1
|
Wen L, Liu J, Hu P, Bi F, Liu S, Jian L, Zhu S, Nie S, Cao F, Lu Q, Yu X, Liu K. MRI-Based Radiomic Models Outperform Radiologists in Predicting Pathological Complete Response to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer. Acad Radiol 2023; 30 Suppl 1:S176-S184. [PMID: 36739228 DOI: 10.1016/j.acra.2022.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/13/2022] [Accepted: 12/21/2022] [Indexed: 02/05/2023]
Abstract
RATIONALE AND OBJECTIVES The 15%-27% of patients with locally advanced rectal cancer (LARC) achieved pathologic complete response (pCR) to neoadjuvant chemoradiotherapy (nCRT) and could avoid proctectomy. We aimed to investigate the effectiveness of treatment response prediction using MRI-based pre-, post-, and delta-radiomic features for LARC patients treated with nCRT and to compare these radiomic models with radiologists' visual assessment. MATERIALS AND METHODS A total of 126 patients with LARC who received nCRT before surgery were included and randomly divided into a training set (n = 84) and a validation set (n = 42). 250 radiomic features were extracted from T2-weighted images from pre- and post-nCRT MRI. Pearson correlation analysis and AONVA or Relief were used to identify radiomic descriptors associated with pCR. Five machine-learning classifiers were compared to construct radiomic models. The radiomic nomogram was built via multivariate logistic regression analysis. Two senior radiologists independently rated tumor regression grades and compared with radiomic models. Area under the curve (AUC) of the models and pooled observers were compared by using the DeLong test. RESULTS The optimal pre-, post-, and delta-radiomic models yielded an AUC of 0.717 (95% CI: 0.639-0.795), 0.805 (95%CI: 0.736-0.874), and 0.724 (95%CI: 0.648-0.800), respectively. The radiomic nomogram based on pre-nCRT cN stage, pre-nCRT radscore, and post-nCRT radscore achieved an AUC of 0.852 (95%CI: 0.774-0.930), which was higher than the single radiomic models and pooled readers (all p < 0.05). CONCLUSIONS The radiomic nomogram is an effective and invasive tool to predict pCR in LARC patients after nCRT, which outperforms radiologists.
Collapse
Affiliation(s)
- Lu Wen
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China
| | - Jun Liu
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China.
| | - Pingsheng Hu
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China
| | - Feng Bi
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China.
| | - Siye Liu
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China
| | - Lian Jian
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China
| | - Suyu Zhu
- Department of Radiotherapy, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410013, P.R. China
| | - Shaolin Nie
- Department of Colorectal Surgery, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China
| | - Fang Cao
- Department of Pathology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China
| | - Qiang Lu
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China
| | - Xiaoping Yu
- Department of Diagnostic Radiology, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, P.R. China
| | - Ke Liu
- Department of Radiotherapy, Hunan Cancer Hospital and the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410013, P.R. China.
| |
Collapse
|
2
|
Azamat S, Karaman Ş, Azamat IF, Ertaş G, Kulle CB, Keskin M, Sakin RND, Bakır B, Oral EN, Kartal MG. Complete Response Evaluation of Locally Advanced Rectal Cancer to Neoadjuvant Chemoradiotherapy Using Textural Features Obtained from T2 Weighted Imaging and ADC Maps. Curr Med Imaging 2022; 18:1061-1069. [PMID: 35240976 DOI: 10.2174/1573405618666220303111026] [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: 08/20/2021] [Revised: 12/07/2021] [Accepted: 12/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The prediction of pathological responses for locally advanced rectal cancer using magnetic resonance imaging (MRI) after neoadjuvant chemoradiotherapy (CRT) is a challenging task for radiologists, as residual tumor cells can be mistaken for fibrosis. Texture analysis of MR images has been proposed to understand the underlying pathology. OBJECTIVE This study aimed to assess the responses of lesions to CRT in patients with locally advanced rectal cancer using the first-order textural features of MRI T2-weighted imaging (T2-WI) and apparent diffusion coefficient (ADC) maps. METHODS Forty-four patients with locally advanced rectal cancer (median age: 57 years) who underwent MRI before and after CRT were enrolled in this retrospective study. The first-order textural parameters of tumors on T2-WI and ADC maps were extracted. The textural features of lesions in pathologic complete responders were compared to partial responders using Student's t- or Mann-Whitney U tests. A comparison of textural features before and after CRT for each group was performed using the Wilcoxon rank sum test. Receiver operating characteristic curves were calculated to detect the diagnostic performance of the ADC. RESULTS Of the 44 patients evaluated, 22 (50%) were placed in a partial response group and 50% were placed in a complete response group. The ADC changes of the complete responders were statistically more significant than those of the partial responders (P = 0.002). Pathologic total response was predicted with an ADC cut-off of 1310 x 10-6 mm2/s, with a sensitivity of 72%, a specificity of 77%, and an accuracy of 78.1% after neoadjuvant CRT. The skewness of the T2-WI before and after neoadjuvant CRT showed a significant difference in the complete response group compared to the partial response group (P = 0.001 for complete responders vs. P = 0.482 for partial responders). Also, relative T2-WI signal intensity in the complete response group was statistically lower than that of the partial response group after neoadjuvant CRT (P = 0.006). CONCLUSION As a result of the conversion of tumor cells to fibrosis, the skewness of the T2-WI before and after neoadjuvant CRT was statistically different in the complete response group compared to the partial response group, and the complete response group showed statistically lower relative T2-WI signal intensity than the partial response group after neoadjuvant CRT. Additionally, the ADC cut-off value of 1310 × 10-6 mm2/s could be used as a marker for complete response along with absolute ADC value changes within this dataset.
Collapse
Affiliation(s)
- Sena Azamat
- Institute of Biomedical Engineering, Bogazici University, Istanbul, Turkey
- Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Şule Karaman
- Department of Radiation Oncology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ibrahim Fethi Azamat
- Department of General Surgery, Faculty of Medicine, Koc University, Istanbul, Turke
| | - Gokhan Ertaş
- Biomedical Engineering Department, Yeditepe University, Istanbul, Turkey
| | - Cemil Burak Kulle
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Metin Keskin
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | | | - Barış Bakır
- Department of Radiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ethem Nezih Oral
- Department of Radiation Oncology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Merve Gulbiz Kartal
- Department of Radiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| |
Collapse
|
3
|
Rectal cancer response to neoadjuvant chemoradiotherapy evaluated with MRI: Development and validation of a classification algorithm. Eur J Radiol 2022; 147:110146. [PMID: 34998098 DOI: 10.1016/j.ejrad.2021.110146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of this study was to develop and validate a decision support model using data mining algorithms, based on morphologic features derived from MRI images, to discriminate between complete responders (CR) and non-complete responders (NCR) patients after neoadjuvant chemoradiotherapy (CRT), in a population of patients with locally advanced rectal cancer (LARC). METHODS Two populations were retrospectively enrolled: group A (65 patients) was used to train a data mining decision tree algorithm whereas group B (30 patients) was used to validate it. All patients underwent surgery; according to the histology evaluation, patients were divided in CR and NCR. Staging and restaging MRI examinations were retrospectively analysed and seven parameters were considered for data mining classification. Five different classification methods were tested and evaluated in terms of sensitivity, specificity, accuracy and AUC in order to identify the classification model able to achieve the best performance. The best classification algorithm was subsequently applied to group B for validation: sensitivity, specificity, positive and negative predictive value, accuracy and ROC curve were calculated. Inter and intra-reader agreement were calculated. RESULTS Four features were selected for the development of the classification algorithm: MRI tumor regression grade (MR-TRG), staging volume (SV), tumor volume reduction rate (TVRR) and signal intensity reduction rate (SIRR). The decision tree J48 showed the highest efficiency: when applied to group B, all the CR and 18/21 NCR were correctly classified (sensitivity 85.71%, specificity 100%, PPV 100%, NPV 94.2%, accuracy 95.7%, AUC 0.833). Both inter- and intra-reader evaluation showed good agreement (κ > 0.6). CONCLUSIONS The proposed decision support model may help in distinguishing between CR and NCR patients with LARC after CRT.
Collapse
|
4
|
Locally Advanced Rectal Cancer: What We Learned in the Last Two Decades and the Future Perspectives. J Gastrointest Cancer 2022; 54:188-203. [PMID: 34981341 DOI: 10.1007/s12029-021-00794-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 12/13/2022]
Abstract
The advancement in surgical techniques, optimization of systemic chemoradiotherapy, and development of refined diagnostic and imaging modalities have brought a phenomenal shift in the treatment of the locally advanced rectal cancer. Although each therapeutic option has shown substantial progress in their field, it is finding their ideal amalgamation which has baffled the clinician and researchers alike. In the effort to identifying the perfect salutary treatment plan, we have even shifted our attention from the trimodal approach to non-operative "watchful waiting" to more recent individualized care. In this article, we acknowledge the scientific progress in the management of locally advanced rectal cancer and compare the opportunities as well as the obstacles while implementing them clinically. We also explore the current challenges and controversies surrounding the multidisciplinary approach and highlight the new trends and recent advances with an ultimate goal to improve the patients' quality of life.
Collapse
|
5
|
Di Re AM, Sun Y, Sundaresan P, Hau E, Toh JWT, Gee H, Or M, Haworth A. MRI radiomics in the prediction of therapeutic response to neoadjuvant therapy for locoregionally advanced rectal cancer: a systematic review. Expert Rev Anticancer Ther 2021; 21:425-449. [PMID: 33289435 DOI: 10.1080/14737140.2021.1860762] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: The standard of care for locoregionally advanced rectal cancer is neoadjuvant therapy (NA CRT) prior to surgery, of which 10-30% experience a complete pathologic response (pCR). There has been interest in using imaging features, also known as radiomics features, to predict pCR and potentially avoid surgery. This systematic review aims to describe the spectrum of MRI studies examining high-performing radiomic features that predict NA CRT response.Areas covered: This article reviews the use of pre-therapy MRI in predicting NA CRT response for patients with locoregionally advanced rectal cancer (T3/T4 and/or N1+). The primary outcome was to identify MRI radiomic studies; secondary outcomes included the power and the frequency of use of radiomic features.Expert opinion: Advanced models incorporating multiple radiomics categories appear to be the most promising. However, there is a need for standardization across studies with regards to; the definition of NA CRT response, imaging protocols, and radiomics features incorporated. Further studies are needed to validate current radiomics models and to fully ascertain the value of MRI radiomics in the response prediction for locoregionally advanced rectal cancer.
Collapse
Affiliation(s)
- Angelina Marina Di Re
- Colorectal Department, Westmead Hospital, Cnr Hawkesbury, Westmead, NSW.,School of Physics, University of Sydney, Camperdown, NSW, Australia
| | - Yu Sun
- School of Physics, University of Sydney, Camperdown, NSW, Australia
| | - Purnima Sundaresan
- Radiation Oncology Network, Western Sydney Local Health District, Cnr Hawkesbury, Westmead, NSW, Australia.,Sydney Medical School, University of Sydney, Camperdown, NSW, Australia
| | - Eric Hau
- Radiation Oncology Network, Western Sydney Local Health District, Cnr Hawkesbury, Westmead, NSW, Australia.,Sydney Medical School, University of Sydney, Camperdown, NSW, Australia.,Centre for Cancer Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
| | - James Wei Tatt Toh
- Colorectal Department, Westmead Hospital, Cnr Hawkesbury, Westmead, NSW.,Sydney Medical School, University of Sydney, Camperdown, NSW, Australia.,Centre for Cancer Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
| | - Harriet Gee
- Radiation Oncology Network, Western Sydney Local Health District, Cnr Hawkesbury, Westmead, NSW, Australia.,Sydney Medical School, University of Sydney, Camperdown, NSW, Australia
| | - Michelle Or
- Radiation Oncology Network, Western Sydney Local Health District, Cnr Hawkesbury, Westmead, NSW, Australia
| | - Annette Haworth
- School of Physics, University of Sydney, Camperdown, NSW, Australia
| |
Collapse
|
6
|
Bae H, Seo N, Han K, Koom WS, Kim MJ, Kim NK, Lim JS. MR prediction of pathologic complete response and early-stage rectal cancer after neoadjuvant chemoradiation in patients with clinical T1/T2 rectal cancer for organ saving strategy. Medicine (Baltimore) 2020; 99:e22746. [PMID: 33080736 PMCID: PMC7571887 DOI: 10.1097/md.0000000000022746] [Citation(s) in RCA: 1] [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] [Indexed: 12/25/2022] Open
Abstract
To evaluate the ability of magnetic resonance imaging (MRI) to predict pathologic complete response (pCR) after neoadjuvant chemoradiation therapy (CRT) in patients with clinical T1/T2 rectal cancer to indicate candidates for organ-saving strategies.Between 2012 and 2016, 38 patients with clinical T1/T2 rectal cancer received neoadjuvant CRT. Radiologic complete response (rCR) was assigned when dense fibrotic tissue without tumor signal intensity was observed on post-CRT MRI. Surgical pathologic assessment was used to evaluate tumor regression. The association between rCR and the mural extent of the primary tumor, pCR, and pathologic T stage were analyzed.In rCR patients, the pCR rate was higher; the odds of achieving pCR were 8.00 times higher than for non-rCR patients (P = .02). rCR patients were also more likely to have early-stage cancer than non-rCR patients (P = 0.01). Patients with partial extent of the primary tumor on post-CRT MRI were more likely to be diagnosed with early-stage cancer than those with transmural extent (P = .01).rCR indicated by post-CRT MRI can be used as a supportive factor to predict pCR after neoadjuvant CRT in patients with clinical T1/T2 rectal cancer and can guide management decisions around organ-saving treatments.
Collapse
Affiliation(s)
- Heejin Bae
- Department of Radiology and Research Institute of Radiological Science
| | - Nieun Seo
- Department of Radiology and Research Institute of Radiological Science
| | - Kyunghwa Han
- Department of Radiology and Research Institute of Radiological Science
| | | | - Myeong-Jin Kim
- Department of Radiology and Research Institute of Radiological Science
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Seok Lim
- Department of Radiology and Research Institute of Radiological Science
| |
Collapse
|
7
|
Magnetic Resonance of Rectal Cancer Response to Therapy: An Image Quality Comparison between 3.0 and 1.5 Tesla. BIOMED RESEARCH INTERNATIONAL 2020; 2020:9842732. [PMID: 33102603 PMCID: PMC7576357 DOI: 10.1155/2020/9842732] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 01/19/2023]
Abstract
Purpose To evaluate signal intensity (SI) differences between 3.0 T and 1.5 T on T2-weighted (T2w), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) in rectal cancer pre-, during, and postneoadjuvant chemoradiotherapy (CRT). Materials and Methods 22 patients with locally advanced rectal cancer were prospectively enrolled. All patients underwent T2w, DWI, and ADC pre-, during, and post-CRT on both 3.0 T MRI and 1.5 T MRI. A radiologist drew regions of interest (ROIs) of the tumor and obturator internus muscle on the selected slice to evaluate SI and relative SI (rSI). Additionally, a subanalysis evaluating the SI before and after-CRT (∆SI pre-post) in complete responder patients (CR) and nonresponder patients (NR) on T2w, DWI, and ADC was performed. Results Significant differences were observed for T2w and DWI on 3.0 T MRI compared to 1.5 T MRI pre-, during, and post-CRT (all P < 0.001), whereas no significant differences were reported for ADC among all controls (all P > 0.05). rSI showed no significant differences in all the examinations for all sequences (all P > 0.05). ∆SI showed significant differences between 3.0 T and 1.5 T MRI for DWI-∆SI in CR and NR (188.39 ± 166.90 vs. 30.45 ± 21.73 and 169.70 ± 121.87 vs. 22.00 ± 31.29, respectively, all P 0.02) and ADC-∆SI for CR (−0.58 ± 0.27 vs. −0.21 ± 0.24P value 0.02), while no significant differences were observed for ADC-∆SI in NR and both CR and NR for T2w-∆SI. Conclusion T2w-SI and DWI-SI showed significant differences for 3.0 T compared to 1.5 T in all three controls, while ADCSI showed no significant differences in all three controls on both field strengths. rSI was comparable for 3.0 T and 1.5 T MRI in rectal cancer patients; therefore, rectal cancer patients can be assessed both at 3.0 T MRI and 1.5 T MRI. However, a significant DWI-∆SI and ADC-∆SI on 3.0 T in CR might be interpreted as a better visual assessment in discriminating response to therapy compared to 1.5 T. Further investigations should be performed to confirm future possible clinical application.
Collapse
|
8
|
Abstract
The management of rectal cancer is complex and continually evolving. With advancements in technology and the use of multidisciplinary teams to guide the treatment decision making, staging, oncologic, and functional outcomes are improving, and the management is moving toward personalized treatment strategies to optimize each individual patient's outcomes. Key in this evolution is imaging. Magnetic resonance imaging (MRI) has emerged as the dominant method of pelvic imaging in rectal cancer, and use of MRI for staging is best practice in multiple international guidelines. MRI allows a noninvasive assessment of the tumor site, relationship to surrounding structures, and provides highly accurate rectal cancer staging, which is necessary for determining the appropriate treatment strategy. However, the applications of MRI extend far beyond pretreatment staging. MRI can be used to predict outcomes in locally advanced rectal cancer and guide the surgical or nonsurgical plan, serving as a predictive and prognostic biomarker. With continued MRI hardware improvement and new sequence development, MRI may offer new perspectives in the assessment of treatment response and new innovations that could provide better insight into the staging, restaging, and outcomes with rectal cancer.
Collapse
Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
9
|
Cai Z, Huang L, Chen Y, Xie X, Zou Y, Lan P, Wu X. CEA Decline Predicts Tumor Regression and Prognosis in Locally Advanced Rectal Cancer Patients with Elevated Baseline CEA. J Cancer 2020; 11:6565-6570. [PMID: 33046977 PMCID: PMC7545678 DOI: 10.7150/jca.49252] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022] Open
Abstract
Purpose: To investigate the value of carcinoembryonic antigen (CEA) decline in predicting pathological tumor regression and outcome for locally advanced rectal cancer (LARC) patients who received neoadjuvant therapy with elevated baseline CEA. Methods: LARC patients with elevated pre-treatment CEA who received neoadjuvant therapy and radical tumor resection were retrospectively collected. Serum CEA level during treatment were recorded and the predictive value of pre-treatment CEA, post-treatment CEA and CEA ratio (CEApost-treatment /CEApre-treatment) for tumor regression grade (TRG), overall survival and diseases free survival were estimated by logistic regression or cox proportional hazard regression. Results: Two hundred and eighty-four LARC patients with elevated pre-treatment CEA were enrolled and the baseline, post-treatment CEA level and CEA ratio were 11.87 (5.02-731.31) ng/ml, 4.23 (0.50-173.80) ng/ml and 0.31(0.01-2.55) respectively. CEA level in 59.2% of the patients declined to normal after neoadjuvant therapy. Multivariate analysis showed that CEA ratio was an independent predictor for TRG (OR=3.463, 95% CI: 1.269-9.446, P=0.015) and tumor downstage (OR=0.393, 95% CI: 0.187-0.829, P=0.014). Patients with normalized post-treatment CEA level had better overall survival (P=0.010) and disease free survival (P=0.003) than those with elevated CEA level. Higher post-treatment CEA was an independent unfavored predictor for overall survival in LARC patients with elevated pre-treatment CEA (OR=1.042, 95% CI: 1.017-1.067, P=0.001). Conclusion: Post/pre-treatment CEA ratio predicted tumor regression in term of TRG and tumor downstage for LARC patients with elevated pre-treatment CEA and higher post-treatment CEA predicted poor overall survival.
Collapse
Affiliation(s)
- Zerong Cai
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lingyu Huang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yufeng Chen
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xiaoyu Xie
- Department of Medical Oncology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yifeng Zou
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ping Lan
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, China
| | - Xiaojian Wu
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangzhou, Guangdong, China
| |
Collapse
|
10
|
Non-surgical “Watch and Wait” Approach to Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2020. [DOI: 10.1007/s11888-020-00460-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
11
|
López-Campos F, Martín-Martín M, Fornell-Pérez R, García-Pérez JC, Die-Trill J, Fuentes-Mateos R, López-Durán S, Domínguez-Rullán J, Ferreiro R, Riquelme-Oliveira A, Hervás-Morón A, Couñago F. Watch and wait approach in rectal cancer: Current controversies and future directions. World J Gastroenterol 2020; 26:4218-4239. [PMID: 32848330 PMCID: PMC7422545 DOI: 10.3748/wjg.v26.i29.4218] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/25/2020] [Accepted: 07/21/2020] [Indexed: 02/06/2023] Open
Abstract
According to the main international clinical guidelines, the recommended treatment for locally-advanced rectal cancer is neoadjuvant chemoradiotherapy followed by surgery. However, doubts have been raised about the appropriate definition of clinical complete response (cCR) after neoadjuvant therapy and the role of surgery in patients who achieve a cCR. Surgical resection is associated with significant morbidity and decreased quality of life (QoL), which is especially relevant given the favourable prognosis in this patient subset. Accordingly, there has been a growing interest in alternative approaches with less morbidity, including the organ-preserving watch and wait strategy, in which surgery is omitted in patients who have achieved a cCR. These patients are managed with a specific follow-up protocol to ensure adequate cancer control, including the early identification of recurrent disease. However, there are several open questions about this strategy, including patient selection, the clinical and radiological criteria to accurately determine cCR, the duration of neoadjuvant treatment, the role of dose intensification (chemotherapy and/or radiotherapy), optimal follow-up protocols, and the future perspectives of this approach. In the present review, we summarize the available evidence on the watch and wait strategy in this clinical scenario, including ongoing clinical trials, QoL in these patients, and the controversies surrounding this treatment approach.
Collapse
Affiliation(s)
- Fernando López-Campos
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | | | - Roberto Fornell-Pérez
- Department of Radiology, Hospital Universitario de Basurto, Bilbao 48013, Vizcaya, Spain
| | | | - Javier Die-Trill
- Department of Surgery, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Raquel Fuentes-Mateos
- Department of Medical Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Sergio López-Durán
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - José Domínguez-Rullán
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Reyes Ferreiro
- Department of Medical Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | | | - Asunción Hervás-Morón
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid 28003, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Universidad Europea de Madrid (UEM), Madrid 28223, Spain
| |
Collapse
|
12
|
Seo N, Kim H, Cho MS, Lim JS. Response Assessment with MRI after Chemoradiotherapy in Rectal Cancer: Current Evidences. Korean J Radiol 2020; 20:1003-1018. [PMID: 31270972 PMCID: PMC6609432 DOI: 10.3348/kjr.2018.0611] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 04/07/2019] [Indexed: 12/20/2022] Open
Abstract
Baseline magnetic resonance imaging (MRI) has become the primary staging modality for surgical plans and stratification of patient populations for more efficient neoadjuvant treatment. Patients who exhibit a complete response to chemoradiotherapy (CRT) may achieve excellent local tumor control and better quality of life with organ-preserving treatments such as local excision or even watch-and-wait management. Therefore, the evaluation of tumor response is a key factor for determining the appropriate treatment following CRT. Although post-CRT MRI is generally accepted as the first-choice method for evaluating treatment response after CRT, its application in the clinical decision process is not fully validated. In this review, we will discuss various oncologic treatment options from radical surgical technique to organ-preservation strategies for achieving better cancer control and improved quality of life following CRT. In addition, the current status of post-CRT MRI in restaging rectal cancer as well as the main imaging features that should be evaluated for treatment planning will also be described for the tailored treatment.
Collapse
Affiliation(s)
- Nieun Seo
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Honsoul Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Soo Cho
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Seok Lim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
13
|
Developing a prediction model based on MRI for pathological complete response after neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Abdom Radiol (NY) 2019; 44:2978-2987. [PMID: 31327039 DOI: 10.1007/s00261-019-02129-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE The aim of this study was to build an appropriate diagnostic model for predicting pathological complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer (LARC), by combining magnetic resonance imaging (MRI) parameters with clinical factors. METHODS Eighty-four patients with LARC who underwent MR examination before and after nCRT were enrolled in this study. MRI parameters including cylindrical approximated tumor volume (CATV) and relative signal intensity of tumor (rT2wSI) were measured; corresponding reduction rates (RR) were calculated; and MR tumor regression grade (mrTRG) and other conventional MRI parameters were assessed. Logistic regression with lasso regularization was performed and the appropriate prediction model for pCR was built up. An external cohort of thirty-six patients was used as the validation group for testing the model. Receiver-operating characteristic (ROC) analysis was used to assess the diagnostic performance. RESULTS In the development and the validation group, 17 patients (20.2%) and 11 patients (30.6%), respectively, achieved pCR. Two CATV-related parameters (CATVpost, which is the CATV measured after nCRT and CATVRR), one rT2wSI-related parameter (rT2wSIRR), and mrTRG were the most important parameters for predicting pCR and were retained in the diagnostic model. In the development group, the area under the receiver-operating characteristic curve (AUC) for predicting pCR is 0.88 [95% confidence interval (CI) 0.78-0.97, p < 0.001], with a sensitivity of 82.4% and a specificity of 83.6%. In the validation group, the AUC is 0.84 (95% CI 0.70-0.98, p = 0.001), with a sensitivity of 81.8% and a specificity of 76.0%. CONCLUSION A diagnostic model including CATVpost, CATVRR, rT2wSIRR, and mrTRG was useful for predicting pCR after nCRT in patients with LARC and may be used as an effective organ-preservation strategy.
Collapse
|
14
|
Ferri V, Vicente Lopez E, Quijano Collazo Y, Caruso R, Duran Gimenez Rico H, Ielpo B, Diaz Reques E, Fabra Cabrera I, Malavè Cardozo L, Isernia R, Pinna E, Plaza Hernandezv C, Garcerant M, Garcia Cañamaques L, Perez Dueñas V. Quantitative analysis of 18-FDG-PET/MRI to assess pathological complete response following neoadjuvant radiochemotherapy in locally advanced rectal cancer. A prospective preliminary study. Acta Oncol 2019; 58:1246-1249. [PMID: 31144557 DOI: 10.1080/0284186x.2019.1622774] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Valentina Ferri
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | - Emilio Vicente Lopez
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | | | - Riccardo Caruso
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | | | - Benedetto Ielpo
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | - Eduardo Diaz Reques
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | - Isabel Fabra Cabrera
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | - Luis Malavè Cardozo
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | - Roberta Isernia
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | - Eva Pinna
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | | | - Marjorie Garcerant
- Division of Nuclear Medicin, Sanchinarro Hospital, San Pablo University, Madrid, Spain
| | | | | |
Collapse
|
15
|
Gollub MJ, Blazic I, Bates DDB, Campbell N, Knezevic A, Gonen M, Lynn P, Weiser MR, Garcia-Aguilar J, Hötker AM, Cercek A, Saltz L. Pelvic MRI after induction chemotherapy and before long-course chemoradiation therapy for rectal cancer: What are the imaging findings? Eur Radiol 2018; 29:1733-1742. [PMID: 30280248 DOI: 10.1007/s00330-018-5726-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 07/31/2018] [Accepted: 08/27/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To determine the appearance of rectal cancer on MRI after oxaliplatin-based chemotherapy (ICT) and make a preliminary assessment of MRI's value in predicting response to total neoadjuvant treatment (TNT). METHODS In this IRB-approved, HIPAA-compliant, retrospective study between 1 January 2010-20 October 2014, pre- and post-ICT tumour T2 volume, relative T2 signal intensity (rT2SI), node size, signal intensity and border characteristics were assessed in 63 patients (65 tumours) by three readers. The strength of association between the reference standard of histopathological percent tumour response and tumour volume change, rT2SI and lymph node characteristics was assessed with Spearman's correlation coefficient and Wilcoxon's rank sum test. Cox regression was used to assess association between DFS and radiological measures. RESULTS Change in T2 volume was not associated with TNT response. Change in rT2SI showed correlation with TNT response for one reader only using selective regions of interest (ROIs) and borderline correlation with response using total volume ROI. There was a significant negative correlation between baseline and post-ICT node size and TNT response (r = -0.25, p = 0.05; r = -0.35, p = 0.005, readers 1 and 2, respectively). Both baseline and post-induction median node sizes were significantly smaller in complete responders (p = 0.03, 0.001; readers 1 and 2, respectively). Change in largest baseline node size and decrease in post-ICT node signal heterogeneity were associated with 100% tumour response (p = 0.04). Nodal sizes at baseline and post-ICT MRI correlated with DFS. CONCLUSION In patients undergoing post-ICT MRI, tumour volume did not correlate with TNT response, but decreased lymph node sizes were significantly associated with complete response to TNT as well as DFS. Relative T2SI showed borderline correlation with TNT response. KEY POINTS • MRI-based tumour volume after induction chemotherapy and before chemoradiotherapy did not correlate with overall tumour response at the end of all treatment. • Lymph node size after induction chemotherapy and before chemoradiotherapy was strongly associated with complete pathological response after all treatment. • Lymph node sizes at baseline and post-induction chemotherapy MRI correlated with disease-free survival.
Collapse
Affiliation(s)
- Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Ivana Blazic
- Department of Radiology, Clinical Hospital Center Zemun, Vukova 9, Belgrade, 11080, Serbia
| | - David D B Bates
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Naomi Campbell
- IMED Radiology Network, Level 3, 104 Breakfast Creek Road, Newstead, QLD, 4006, Australia
| | - Andrea Knezevic
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Patricio Lynn
- Department of Surgery, New York University Medical Center, New York, NY, USA
| | - Martin R Weiser
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia-Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas M Hötker
- Department of Diagnostic and Interventional Radiology, Johannes Gutenberg-University Medical Centre, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Andrea Cercek
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Leonard Saltz
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
16
|
Histogram Analysis of Perfusion Parameters from Dynamic Contrast-Enhanced MR Imaging with Tumor Characteristics and Therapeutic Response in Locally Advanced Rectal Cancer. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3724393. [PMID: 30186857 PMCID: PMC6110013 DOI: 10.1155/2018/3724393] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 07/22/2018] [Accepted: 08/07/2018] [Indexed: 01/21/2023]
Abstract
Purpose To explore the role of histogram analysis of perfusion parameters from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) based on entire tumor volume in discriminating tumor characteristics and predicting therapeutic response in rectal cancer. Materials and Methods Thirty-seven DCE-MRIs of locally advanced rectal cancer patients who received chemoradiation therapy (CRT) before surgery were analyzed by pharmacokinetic model for quantification and histogram analysis of perfusion parameters. The results were correlated with tumor characteristics including EGFR expression, KRAS mutation, and CRT response based on the pathologic tumor regression grade (TRG). Results The area under the contrast agent concentration-time curve (AUC) skewness was significantly lower in patients with node metastasis. The vp histogram parameters were significantly higher in group with perineural invasion (PNI). The receiver operating characteristics (ROC) curve analyses showed that mode vp revealed the best diagnostic performance of PNI. The values of Ktrans and kep were significantly higher in the group with KRAS mutation. ROC curve analyses showed that mean and mode Ktrans demonstrated excellent diagnostic performance of KRAS mutation. DCE-MRI parameters did not demonstrate statistical significance in correlating with TRG. Conclusion These preliminary results suggest that a larger proportion of higher AUC skewness was present in LN metastasis group and a higher vp histogram value was present in rectal cancer with PNI. In addition, Ktrans and kep histogram parameters showed difference according to the KRAS mutation, demonstrating the utility of the histogram of perfusion parameters derived from DCE-MRI as potential imaging biomarkers of tumor characteristics and genetic features.
Collapse
|
17
|
Kim S, Han K, Seo N, Kim HJ, Kim MJ, Koom WS, Ahn JB, Lim JS. T2-weighted signal intensity-selected volumetry for prediction of pathological complete response after preoperative chemoradiotherapy in locally advanced rectal cancer. Eur Radiol 2018; 28:5231-5240. [PMID: 29858637 DOI: 10.1007/s00330-018-5520-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/22/2018] [Accepted: 04/27/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To evaluate the diagnostic value of signal intensity (SI)-selected volumetry findings in T2-weighted magnetic resonance imaging (MRI) as a potential biomarker for predicting pathological complete response (pCR) to preoperative chemoradiotherapy (CRT) in patients with rectal cancer. METHODS Forty consecutive patients with pCR after preoperative CRT were compared with 80 age- and sex-matched non-pCR patients in a case-control study. SI-selected tumor volume was measured on post-CRT T2-weighted MRI, which included voxels of the treated tumor exceeding the SI (obturator internus muscle SI + [ischiorectal fossa fat SI - obturator internus muscle SI] × 0.2). Three blinded readers independently rated five-point pCR confidence scores and compared the diagnostic outcome with SI-selected volumetry findings. The SI-selected volumetry protocol was validated in 30 additional rectal cancer patients. RESULTS The area under the receiver-operating characteristic curve (AUC) of SI-selected volumetry for pCR prediction was 0.831, with an optimal cutoff value of 649.6 mm3 (sensitivity 0.850, specificity 0.725). The AUC of the SI-selected tumor volume was significantly greater than the pooled AUC of readers (0.707, p < 0.001). At this cutoff, the validation trial yielded an accuracy of 0.87. CONCLUSION SI-selected volumetry in post-CRT T2-weighted MRI can help predict pCR after preoperative CRT in patients with rectal cancer. KEY POINTS • Fibrosis and viable tumor MRI signal intensities (SIs) are difficult to distinguish. • T2 SI-selected volumetry yields high diagnostic performance for assessing pathological complete response. • T2 SI-selected volumetry is significantly more accurate than readers and non-SI-selected volumetry. • Post-chemoradiation therapy T2-weighted MRI SI-selected volumetry facilitates prediction of pathological complete response.
Collapse
Affiliation(s)
- Sungwon Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Kyunghwa Han
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Nieun Seo
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Hye Jin Kim
- Department of Radiology, Ajou University Hospital, Suwon, Republic of Korea
| | - Myeong-Jin Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joong Bae Ahn
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Seok Lim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
| |
Collapse
|
18
|
Zhang C, Ye F, Liu Y, Ouyang H, Zhao X, Zhang H. Morphologic predictors of pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer. Oncotarget 2017; 9:4862-4874. [PMID: 29435147 PMCID: PMC5797018 DOI: 10.18632/oncotarget.23419] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 10/02/2017] [Indexed: 12/16/2022] Open
Abstract
Purpose To evaluate the value of morphological parameters that can be obtained conveniently by MRI for predicting pathologically complete response (pCR) in patients with rectal cancer. Materials and Methods A cohort of 101 patients was examined using MRI before and after Neoadjuvant chemoradiotherapy (nCRT). Morphological parameters including maximum tumor area (MTA), maximum tumor length (MTL) and maximum tumor thickness (MTT), as well as cylindrical approximated tumor volume (CATV), distance to anal verge (DTA), and the reduction rates were evaluated by two experienced readers independently. Results Post-nCRT MTA and MTL, reduction rates and pre-nCRT DTA were proved to be significantly different between pCR and non-pCR with the AUCs of 0.672-0.853. The sensitivity and specificity for assessing pCR were 61.1-89.9% and 59.0-80.7% respectively. No significant correlation between pre-nCRT size measurements and pCR was obtained. Conclusion The convenient morphological measurements may be useful for predicting pCR with moderate sensitivity and specificity. Combining these predictors with the aim of building diagnostic model should be explored.
Collapse
Affiliation(s)
- Chongda Zhang
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 10021, China
| | - Feng Ye
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 10021, China
| | - Yuan Liu
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 10021, China
| | - Han Ouyang
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 10021, China
| | - Xinming Zhao
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 10021, China
| | - Hongmei Zhang
- Department of Diagnostic Radiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 10021, China
| |
Collapse
|
19
|
Srisajjakul S, Prapaisilp P, Bangchokdee S. Pitfalls in MRI of rectal cancer: What radiologists need to know and avoid. Clin Imaging 2017; 50:130-140. [PMID: 29414101 DOI: 10.1016/j.clinimag.2017.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/14/2017] [Accepted: 11/28/2017] [Indexed: 12/23/2022]
Abstract
Preoperative staging of rectal cancer using magnetic resonance imaging (MRI) has become an important component of clinical management. Although MRI is the modality of choice for rectal cancer diagnosis and staging, there are certain inherent potential pitfalls that radiologists need to recognize in order to avoid imaging misinterpretation, including choice of MRI protocol; choice of MRI technique; potential mimickers of rectal cancer; mucinous rectal tumor; differentiation between extramural tumor invasion and desmoplastic reaction; differentiation between low rectal cancer and anal cancer; problems relating to nodal involvement, peritoneal reflection, and mesorectal fascia invasion; and, challenges associated with restaging, post-treatment changes, and complications. The aim of this article was to heighten radiologist awareness of these potential pitfalls in order to improve diagnosis, decision-making, and patient outcomes.
Collapse
Affiliation(s)
- Sitthipong Srisajjakul
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand.
| | - Patcharin Prapaisilp
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, 2 Wanglang Road, Bangkoknoi, Bangkok 10700, Thailand
| | - Sirikan Bangchokdee
- Department of Internal Medicine, Pratumtani Hospital, 7 Ladlumkaew, Muang District, Pratumtani 12000, Thailand
| |
Collapse
|
20
|
Park SH, Lim JS, Lee J, Kim HY, Koom WS, Hur H, Park MS, Kim MJ, Kim H. Rectal Mucinous Adenocarcinoma: MR Imaging Assessment of Response to Concurrent Chemotherapy and Radiation Therapy—A Hypothesis-generating Study. Radiology 2017; 285:124-133. [DOI: 10.1148/radiol.2017162657] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Seung Hyun Park
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Joon Seok Lim
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Jinae Lee
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Ha Yan Kim
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Woong Sub Koom
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Hyuk Hur
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Mi-Suk Park
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Myeong-Jin Kim
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Honsoul Kim
- From the Department of Radiology and Research Institute of Radiological Science (S.H.P., J.S.L., M.S.P., M.J.K., H.K.); Biostatistics Collaboration Unit (J.L., H.Y.K.); Department of Radiation Oncology (W.S.K.); and Department of Surgery, Division of Colon and Rectal Surgery (H.H.); Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| |
Collapse
|
21
|
Abstract
INTRODUCTION The treatment of rectal cancer has diversified in recent years, presenting the clinician and patient with increasingly challenging management decisions. At the heart of this decision-making process are two competing interests; more radical but more morbid treatments which optimize oncological outcome, and less radical treatments which preserve organs and function but may pose a greater risk of disease recurrence. AREAS COVERED Imaging plays a vital role informing this decision-making process, both by providing prognostic details about the cancer before the start of treatment and by updating this picture as the cancer responds or fails to respond to treatment. There is a range of available imaging modalities, each with its strengths and weaknesses. Optimizing rectal cancer treatment requires a clear understanding of the important questions that imaging needs to answer and the optimum imaging strategy. Expert Commentary: This article provides an evidence-based review of the available imaging techniques and an expert commentary on the best imaging strategy.
Collapse
Affiliation(s)
- Chris Hunter
- a Department of Colorectal Surgery , Hull and East Yorkshire NHS Trust , Hull , UK.,b Department of Surgery and Cancer , Imperial College London , London , UK
| | - Gina Brown
- b Department of Surgery and Cancer , Imperial College London , London , UK.,c Department of Academic Radiology , The Royal Marsden Hospital , Sutton , UK
| |
Collapse
|
22
|
Foti PV, Privitera G, Piana S, Palmucci S, Spatola C, Bevilacqua R, Raffaele L, Salamone V, Caltabiano R, Magro G, Li Destri G, Milone P, Ettorre GC. Locally advanced rectal cancer: Qualitative and quantitative evaluation of diffusion-weighted MR imaging in the response assessment after neoadjuvant chemo-radiotherapy. Eur J Radiol Open 2016; 3:145-52. [PMID: 27489868 PMCID: PMC4959919 DOI: 10.1016/j.ejro.2016.06.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/29/2016] [Accepted: 06/29/2016] [Indexed: 12/15/2022] Open
Abstract
PURPOSE to investigate the added value of qualitative and quantitative evaluation of diffusion weighted (DW) magnetic resonance (MR) imaging in response assessment after neoadjuvant chemo-radiotherapy (CRT) in patients with locally advanced rectal cancer (LARC). METHODS 31 patients with LARC (stage ≥ T3) were enrolled in the study. All patients underwent conventional MRI and DWI before starting therapy and after neoadjuvant CRT. All patients underwent surgery; pathologic staging represented the reference standard. For qualitative analysis, two radiologists retrospectively reviewed conventional MR images and the combined set of conventional and DW MR images and recorded their confidence level with respect to complete response (ypCR). For quantitative analysis, tumor's apparent diffusion coefficient (ADC) values were measured at each examination. ADC pre-CRT, ADC post-CRT and Δ ADC post-ADC pre of the three groups of response (ypCR, partial response ypPR, stable disease ypSD) were compared. Receiver-operating characteristics (ROC) curve analysis was employed to investigate the discriminatory capability for ypCR, responders (ypCR, ypPR) and ypSD of each measure. RESULTS addition of DWI to conventional T2-weighted sequences improved diagnostic performance of MRI in the evaluation of ypCR. A low tumor ADC value in the pre-CRT examination, a high ADC value in the post-CRT examination, a high Δ ADC post-ADC pre [>0.3 (×10(-3) mm(2)/s)] were predictive of ypCR. CONCLUSIONS DW sequences improve MR capability to evaluate tumor response to CRT. Nevertheless, no functional MR technique alone seems accurate enough to safely select patients with ypCR.
Collapse
Affiliation(s)
- Pietro Valerio Foti
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Giuseppe Privitera
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Sebastiano Piana
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Stefano Palmucci
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Corrado Spatola
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Roberta Bevilacqua
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Luigi Raffaele
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Vincenzo Salamone
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Rosario Caltabiano
- Department G.F. Ingrassia-Institute of Pathology, University of Catania, Catania, Italy
| | - Gaetano Magro
- Department G.F. Ingrassia-Institute of Pathology, University of Catania, Catania, Italy
| | - Giovanni Li Destri
- Department G.F. Ingrassia-Unità Operativa Chirurgia Digerente Colorettale, University of Catania, Catania, Italy
| | - Pietro Milone
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Giovanni Carlo Ettorre
- Radiodiagnostic and Radiotherapy Unit, University Hospital "Policlinico-Vittorio Emanuele", Catania, Italy
| |
Collapse
|
23
|
Paspulati RM, Partovi S, Herrmann KA, Krishnamurthi S, Delaney CP, Nguyen NC. Comparison of hybrid FDG PET/MRI compared with PET/CT in colorectal cancer staging and restaging: a pilot study. ACTA ACUST UNITED AC 2016; 40:1415-25. [PMID: 26112492 DOI: 10.1007/s00261-015-0474-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE We report our initial clinical experience from a pilot study to compare the diagnostic accuracy of hybrid PET/MRI with PET/CT in colorectal cancer and discuss potential PET/MRI workflow solutions for colorectal cancer. METHODS Patients underwent both FDG PET/CT and PET/MRI (Ingenuity TF PET/MRI, Philips Healthcare) for rectal cancer staging or colorectal cancer restaging. The PET acquisition of PET/MRI was similar to that of PET/CT whereas the MRI protocol was selected individually based on the patient's medical history. One nuclear medicine physician reviewed the PET/CT studies and one radiologist reviewed the PET/MRI studies independently. The diagnostic accuracy of each modality was determined in consensus, using available medical records as a reference. RESULTS Of the 12 patients enrolled, two were for initial staging and ten for restaging. The median scan delay between the two modalities was 60 min. The initial imaging was PET/CT in nine patients and PET/MRI in three patients. When PET/CT was performed first, the SUV values of the 16 FDG avid lesions were greater at PET/MRI than at PET/CT. In contrast, when PET/MRI was performed first, the SUV values of the seven FDG avid lesions were greater at PET/CT than at PET/MRI. PET/MRI provided more detailed T staging than PET/CT. On a per-patient basis, with both patient groups combined for the evaluation of N and M staging/restaging, the true positive rate was 5/7 (71%) for PET/CT and 6/7 (86%) for PET/MRI, and true negative rate was 5/5 (100%) for both modalities. On a per-lesion basis, PET/CT identified 26 of 29 (90%) tumor lesions that were correctly detected by PET/MRI. Our proposed workflow allows for comprehensive cancer staging including integrated local and whole-body assessment. CONCLUSIONS Our initial experience shows a high diagnostic accuracy of PET/MRI in T staging of rectal cancer compared with PET/CT. In addition, PET/MRI shows at least comparable accuracy in N and M staging as well as restaging to PET/CT. However, the small sample size limits the generalizability of the results. It is expected that PET/MRI would yield higher diagnostic accuracy than PET/CT considering the high soft tissue contrast provided by MRI compared with CT, but larger studies are necessary to fully assess the benefit of PET/MRI in colorectal cancer.
Collapse
Affiliation(s)
- Raj Mohan Paspulati
- Department of Radiology, UH Case Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA,
| | | | | | | | | | | |
Collapse
|
24
|
Multiparametric MRI in the assessment of response of rectal cancer to neoadjuvant chemoradiotherapy: A comparison of morphological, volumetric and functional MRI parameters. Eur Radiol 2016; 26:4303-4312. [PMID: 26945761 DOI: 10.1007/s00330-016-4283-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 02/07/2016] [Accepted: 02/11/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE To compare morphological and functional MRI metrics and determine which ones perform best in assessing response to neoadjuvant chemoradiotherapy (CRT) in rectal cancer. MATERIALS AND METHODS This retrospective study included 24 uniformly-treated patients with biopsy-proven rectal adenocarcinoma who underwent MRI, including diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) sequences, before and after completion of CRT. On all MRI exams, two experienced readers independently measured longest and perpendicular tumour diameters, tumour volume, tumour regression grade (TRG) and tumour signal intensity ratio on T2-weighted imaging, as well as tumour volume and apparent diffusion coefficient on DW-MRI and tumour volume and transfer constant Ktrans on DCE-MRI. These metrics were correlated with histopathological percent tumour regression in the resected specimen (%TR). Inter-reader agreement was assessed using the concordance correlation coefficient (CCC). RESULTS For both readers, post-treatment DW-MRI and DCE-MRI volumetric tumour assessments were significantly associated with %TR; DCE-MRI volumetry showed better inter-reader agreement (CCC=0.700) than DW-MRI volumetry (CCC=0.292). For one reader, mrTRG, post-treatment T2 tumour volumetry and assessments of volume change made with T2, DW-MRI and DCE-MRI were also significantly associated with %TR. CONCLUSION Tumour volumetry on post-treatment DCE-MRI and DW-MRI correlated well with %TR, with DCE-MRI volumetry demonstrating better inter-reader agreement. KEY POINTS • Volumetry on post-treatment DCE-/DW-MRI sequences correlated well with histopathological tumour regression. • DCE-MRI volumetry demonstrated good inter-reader agreement. • Inter-reader agreement was higher for DCE-MRI volumetry than for DW-MRI volumetry. • DCE-MRI volumetry merits further investigation as a metric for evaluating treatment response.
Collapse
|
25
|
Ryan JE, Warrier SK, Lynch AC, Ramsay RG, Phillips WA, Heriot AG. Predicting pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer: a systematic review. Colorectal Dis 2016; 18:234-46. [PMID: 26531759 DOI: 10.1111/codi.13207] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 09/17/2015] [Indexed: 02/08/2023]
Abstract
AIM Approximately 20% of patients treated with neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer achieve a pathological complete response (pCR) while the remainder derive the benefit of improved local control and downstaging and a small proportion show a minimal response. The ability to predict which patients will benefit would allow for improved patient stratification directing therapy to those who are likely to achieve a good response, thereby avoiding ineffective treatment in those unlikely to benefit. METHOD A systematic review of the English language literature was conducted to identify pathological factors, imaging modalities and molecular factors that predict pCR following chemoradiotherapy. PubMed, MEDLINE and Cochrane Database searches were conducted with the following keywords and MeSH search terms: 'rectal neoplasm', 'response', 'neoadjuvant', 'preoperative chemoradiation', 'tumor response'. After review of title and abstracts, 85 articles addressing the prediction of pCR were selected. RESULTS Clear methods to predict pCR before chemoradiotherapy have not been defined. Clinical and radiological features of the primary cancer have limited ability to predict response. Molecular profiling holds the greatest potential to predict pCR but adoption of this technology will require greater concordance between cohorts for the biomarkers currently under investigation. CONCLUSION At present no robust markers of the prediction of pCR have been identified and the topic remains an area for future research. This review critically evaluates existing literature providing an overview of the methods currently available to predict pCR to nCRT for locally advanced rectal cancer. The review also provides a comprehensive comparison of the accuracy of each modality.
Collapse
Affiliation(s)
- J E Ryan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia.,Austin Academic Centre, University of Melbourne, Parkville, Victoria, Australia
| | - S K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A C Lynch
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - R G Ramsay
- Differentiation and Transcription Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - W A Phillips
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia.,Cancer Biology and Surgical Oncology Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| |
Collapse
|
26
|
Abstract
Preoperative chemoradiotherapy (CRT) followed by total mesorectal excision has been the standard of care for locally advanced patients with rectal cancer. Some patients achieve a pathologic complete response (pCR) to CRT and the oncologic outcomes are particularly favorable in this group. The role of surgery in patients with a pCR is now being questioned as radical rectal resection is associated with significant morbidity and long-term effects on quality of life. In an attempt to better tailor therapy, there is an interest in a "watch-and-wait" approach in patients who have a clinical complete response (cCR) after CRT with the goal of omitting surgery and allowing for organ preservation. However, a cCR does not always indicate a pCR, and improved clinical and imaging modalities are needed to better predict which patients have achieved a pCR and therefore can safely undergo a "watch-and-wait" approach. This article reviews the current data on nonoperative management and on-going controversies associated with this approach.
Collapse
|
27
|
Ryan JE, Warrier SK, Lynch AC, Heriot AG. Assessing pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer: a systematic review. Colorectal Dis 2015; 17:849-61. [PMID: 26260213 DOI: 10.1111/codi.13081] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 05/11/2015] [Indexed: 12/13/2022]
Abstract
AIM Pathological complete response to neoadjuvant chemoradiotherapy is found in 20% of patients with rectal cancer undergoing long-course chemoradiotherapy. Some authors have suggested that these patients do not need to undergo surgery and can be managed with careful follow-up, with surgery only used in the event of clinical failure. Widespread adoption of this regimen is limited by the accuracy of methods to confirm a pathological complete response (pCR). METHOD A systematic search of PubMed, Medline and Cochrane databases was conducted to identify clinical, histological and radiological features in those patients with rectal cancer who achieved a pCR following chemoradiotherapy. Searches were conducted with the following keywords and MeSH search terms: 'rectal neoplasm', 'response', 'neoadjuvant', 'preoperative chemoradiation' and 'tumour response'. After review of title and abstracts, 89 articles addressing the assessment of pCR were identified. RESULTS Histology and clinical assessment are the most effective methods of assessment of pCR, with histology considered the gold standard. Clinical assessment is limited to low rectal tumours and is open to significant inter-rater variability, while histological examination requires a surgical specimen. Diffusion-weighted MRI and (18) F-fluorodeoxyglucose positron emission tomography/CT demonstrate the greatest potential for the assessment of pCR, but both modalities have limited accuracy. CONCLUSION Determination of a pCR is crucial if a nonoperative approach is to be undertaken proactively. Various methods are available, but currently they lack sufficient sensitivity and specificity to define management. This is likely to be an area of further research in the future.
Collapse
Affiliation(s)
- J E Ryan
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia.,Austin Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - S K Warrier
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A C Lynch
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A G Heriot
- Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| |
Collapse
|
28
|
Cho SH, Kim GC, Jang YJ, Ryeom H, Kim HJ, Shin KM, Park JS, Choi GS, Kim SH. Locally advanced rectal cancer: post-chemoradiotherapy ADC histogram analysis for predicting a complete response. Acta Radiol 2015; 56:1042-50. [PMID: 25270374 DOI: 10.1177/0284185114550193] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 08/13/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND The value of diffusion-weighted imaging (DWI) for reliable differentiation between pathologic complete response (pCR) and residual tumor is still unclear. Recently, a few studies reported that histogram analysis can be helpful to monitor the therapeutic response in various cancer research. PURPOSE To investigate whether post-chemoradiotherapy (CRT) apparent diffusion coefficient (ADC) histogram analysis can be helpful to predict a pCR in locally advanced rectal cancer (LARC). MATERIAL AND METHODS Fifty patients who underwent preoperative CRT followed by surgery were enrolled in this retrospective study, non-pCR (n = 41) and pCR (n = 9), respectively. ADC histogram analysis encompassing the whole tumor was performed on two post-CRT ADC600 and ADC1000 (b factors 0, 600 vs. 0, 1000 s/mm(2)) maps. Mean, minimum, maximum, SD, mode, 10th, 25th, 50th, 75th, 90th percentile ADCs, skewness, and kurtosis were derived. Diagnostic performance for predicting pCR was evaluated and compared. RESULTS On both maps, 10th and 25th ADCs showed better diagnostic performance than that using mean ADC. Tenth percentile ADCs revealed the best diagnostic performance on both ADC600 (AZ 0.841, sensitivity 100%, specificity 70.7%) and ADC1000 (AZ 0.821, sensitivity 77.8%, specificity 87.8%) maps. In comparison between 10th percentile and mean ADC, the specificity was significantly improved on both ADC600 (70.7% vs. 53.7%; P = 0.031) and ADC1000 (87.8% vs. 73.2%; P = 0.039) maps. CONCLUSION Post-CRT ADC histogram analysis is helpful for predicting pCR in LARC, especially, in improving the specificity, compared with mean ADC.
Collapse
Affiliation(s)
- Seung Hyun Cho
- Department of Radiology, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Gab Chul Kim
- Department of Radiology, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yun-Jin Jang
- Department of Radiology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hunkyu Ryeom
- Department of Radiology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hye Jung Kim
- Department of Radiology, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Kyung-Min Shin
- Department of Radiology, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jun Seok Park
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Gyu-Seog Choi
- Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - See Hyung Kim
- Department of Radiology, Dongsan Hospital, College of Medicine, Keimyung University, Daegu, Republic of Korea
| |
Collapse
|
29
|
Magnetization transfer imaging to assess tumour response after chemoradiotherapy in rectal cancer. Eur Radiol 2015; 26:390-7. [PMID: 26065396 PMCID: PMC4712249 DOI: 10.1007/s00330-015-3856-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 05/10/2015] [Accepted: 05/20/2015] [Indexed: 01/28/2023]
Abstract
Purpose Single-slice magnetization transfer (MT) imaging has shown promising results for evaluating post-radiation fibrosis. The study aim was to evaluate the value of multislice MT imaging to assess tumour response after chemoradiotherapy by comparing magnetization transfer ratios (MTR) with histopathological tumour regression grade (TRG). Materials and Methods Thirty patients with locally advanced rectal cancer (cT3-4 and/or cN2) underwent routine restaging MRI 8 weeks post-chemoradiotherapy, including multislice MT-sequence, covering the entire tumour bed. Two independent readers delineated regions of interest on MTR maps, covering all potential remaining tumour and fibrotic areas. Mean MTR and histogram parameters (minimum, maximum, median, standard deviation, skewness, kurtosis, and 5-30-70-95th percentiles) were calculated. Reference standard was histological TRG1-2 (good response) and TRG3-5 (poor response). Results 24/30 patients were male; mean age was 67.7 ± 10.8 years. Mean MTR rendered AUCs of 0.65 (reader1) and 0.87 (reader2) to differentiate between TRG1-2 versus TRG3-5. Best results were obtained for 95th percentile (AUC 0.75- 0.88). Interobserver agreement was moderate (ICC 0.50) for mean MTR and good (ICC 0.80) for 95th percentile. Conclusions MT imaging is a promising tool to assess tumour response post-chemoradiotherapy in rectal cancer. Particularly, 95th percentile results in AUCs up to 0.88 to discriminate a good tumour response. Key Points • The mean MTR can differentiate between good and poor responders after chemoradiation. • In addition to measurement of the mean value, histogram analyses can be beneficial. • The histogram parameter 95thpercentile can reach AUCs of 0.75–0.88.
Collapse
|
30
|
Arya S, Das D, Engineer R, Saklani A. Imaging in rectal cancer with emphasis on local staging with MRI. Indian J Radiol Imaging 2015; 25:148-61. [PMID: 25969638 PMCID: PMC4419424 DOI: 10.4103/0971-3026.155865] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Imaging in rectal cancer has a vital role in staging disease, and in selecting and optimizing treatment planning. High-resolution MRI (HR-MRI) is the recommended method of first choice for local staging of rectal cancer for both primary staging and for restaging after preoperative chemoradiation (CT-RT). HR-MRI helps decide between upfront surgery and preoperative CT-RT. It provides high accuracy for prediction of circumferential resection margin at surgery, T category, and nodal status in that order. MRI also helps assess resectability after preoperative CT-RT and decide between sphincter saving or more radical surgery. Accurate technique is crucial for obtaining high-resolution images in the appropriate planes for correct staging. The phased array external coil has replaced the endorectal coil that is no longer recommended. Non-fat suppressed 2D T2-weighted (T2W) sequences in orthogonal planes to the tumor are sufficient for primary staging. Contrast-enhanced MRI is considered inappropriate for both primary staging and restaging. Diffusion-weighted sequence may be of value in restaging. Multidetector CT cannot replace MRI in local staging, but has an important role for evaluating distant metastases. Positron emission tomography-computed tomography (PET/CT) has a limited role in the initial staging of rectal cancer and is reserved for cases with resectable metastatic disease before contemplating surgery. This article briefly reviews the comprehensive role of imaging in rectal cancer, describes the role of MRI in local staging in detail, discusses the optimal MRI technique, and provides a synoptic report for both primary staging and restaging after CT-RT in routine practice.
Collapse
Affiliation(s)
- Supreeta Arya
- Department of Radio-Diagnosis, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Deepak Das
- Department of Radio-Diagnosis, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| |
Collapse
|
31
|
Yang TJ, Goodman KA. Predicting complete response: is there a role for non-operative management of rectal cancer? J Gastrointest Oncol 2015; 6:241-6. [PMID: 25830042 PMCID: PMC4311100 DOI: 10.3978/j.issn.2078-6891.2014.110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 12/13/2014] [Indexed: 12/29/2022] Open
Abstract
Pre-operative chemoradiotherapy followed by a total mesorectal excision (TME) is the standard of care for patients with locally advanced (stage II or III) rectal cancer. Approximately 20% of patients may achieve a pathologic complete response after chemoradiation therapy (CRT), which has been shown to be associated with better oncologic outcomes. Whether surgery can be avoided in this population is an area of active investigation. Recent studies demonstrated feasibility and safety of non-operative management in patients with clinical complete response (cCR) after chemoradiotherapy. In this article, we set out to review the current data on non-operative management and to identify areas requiring further investigation, including improvement in imaging for reassessment after CRT and identifying the optimal time frame for restaging. As the field moves forward with non-operative management in select patients with rectal cancer, there continues to be a need to better understand the prognostic factors and biomarkers that may more accurately characterize patients who are qualified for this "wait-and-see" approach and thereby avoid overtreatment, potentially leading to improvements in long-term quality of life.
Collapse
Affiliation(s)
- T Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| |
Collapse
|
32
|
Fujii S, Nougaret S, Escal L, Azria D, Assenat E, Rouanet P, Reinhold C, Guiu B. MR imaging of locally advanced low rectal cancer: Relationships between imaging findings and the pathological tumor regression grade. J Magn Reson Imaging 2014; 42:421-6. [PMID: 25351373 DOI: 10.1002/jmri.24783] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 09/16/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To evaluate the relationship between MR measurements and the pathological tumor regression grade (pTRG). METHODS Two radiologists independently reviewed the pre- and postchemoradiation therapy (CRT) rectal MR images of 73 consecutive patients with locally advanced low rectal cancer who underwent neoadjuvant CRT and subsequent surgery and measured tumor diameter, area, signal intensity (SI). The percentage reduction rate for each parameter was calculated. The absolute SI ratio reduction rate was defined as the absolute value of the SI ratio reduction rate. The Kruskal-Wallis test and multivariate analysis were performed to assess the correlation between each parameter and the pTRG. Receiver operating characteristic (ROC) curves were plotted for predicting favorable regression outcomes (pTRG 3-4). RESULTS In multivariate analysis, the absolute SI ratio reduction rate was a significant predictor of pTRG for both radiologists. Area under the ROC curve (Az) values were 0.77-0.709 for diameter reduction rate, 0.757-0.694 for area, 0.652-0.648 for the SI ratio, 0.736-0.837 for the absolute SI ratio. CONCLUSION The absolute SI ratio reduction rate was significantly associated with pTRG and predicted favorable responses to CRT. Measurement of the diameter reduction rate is convenient and reliable in predicting favorable responses.
Collapse
Affiliation(s)
- Shinya Fujii
- Division of Radiology, Department of Pathophysiological and Therapeutic Science, Faculty of Medicine, Tottori University, Yonago, Japan.,Department of Abdominal Imaging, MUHC McGill University, Montreal, Canada
| | - Stephanie Nougaret
- Department of Abdominal Imaging, MUHC McGill University, Montreal, Canada.,Department of Imaging, CHU Montpellier, St Eloi Hospital, Montpellier, France
| | - Laure Escal
- Department of Imaging, CHU Montpellier, St Eloi Hospital, Montpellier, France
| | - David Azria
- Department of Radiotherapy, ICM, Montpellier, France
| | | | | | - Caroline Reinhold
- Department of Abdominal Imaging, MUHC McGill University, Montreal, Canada
| | - Boris Guiu
- Department of Imaging, CHU Montpellier, St Eloi Hospital, Montpellier, France
| |
Collapse
|
33
|
Huh JW, Kim HC, Lee SJ, Yun SH, Lee WY, Park YA, Cho YB, Chun HK. Diagnostic accuracy and prognostic impact of restaging by magnetic resonance imaging after preoperative chemoradiotherapy in patients with rectal cancer. Radiother Oncol 2014; 113:24-8. [DOI: 10.1016/j.radonc.2014.08.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 08/06/2014] [Accepted: 08/12/2014] [Indexed: 12/23/2022]
|
34
|
Beets-Tan RGH, Beets GL. MRI for assessing and predicting response to neoadjuvant treatment in rectal cancer. Nat Rev Gastroenterol Hepatol 2014; 11:480-8. [PMID: 24662278 DOI: 10.1038/nrgastro.2014.41] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Guidelines recommend MRI as part of the staging work-up of patients with rectal cancer because it can identify high-risk groups requiring preoperative treatment. Phenomenal tumour responses have been observed with current chemoradiotherapy regimens-even complete regression in 25% of patients. For these patients, the options of organ-saving treatment as an alternative to surgery are now discussed, and critical for this approach is the availability of tools that can accurately measure response. The value of MRI in rectal cancer staging is established, but the role of MRI for the selection of patients for organ-saving treatment is debatable, because MRI is not able to accurately assess tumour response to preoperative chemoradiotherapy (owing to its reliance on morphological changes). Functional MRI is emerging in the field of oncology. It combines information on detailed anatomy with that of tumour biology, providing comprehensive information on tumour heterogeneity and its changes as a result of treatment. This Review provides knowledge on the strengths and weaknesses of MRI for response assessment after chemoradiotherapy in rectal cancer and on its ability to predict tumour response at the time of primary diagnosis. It elaborates on new functional magnetic resonance technology and discusses whether this and new postprocessing approaches have the potential to improve prediction and assessment of response.
Collapse
Affiliation(s)
- Regina G H Beets-Tan
- Department of Radiology, Maastrict University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, Netherlands
| | - Geerard L Beets
- Department of Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, Netherlands
| |
Collapse
|
35
|
McKeown E, Nelson DW, Johnson EK, Maykel JA, Stojadinovic A, Nissan A, Avital I, Brücher BL, Steele SR. Current approaches and challenges for monitoring treatment response in colon and rectal cancer. J Cancer 2014; 5:31-43. [PMID: 24396496 PMCID: PMC3881219 DOI: 10.7150/jca.7987] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 11/25/2013] [Indexed: 12/18/2022] Open
Abstract
Introduction: With the advent of multidisciplinary and multimodality approaches to the management of colorectal cancer patients, there is an increasing need to define how we monitor response to novel therapies in these patients. Several factors ranging from the type of therapy used to the intrinsic biology of the tumor play a role in tumor response. All of these can aid in determining the ideal course of treatment, and may fluctuate over time, pending down-staging or progression of disease. Therefore, monitoring how disease responds to therapy requires standardization in order to ultimately optimize patient outcomes. Unfortunately, how best to do this remains a topic of debate among oncologists, pathologists, and colorectal surgeons. There may not be one single best approach. The goal of the present article is to shed some light on current approaches and challenges to monitoring treatment response for colorectal cancer. Methods: A literature search was conducted utilizing PubMed and the OVID library. Key-word combinations included colorectal cancer metastases, neoadjuvant therapy, rectal cancer, imaging modalities, CEA, down-staging, tumor response, and biomarkers. Directed searches of the embedded references from the primary articles were also performed in selected circumstances. Results: Pathologic examination of the post-treatment surgical specimen is the gold standard for monitoring response to therapy. Endoscopy is useful for evaluating local recurrence, but not in assessing tumor response outside of the limited information gained by direct examination of intra-lumenal lesions. Imaging is used to monitor tumors throughout the body for response, with CT, PET, and MRI employed in different circumstances. Overall, each has been validated in the monitoring of patients with colorectal cancer and residual tumors. Conclusion: Although there is no imaging or serum test to precisely correlate with a tumor's response to chemo- or radiation therapy, these modalities, when used in combination, can aid in allowing clinicians to adjust medical therapy, pursue operative intervention, or (in select cases) identify complete responders. Improvements are needed, however, as advances across multiple modalities could allow appropriate selection of patients for a close surveillance regimen in the absence of operative intervention.
Collapse
Affiliation(s)
| | - Daniel W Nelson
- 2. Department of Surgery, Madigan Army Center, Tacoma, WA, USA
| | - Eric K Johnson
- 2. Department of Surgery, Madigan Army Center, Tacoma, WA, USA
| | - Justin A Maykel
- 3. Division of Colorectal Surgery, UMass Medical Center, Worcester, MA, USA
| | - Alexander Stojadinovic
- 4. Department of Surgery, Division of Surgical Oncology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Aviram Nissan
- 5. Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | | | - Scott R Steele
- 2. Department of Surgery, Madigan Army Center, Tacoma, WA, USA
| |
Collapse
|