mortality of patients with extramesenteric lymph node metastases was observed in 6 patients (14.6%) and 14 patients (34%), respectively. CONCLUSIONS Preoperative EUS-FNA identification of extramesenteric lymph node metastases outside of standard radiation fields or total mesorectal excision resection margins could affect medical and surgical planning.
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Affiliation(s)
- Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Ravizza D, Tamayo D, Fiori G, Trovato C, De Roberto G, de Leone A, Crosta C. Linear array ultrasonography to stage rectal neoplasias suitable for local treatment. Dig Liver Dis 2011; 43:636-41. [PMID: 21550864 DOI: 10.1016/j.dld.2011.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 02/08/2011] [Accepted: 03/27/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Because of the many therapeutic options available, a reliable staging is crucial for rectal neoplasia management. Adenomas and cancers limited to the submucosa without lymph node involvement may be treated locally. AIMS The aim of this study is to evaluate the diagnostic accuracy of endorectal ultrasonography in the staging of neoplasias suitable for local treatment. METHODS We considered all patients who underwent endorectal ultrasonography between 2001 and 2010. The study population consisted of 92 patients with 92 neoplasias (68 adenocarcinomas and 24 adenomas). A 5 and 7.5MHz linear array echoendoscope was used. The postoperative histopathologic result was compared with the preoperative staging defined by endorectal ultrasonography. Adenomas and cancers limited to the submucosa were considered together (pT0-1). RESULTS The sensitivity, specificity, overall accuracy rate, positive predictive value, and negative predictive value of endorectal ultrasonography for pT0-1 were 86%, 95.6%, 91.3%, 94.9% and 88.7%. Those for nodal involvement were 45.4%, 95.5%, 83%, 76.9% and 84%, with 3 false positive results and 12 false negative. For combined pT0-1 and pN0, endorectal ultrasonography showed an 87.5% sensitivity, 95.9% specificity, 92% overall accuracy rate, 94.9% positive predictive value and 90.2% negative predictive value. CONCLUSION Endorectal linear array ultrasonography is a reliable tool to detect rectal neoplasias suitable for local treatment.
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Affiliation(s)
- Davide Ravizza
- European Institute of Oncology, Division of Endoscopy, Milan, Italy.
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Cui C, Cai H, Liu L, Li L, Tian H, Li L. Quantitative analysis and prediction of regional lymph node status in rectal cancer based on computed tomography imaging. Eur Radiol 2011; 21:2318-25. [PMID: 21713526 DOI: 10.1007/s00330-011-2182-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Revised: 04/24/2011] [Accepted: 04/27/2011] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To quantitatively evaluate regional lymph nodes in rectal cancer patients by using an automated, computer-aided approach, and to assess the accuracy of this approach in differentiating benign and malignant lymph nodes. METHODS Patients (228) with newly diagnosed rectal cancer, confirmed by biopsy, underwent enhanced computed tomography (CT). Patients were assigned to the benign node or malignant node group according to histopathological analysis of node samples. All CT-detected lymph nodes were segmented using the edge detection method, and seven quantitative parameters of each node were measured. To increase the prediction accuracy, a hierarchical model combining the merits of the support and relevance vector machines was proposed to achieve higher performance. RESULTS Of the 220 lymph nodes evaluated, 125 were positive and 95 were negative for metastases. Fractal dimension obtained by the Minkowski box-counting approach was higher in malignant nodes than in benign nodes, and there was a significant difference in heterogeneity between metastatic and non-metastatic lymph nodes. The overall performance of the proposed model is shown to have accuracy as high as 88% using morphological characterisation of lymph nodes. CONCLUSIONS Computer-aided quantitative analysis can improve the prediction of node status in rectal cancer.
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Affiliation(s)
- Chunyan Cui
- State Key Laboratory of Oncology in Southern China, Imaging Diagnosis and Interventional Center, Cancer Center, Sun Yat-sen University, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
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Zoccali M, Fichera A. Role of radiation in intermediate-risk rectal cancer. Ann Surg Oncol 2011; 19:126-30. [PMID: 21701926 DOI: 10.1245/s10434-011-1849-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Indexed: 12/28/2022]
Abstract
The treatment of rectal cancer has greatly evolved during the last several decades as a result of the understanding of the pathways of cancer spread, natural history of the disease, stages prognosis and prognostic markers. The tendency is clearly to move toward a more personalized approach to these patients based on preoperative staging and response to therapy. Although in the past we have been adding more treatment modalities to surgery to the point that every stage II/III cancer was treated with neoadjuvant chemo and radiotherapy followed by radical surgery by total mesorectal excision with or without sphincter preservation and more chemotherapy to follow, more recently this algorithm has been under discussion and scrutiny. Two of the major topics of controversy are: the use of local excision or even a watch-and-wait approach after a clinical complete response and the need for radiotherapy in the intermediate risk group. In this manuscript we will present the historical perspective that has brought the treatment of rectal cancer to the current standard of care and present the evidence supporting further investigation in the intermediate risk group.
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Affiliation(s)
- Marco Zoccali
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
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Topova L, Hellmich G, Puffer E, Schubert C, Christen N, Boldt T, Wiedemann B, Witzigmann H, Stelzner S. Prognostic value of tumor response to neoadjuvant therapy in rectal carcinoma. Dis Colon Rectum 2011; 54:401-11. [PMID: 21383559 DOI: 10.1007/dcr.0b013e3182070efb] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Neoadjuvant treatment in the multimodal therapy concept of rectal carcinoma has considerable effects on prognosis appraisal. OBJECTIVE This study aimed to evaluate the tumor response specified as an improvement by at least one stage defined in terms of the International Union Against Cancer stages as a prognostic factor. DESIGN This investigation was designed as a prospective cohort study. SETTING This study was performed at a community-based hospital with a specialized colorectal unit. PATIENTS One hundred seventy-four patients with locally advanced rectal carcinoma, treated in the Dresden-Friedrichstadt hospital from 1997 to 2009, who received long-term preoperative chemoradiotherapy and underwent curative resection, were included in this study. MAIN OUTCOME MEASURES The main outcome measures were cause-specific and disease-free survival with respect to T and N category, International Union Against Cancer stage, venous and lymphatic invasions, grading, CEA level, complete pathologic response, tumor regression grading, International Union Against Cancer stage shift, T, N, and CEA shift, types of neoadjuvant therapy, adjuvant therapy, interval between completion of neoadjuvant chemoradiotherapy and surgery, and number of extracted lymph nodes in resected specimens. Univariate and multivariate analyses were performed. RESULTS Median follow-up was 45 months. One hundred twenty-one patients (69.5%) showed a response to the treatment, whereas 53 (30.5%) did not. Five-year cause-specific and disease-free survival for responders (n = 121) vs nonresponders (n = 53) were 92.6% and 73.7% vs 84.9% and 47.9%. In the univariate analysis, ypN category, venous and lymphatic invasion, tumor regression grading, International Union Against Cancer stage shift, and T and N shift were significantly predictive for cause-specific and disease-free survival. Furthermore, ypUICC stage, ypT category, grading, and complete pathologic response had an impact on disease-free survival. In the multivariate analysis, only the International Union Against Cancer stage shift kept its independent explanatory power for cause-specific P = .012, HR 3.10 (95% CI 1.28-7.51) and disease-free survival P < .001, HR 3.85 (95% CI 1.98-7.51). LIMITATIONS The determination of International Union Against Cancer stage shift depends on the pretreatment staging modalities. CONCLUSION Our investigation demonstrates that the response of tumor to neoadjuvant therapy is an independent prognostic factor in patients with rectal carcinoma.
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Affiliation(s)
- Larysa Topova
- Department of General and Visceral Surgery, Dresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of Dresden, Dresden, Germany.
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Ronnekleiv-Kelly SM, Kennedy GD. Management of stage IV rectal cancer: Palliative options. World J Gastroenterol 2011; 17:835-47. [PMID: 21412493 PMCID: PMC3051134 DOI: 10.3748/wjg.v17.i7.835] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 01/04/2011] [Accepted: 01/11/2011] [Indexed: 02/06/2023] Open
Abstract
Approximately 30% of patients with rectal cancer present with metastatic disease. Many of these patients have symptoms of bleeding or obstruction. Several treatment options are available to deal with the various complications that may afflict these patients. Endorectal stenting, laser ablation, and operative resection are a few of the options available to the patient with a malignant large bowel obstruction. A thorough understanding of treatment options will ensure the patient is offered the most effective therapy with the least amount of associated morbidity. In this review, we describe various options for palliation of symptoms in patients with metastatic rectal cancer. Additionally, we briefly discuss treatment for asymptomatic patients with metastatic disease.
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Tan KK, Tsang CB. Staging of Rectal Cancer—Technique and Interpretation of Evaluating Rectal Adenocarcinoma, uT1-4, N Disease: 2D and 3D Evaluation. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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El Ounani F, Allali N, Dafiri R. [Von Recklinghausen disease presenting with rectal bleeding]. JOURNAL DE RADIOLOGIE 2010; 91:801-803. [PMID: 20814364 DOI: 10.1016/s0221-0363(10)70118-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Edelman BR, Weiser MR. Endorectal ultrasound: its role in the diagnosis and treatment of rectal cancer. Clin Colon Rectal Surg 2010; 21:167-77. [PMID: 20011415 DOI: 10.1055/s-2008-1080996] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
With development over the past 25 years of new surgical techniques and neoadjuvant therapy regimens for rectal cancer, physicians now have a range of treatment options that minimize morbidity and maximize the potential for cure. Accurate pretreatment staging is critical, ensuring adequate therapy and preventing overtreatment. Many options exist for staging primary rectal cancer. However, endorectal ultrasound (ERUS) remains the most attractive modality. It is an extension of the physical examination, and can be performed easily in the office. It is cost effective and is generally well tolerated by the patient, without need for general anesthesia. The authors discuss the data currently available on ERUS, including its accuracy and limitations, as well as the technical aspects of performing ERUS and interpreting the results. They also discuss new ultrasound technologies, which may improve rectal cancer staging in the future.
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Affiliation(s)
- Bret R Edelman
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Tarantino I, Warschkow R, Linke GR, Zerz A. Minimally Invasive Approaches to Staging of Locally Excised Distal, Early Rectal Cancers. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wang X, Lv D, Song H, Deng L, Gao Q, Wu J, Shi Y, Li L. Multimodal preoperative evaluation system in surgical decision making for rectal cancer: a randomized controlled trial. Int J Colorectal Dis 2010; 25:351-8. [PMID: 19921223 PMCID: PMC2814035 DOI: 10.1007/s00384-009-0839-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2009] [Indexed: 02/05/2023]
Abstract
PURPOSE Multimodal preoperative evaluation (MPE) is a novel strategy for surgical decision making, incorporating the transrectal ultrasound (TRUS), 64 multi-slice spiral computer tomography (MSCT), and serum amyloid A protein (SAA) for rectal cancer. This trial aims to determine the accuracy of MPE in preoperative staging and its role in surgical decision making for rectal cancer. METHODS Two hundred twenty-five participants with histologically proven rectal cancer with tumor height less than 10 cm were randomly assigned into three arms in the ratio 1:1:1. Arm A (MPE) was multimodal staged by the combination of MSCT, TRUS, and SAA. Arm B (MSCT+SAA) was staged by MSCT and SAA. Arm C (MSCT) was staged only by MSCT. The primary endpoints were the accuracy of preoperative staging and expected surgical procedures. This study is registered as an International Standard Randomised Controlled Trial, number ChiCTR-DT-00000409. RESULTS The analysis showed statistical difference in the accuracy of T staging between arm A and B (94.6% vs. 77.8%, P=0.003) and arm A and C (94.6% vs. 80.6%, P=0.010). Statistical difference was also observed between the accuracies of preoperative N staging between arm A and C (85.1% vs. 69.4%, P=0.023) and arm A and B (85.1% vs. 84.7%, P=0.029). Surgical decision making in arm A was more accurate than that in arm C (95.9% vs. 80.6%, P=0.001). Pathological T stage (P<0.001), N stage (P<0.001), tumor node metastasis stage (P<0.001), serum level of SAA (P=0.002), and tumor height (P=0.030) were significantly associated with final surgical procedures. CONCLUSION MPE is an effective strategy in preoperative staging and more accurate than other available strategies in surgical decision making for rectal cancer.
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Affiliation(s)
- Xiaodong Wang
- Anal-Colorectal Surgery, West China Hospital, Sichuan University, 37, Guo Xue Xiang, Chengdu, China 610041
| | - Donghao Lv
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Huan Song
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Lei Deng
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Qiang Gao
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Junhua Wu
- Radiology, West China Hospital, Chengdu, China
| | - Yingyu Shi
- Sonography, West China Hospital, Chengdu, China
| | - Li Li
- Anal-Colorectal Surgery, West China Hospital, Sichuan University, 37, Guo Xue Xiang, Chengdu, China 610041
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Berardi R, Mantello G, Scartozzi M, Del Prete S, Luppi G, Martinelli R, Fumagalli M, Grillo-Ruggieri F, Bearzi I, Mandolesi A, Marmorale C, Cascinu S. Locally Advanced Rectal Cancer Patients Receiving Radio-Chemotherapy: A Novel Clinical–Pathologic Score Correlates With Global Outcome. Int J Radiat Oncol Biol Phys 2009; 75:1437-43. [DOI: 10.1016/j.ijrobp.2009.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Revised: 01/04/2009] [Accepted: 01/06/2009] [Indexed: 01/08/2023]
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Shi GH, Wang XM, Yu YJ, Li YY, Dong XP. Transrectal ultrasonography in preoperative staging of rectal carcinoma: diagnostic value and relationship with TNM staging. Shijie Huaren Xiaohua Zazhi 2009; 17:3465-3468. [DOI: 10.11569/wcjd.v17.i33.3465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the diagnostic value of transrectal ultrasonography (TRUS) in preoperative staging of rectal carcinoma and the relationship between TRUS and TNM staging.
METHODS: Sixty-five patients with pathologically confirmed rectal carcinoma were detected by TRUS before surgery. The circumference of the bowel wall involved by tumor was recorded. The preoperative transrectal ultrasonographic staging of rectal carcinoma was performed using the TNM staging system. The preoperative staging results were then compared with those of postoperative pathologic staging.
RESULTS: The overall accuracy rate of preoperative staging of rectal carcinoma by TRUS was 86.15%. The diagnostic accuracy in T1-T4-stage patients by TRUS was 93.85%, 87.69%, 90.77% and 100%, respectively. The circumference of the bowel wall involved by tumor was positively correlated with pathological tumor stage (r = 0.89, P < 0.01). The overall accuracy rate of preoperative staging of rectal carcinoma by TRUS in combination with the circumference of the bowel wall involved by tumor was 95.38%.
CONCLUSION: TRUS has a high diagnostic accuracy in preoperative staging of rectal carcinoma. TRUS in combination with the circumference of the bowel wall involved by tumor can improve the diagnostic accuracy of preoperative staging of rectal carcinoma.
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Santoro GA, Gizzi G, Pellegrini L, Battistella G, Di Falco G. The value of high-resolution three-dimensional endorectal ultrasonography in the management of submucosal invasive rectal tumors. Dis Colon Rectum 2009; 52:1837-43. [PMID: 19966629 DOI: 10.1007/dcr.0b013e3181b16ce9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aims of this prospective study were 1) to evaluate the accuracy of high-resolution three-dimensional endorectal ultrasonography in distinguishing slight from massive submucosal invasion of early rectal tumors, and 2) to determine the technology's role in treatment selection. METHODS A total of 142 consecutive patients with clinically possible pT1 rectal cancers underwent three-dimensional endorectal ultrasonography. Slight or massive irregularity of the hyperechoic submucosal layer was considered to characterize uT1-slight or uT1-massive tumors. Treatment was selected on the basis of ultrasonographic findings: endoscopic resection or full-thickness transanal local excision was selected for uT1-slight lesions, and radical resection was selected for uT1-massive tumors. Ultrasonographic staging was compared with histopathologic staging. RESULTS One hundred twenty-six patients were included in the final analyses. Three-dimensional endorectal ultrasonography staged 77 lesions as uT0, 25 as uT1-slight, 20 as uT1-massive, and 4 as uT2. Histologically, adenomas were found in 75 patients and tumor invasion was found in 44 lesions (24 pT1-slight, 16 pT1-massive, 4 pT2). The overall kappa for the concordance between ultrasonographic and histopathologic stagings was 0.81 (95% confidence interval, 0.72-0.89). No invasive carcinomas remained undetected. The depth of invasion was correctly determined in 87.2% of both pT1-slight and pT1-massive lesions. Considering the complete series of 126 patients, the accuracy of this modality in selecting appropriate management was 95.2% (kappa, 0.84; 95% confidence interval, 0.71-0.96). Adequate surgery was performed in 87.5% of pT1 tumors. CONCLUSION Three-dimensional endorectal ultrasonography is useful for assessing the depth of submucosal invasion in early rectal cancer and for selecting therapeutic options.
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Affiliation(s)
- Giulio A Santoro
- I degrees Department of Surgery, Regional Hospital, 31100 Treviso, Italy.
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Yeung JMC, Ferris NJ, Lynch AC, Heriot AG. Preoperative staging of rectal cancer. Future Oncol 2009; 5:1295-306. [DOI: 10.2217/fon.09.100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Preoperative staging is now an essential factor in the multidisciplinary management of rectal cancer because tumor stage is the strongest predictive factor for recurrence. Preoperative staging of rectal cancer can be divided into either local or distant staging. Local staging incorporates the assessment of mural wall invasion, circumferential resection margin involvement, as well as the nodal status for metastasis. Distant staging assesses for evidence of metastatic disease. The aim of this review is to consider the indications and limitations of the current preoperative imaging modalities for rectal cancer staging including clinical examination, endorectal ultrasound, magnetic resonance imaging, computed tomography and positron emission tomography–computed tomography, with respect to local and distant disease.
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Affiliation(s)
- Justin MC Yeung
- Colorectal Fellow, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Nicholas J Ferris
- Consultant Radiologist, Department of Diagnostic Radiology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - A Craig Lynch
- Consultant Surgeon, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Alexander G Heriot
- Consultant Surgeon, Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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Tumor volume changes assessed by three-dimensional magnetic resonance volumetry in rectal cancer patients after preoperative chemoradiation: the impact of the volume reduction ratio on the prediction of pathologic complete response. Int J Radiat Oncol Biol Phys 2009; 76:1018-25. [PMID: 19647949 DOI: 10.1016/j.ijrobp.2009.03.066] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 03/09/2009] [Accepted: 03/09/2009] [Indexed: 01/11/2023]
Abstract
PURPOSE The aim of this study was to determine the correlation between tumor volume changes assessed by three-dimensional (3D) magnetic resonance (MR) volumetry and the histopathologic tumor response in rectal cancer patients undergoing preoperative chemoradiation therapy (CRT). METHODS AND MATERIALS A total of 84 patients who underwent preoperative CRT followed by radical surgery were prospectively enrolled in the study. The post-treatment tumor volume and tumor volume reduction ratio (% decrease ratio), as shown by 3D MR volumetry, were compared with the histopathologic response, as shown by T and N downstaging and the tumor regression grade (TRG). RESULTS There were no significant differences in the post-treatment tumor volume and the volume reduction ratio shown by 3D MR volumetry with respect to T and N downstaging and the tumor regression grade. In a multivariate analysis, the tumor volume reduction ratio was not significantly associated with T and N downstaging. The volume reduction ratio (>75%, p = 0.01) and the pretreatment carcinoembryonic antigen level (< or =3 ng/ml, p = 0.01), but not the post-treatment volume shown by 3D MR (< or = 5 ml), were, however, significantly associated with an increased pathologic complete response rate. CONCLUSION More than 75% of the tumor volume reduction ratios were significantly associated with a high pathologic complete response rate. Therefore, limited treatment options such as local excision or simple observation might be considered after preoperative CRT in this patient population.
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