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Curcean S, Curcean A, Martin D, Fekete Z, Irimie A, Muntean AS, Caraiani C. The Role of Predictive and Prognostic MRI-Based Biomarkers in the Era of Total Neoadjuvant Treatment in Rectal Cancer. Cancers (Basel) 2024; 16:3111. [PMID: 39272969 PMCID: PMC11394290 DOI: 10.3390/cancers16173111] [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: 08/13/2024] [Revised: 09/02/2024] [Accepted: 09/06/2024] [Indexed: 09/15/2024] Open
Abstract
The role of magnetic resonance imaging (MRI) in rectal cancer management has significantly increased over the last decade, in line with more personalized treatment approaches. Total neoadjuvant treatment (TNT) plays a pivotal role in the shift from traditional surgical approach to non-surgical approaches such as 'watch-and-wait'. MRI plays a central role in this evolving landscape, providing essential morphological and functional data that support clinical decision-making. Key MRI-based biomarkers, including circumferential resection margin (CRM), extramural venous invasion (EMVI), tumour deposits, diffusion-weighted imaging (DWI), and MRI tumour regression grade (mrTRG), have proven valuable for staging, response assessment, and patient prognosis. Functional imaging techniques, such as dynamic contrast-enhanced MRI (DCE-MRI), alongside emerging biomarkers derived from radiomics and artificial intelligence (AI) have the potential to transform rectal cancer management offering data that enhance T and N staging, histopathological characterization, prediction of treatment response, recurrence detection, and identification of genomic features. This review outlines validated morphological and functional MRI-derived biomarkers with both prognostic and predictive significance, while also exploring the potential of radiomics and artificial intelligence in rectal cancer management. Furthermore, we discuss the role of rectal MRI in the 'watch-and-wait' approach, highlighting important practical aspects in selecting patients for non-surgical management.
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Affiliation(s)
- Sebastian Curcean
- Department of Radiation Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- Department of Radiation Oncology, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Andra Curcean
- Department of Imaging, Affidea Center, 15c Ciresilor Street, 400487 Cluj-Napoca, Romania
| | - Daniela Martin
- Department of Radiation Oncology, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Zsolt Fekete
- Department of Radiation Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- Department of Radiation Oncology, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Alexandru Irimie
- Department of Oncological Surgery and Gynecological Oncology, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- Department of Oncological Surgery, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Alina-Simona Muntean
- Department of Radiation Oncology, 'Prof. Dr. Ion Chiricuta' Oncology Institute, 34-36 Republicii Street, 400015 Cluj-Napoca, Romania
| | - Cosmin Caraiani
- Department of Medical Imaging and Nuclear Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Gong ZX, Li GL, Dong WM, Xu Z, Li R, Lv WX, Yang J, Li ZX, Xing W. Waist subcutaneous soft tissue metastasis of rectal mucinous adenocarcinoma: A case report. World J Clin Cases 2024; 12:2412-2419. [PMID: 38765752 PMCID: PMC11099417 DOI: 10.12998/wjcc.v12.i14.2412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/03/2024] [Accepted: 04/01/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Rectal mucinous adenocarcinoma (MAC) is a rare pathological type of rectal cancer with unique pathological features and a poor prognosis. It is difficult to diagnose and treat early because of the lack of specific manifestations in some aspects of the disease. The common metastatic organs of rectal cancer are the liver and lung; however, rectal carcinoma with metastasis to subcutaneous soft tissue is a rare finding. CASE SUMMARY In this report, the clinical data, diagnosis and treatment process, and postoperative pathological features of a patient with left waist subcutaneous soft tissue masses were retrospectively analyzed. The patient underwent surgical treatment after admission and recovered well after surgery. The final pathological diagnosis was rectal MAC with left waist subcutaneous soft tissue metastasis. CONCLUSION Subcutaneous soft tissue metastasis of rectal MAC is rare, and it can suggest that the tumor is disseminated, and it can appear even earlier than the primary malignant tumor, which is occult and leads to a missed diagnosis and misdiagnosis clinically. When a subcutaneous soft tissue mass of unknown origin appears in a patient with rectal cancer, a malignant tumor should be considered.
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Affiliation(s)
- Zi-Xing Gong
- Department of General Surgery, Hebei Provincial Hospital of Chinese Medicine, Shijiazhuang 050011, Hebei Province, China
| | - Guo-Lei Li
- Department of General Surgery, Hebei Provincial Hospital of Chinese Medicine, Shijiazhuang 050011, Hebei Province, China
| | - Wen-Min Dong
- Department of General Surgery, Hebei Provincial Hospital of Chinese Medicine, Shijiazhuang 050011, Hebei Province, China
| | - Zhao Xu
- Department of General Surgery, Hebei Provincial Hospital of Chinese Medicine, Shijiazhuang 050011, Hebei Province, China
| | - Rui Li
- Department of Medical Imaging, Hebei Provincial Hospital of Chinese Medicine, Shijiazhuang 050011, Hebei Province, China
| | - Wen-Xia Lv
- Department of Pathology, Hebei Provincial Hospital of Chinese Medicine, Shijiazhuang 050011, Hebei Province, China
| | - Jing Yang
- Department of Gastroendoscopy, Hebei Provincial Hospital of Chinese Medicine, Shijiazhuang 050011, Hebei Province, China
| | - Zhong-Xin Li
- Gastrointestinal Disease Diagnosis and Treatment Center, The First Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China
| | - Wei Xing
- Department of General Surgery, Hebei Provincial Hospital of Chinese Medicine, Shijiazhuang 050011, Hebei Province, China
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Sheng L, Yuan E, Yuan F, Song B. Amide proton transfer-weighted imaging of the abdomen: Current progress and future directions. Magn Reson Imaging 2024; 107:88-99. [PMID: 38242255 DOI: 10.1016/j.mri.2024.01.006] [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: 10/17/2023] [Revised: 01/13/2024] [Accepted: 01/14/2024] [Indexed: 01/21/2024]
Abstract
The chemical exchange saturation transfer technique serves as a valuable tool for generating in vivo image contrast based on the content of various proton groups, including amide protons, amine protons, and aliphatic protons. Among these, amide proton transfer-weighted (APTw) imaging has seen extensive development as a means to assess the biochemical status of lesions. The exchange from saturated amide protons to bulk water protons during and following the saturation ratio frequency pulse contributes to detectable APT signals. While APTw imaging has garnered significant attention in the central nervous system, demonstrating noteworthy findings in cerebral neoplasia, stroke, and Alzheimer's disease over the past decade, its application in the abdomen has been a relatively recent progression. Notably, studies have explored its utility in hepatocellular carcinoma, prostate cancer, and cervical carcinoma within the abdominal context. Despite these advancements, there is a paucity of reviews on APTw imaging in abdominal applications. This paper aims to fill this gap by providing a concise overview of the fundamental theories underpinning APTw imaging. Additionally, we systematically summarize its diverse clinical applications in the abdomen, with a particular focus on the digestive and urogenital systems. Finally, the manuscript concludes by discussing technical limitations and factors influencing APTw imaging in abdominal applications, along with prospects for future research.
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Affiliation(s)
- Liuji Sheng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Enyu Yuan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fang Yuan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Bin Song
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Department of Radiology, Sanya People's Hospital, Sanya, Hainan, China.
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Liang Y, Liao H, Shi H, Li T, Liu Y, Yuan Y, Li M, Li A, Liu Y, Yao Y, Li T. Risk stratification of stage II rectal mucinous adenocarcinoma to predict the benefit of adjuvant chemotherapy following neoadjuvant chemoradiation and surgery. Front Oncol 2024; 14:1352660. [PMID: 38511138 PMCID: PMC10952835 DOI: 10.3389/fonc.2024.1352660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024] Open
Abstract
Background The treatment strategy for stage II rectal mucinous adenocarcinoma (RMA) recommends neoadjuvant chemoradiotherapy (NCR) followed by total mesorectal excision (TME). However, the necessity of adjuvant chemotherapy (AC) remains controversial. Materials and methods Chi-square test was used to assess the relationship between pathological classification, AC and clinicopathological characteristics. Kaplan-Meier (KM) curves and the log-rank test were utilized to analyze differences in overall survival (OS) and cancer-specific survival (CSS) among different groups. Cox regression identified prognostic factors. Nomogram was established utilizing the independent prognostic factors. X-tile divided patients into three risk subgroups. Results Compared to RMA, rectal adenocarcinoma (RA) demonstrates longer OS and CSS in all and non-AC stage II patients, with no difference in OS and CSS for AC stage II patients. Propensity score matching analyses yielded similar results. Stratified analysis found that AC both improve OS of RA and RMA patients. Age, gender, pathologic T stage, regional nodes examined, and tumor size were identified as independent prognostic factors for RMA patients without AC. A nomogram was constructed to generate risk scores and categorize RMA patients into three subgroups based on these scores. KM curves revealed AC benefits for moderate and high-risk groups but not for the low-risk group. The external validation cohort yielded similar results. Conclusions In summary, our study suggests that, compared to stage II RA patients, stage II RMA patients benefit more from AC after NCR. AC is recommended for moderate and high-risk stage II RMA patients after NCR, whereas low-risk patients do not require AC.
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Affiliation(s)
- Yahang Liang
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
| | - Hualin Liao
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
| | - Haoran Shi
- Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
| | - Tao Li
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
| | - Yaxiong Liu
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
| | - Yuli Yuan
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
| | - Mingming Li
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
| | - Aidi Li
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
| | - Yang Liu
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
| | - Yao Yao
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
| | - Taiyuan Li
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, China
- Gastrointestinal Surgical Institute, Nanchang University, Nanchang Jiangxi, China
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Monno M, Ogiri M, Seishima R, Suzuki Y, Hattori K, Matsui S, Shigeta K, Okabayashi K, Kitagawa Y. POFUT1 and PLAGL2 are characteristic markers of mucinous colorectal cancer associated with MUC2 expression. Cell Biochem Funct 2024; 42:e3989. [PMID: 38500386 DOI: 10.1002/cbf.3989] [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: 08/24/2023] [Revised: 02/17/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024]
Abstract
Colorectal mucinous adenocarcinoma (MAC) is one of the most lethal histological types of colorectal cancer, and its mechanism of development is not well understood. In this study, we aimed to clarify the molecular characteristics of MAC via in silico analysis using The Cancer Genome Atlas database. The expression of genes on chromosome 20q (Chr20q) was negatively associated with the expression of MUC2, which is a key molecule that can be used to distinguish between MAC and nonmucinous adenocarcinoma (NMAC). This was consistent with a significant difference in copy number alteration of Chr20q between the two histological types. We further identified 475 differentially expressed genes (DEGs) between MAC and NMAC, and some of the Chr20q genes among the DEGs are considered to be pivotal genes used to define MAC. Both in vitro and in vivo analysis showed that simultaneous knockdown of POFUT1 and PLAGL2, both of which are located on Chr20q, promoted MUC2 expression. Moreover, these genes were highly expressed in NMAC but not in MAC according to the results of immunohistological studies using human samples. In conclusion, POFUT1 and PLAGL2 are considered to be important for defining MAC, and these genes are associated with MUC2 expression.
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Affiliation(s)
- Masayoshi Monno
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masayo Ogiri
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Seishima
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Suzuki
- Department of Surgery, Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Kaoru Hattori
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shimpei Matsui
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kohei Shigeta
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Koji Okabayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Quantitative synthetic MRI for predicting locally advanced rectal cancer response to neoadjuvant chemoradiotherapy. Eur Radiol 2023; 33:1737-1745. [PMID: 36380196 DOI: 10.1007/s00330-022-09191-7] [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: 05/24/2022] [Revised: 08/08/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate the value of pre-treatment quantitative synthetic MRI (SyMRI) for predicting a good response to neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer. METHODS This prospective study enrolled 63 patients with locally advanced rectal cancer scheduled to undergo preoperative chemoradiotherapy from January 2019 to June 2021. T1 relaxation time (T1), T2 relaxation time (T2), proton density (PD) from synthetic MRI, and apparent diffusion coefficient (ADC) from diffusion-weighted imaging (DWI) were measured. Independent-sample t-test, the Mann-Whitney U test, the Delong test, and receiver operating characteristic curve (ROC) analyses were used to predict the pathologic complete response (pCR) and T-downstaging. RESULTS Among the 63 patients, 19 (30%) achieved pCR and 44 (70%) did not, and 24 (38%) achieved T-downstaging, while 44 (62%) did not. The mean T1 and T2 values were significantly lower in the pCR group compared with those in the non-pCR group and in the T-downstage group compared with those in the non-T-downstage group (all p < 0.05). There were no significant differences in the PD and ADC values between the two groups. There were no significant differences between the mean values of T1 and T2 for predicting pCR after CRT (AUC, 0.767 vs. 0.831, p = 0.37). There were no significant differences between the AUC values of T1 and T2 values for the assessment of post-CRT T-downstaging (AUC, 0.746 vs. 0.820, p = 0.506). CONCLUSIONS In patients with locally advanced rectal cancer, the synthetic MRI-derived T1 relaxation time and T2 relaxation time values are promising imaging markers for predicting a good response to neoadjuvant chemoradiotherapy. KEY POINTS • Mean T1 and T2 values were significantly lower in the pathologic complete response group and the T-downstage group. • There were no significant differences in the proton density and apparent diffusion coefficient values between the two groups.
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Huang A, Yang Y, Shi JY, Li YK, Xu JX, Cheng Y, Gu J. Mucinous adenocarcinoma: A unique clinicopathological subtype in colorectal cancer. World J Gastrointest Surg 2021; 13:1567-1583. [PMID: 35070064 PMCID: PMC8727185 DOI: 10.4240/wjgs.v13.i12.1567] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/02/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
Mucinous adenocarcinoma (MAC) is a unique clinicopathological subtype of colorectal cancer, which is characterized by extracellular mucinous components that comprise at least 50% of the tumor tissue. The clinical characteristics, molecular features, response to chemo-/radiotherapy, and prognosis of MAC are different from that of non-MAC (NMAC). MAC is more common in the proximal colon, with larger volume, higher T-stage, a higher proportion of positive lymph nodes, poorer tumor differentiation, and a higher proportion of peritoneal implants compared to NMAC. Although biopsy is the main diagnostic method for MAC, magnetic resonance imaging is superior in accuracy, especially for rectal carcinoma. The aberrant expression of mucins, including MUC1, MUC2 and MUC5AC, is a notable feature of MAC, which may be related to tumor invasion, metastasis, inhibition of apoptosis, and chemo-/radiotherapy resistance. The genetic origin of MAC is mainly related to BRAF mutation, microsatellite instability, and the CpG island methylator phenotype pathway. In addition, the poor prognosis of rectal MAC has been confirmed by various studies, and that of colonic MAC is still controversial. In this review, we summarize the epidemiology, clinicopathological characteristics, molecular features, methods of diagnosis, and treatments of MAC in order to provide references for further fundamental and clinical research.
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Affiliation(s)
- An Huang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yong Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jing-Yi Shi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yu-Kun Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jing-Xuan Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yu Cheng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jin Gu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Surgery III, Peking University Cancer Hospital & Institute, Beijing 100142, China
- Peking-Tsinghua Center for Life Science, Peking University International Cancer Center, Beijing 100142, China
- Department of Gastrointestinal Surgery, Peking University Shougang Hospital, Beijing 100144, China
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8
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Unusual Presentation of Carcinoma Rectum—a Case Report. Indian J Surg Oncol 2021; 12:319-321. [DOI: 10.1007/s13193-021-01336-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 04/21/2021] [Indexed: 10/21/2022] Open
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Mucinous Adenocarcinoma Predicts Poor Response and Prognosis in Patients With Locally Advanced Rectal Cancer: A Pooled Analysis of Individual Participant Data From 3 Prospective Studies. Clin Colorectal Cancer 2021; 20:e240-e248. [PMID: 34334298 DOI: 10.1016/j.clcc.2021.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/20/2021] [Accepted: 06/23/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate the predictive implications and prognosis of mucinous adenocarcinoma (MAC) in locally advanced rectal cancer (LARC) with intensified neoadjuvant treatment. METHODS Individual patient data of LARC patients from 3 prospective clinical trials was analyzed. Neoadjuvant treatment regimens comprised chemoradiotherapy (CRT) with fluorouracil (5-FU) or mFOLFOX6, neoadjuvant chemotherapy alone with mFOLFOX6 or mFOLFOXIRI. The postoperative pathological result, local recurrence and disease-free survival (DFS) were retrospectively analyzed in patients with MAC and adenocarcinoma (AC) with neoadjuvant treatment. RESULTS Totally, 743 patients were recruited, with 620 patients eligible for analysis. Fifty-three (8.5%) patients were MAC. The pathological complete response (pCR) rate and tumor downstaging rate (ypStage 0-I) between MAC and AC patients was 7.5% vs. 22.0% (P = .01) and 20.8% vs. 48.7% (P < .001), respectively. Among patients receiving preoperative CRT with 5FU or mFOLFOX6, the pCR rate and tumor downstaging rate between MAC and AC patients was 11.1% vs. 27.3% (P = .03) and 23.7% vs. 52.6% (P = .001), respectively. Regarding neoadjuvant chemotherapy alone with mFOLFOX6 or mFOLFOXIRI, the pCR rate and tumor downstaging rate was 0 vs.13.2% (P = .11) and 11.8% vs. 42.5% (P = .03) between MAC and AC group, respectively. With the median follow-up time of 38.9 months, the 3-year DFS and 3-year locoregional recurrence rate was 58.4% vs. 77.6% (P = .02) and 26.0% vs. 5.7% (P = .001) in the MAC and AC group, respectively. MAC (hazard ratio [HR] 1.85, 95% confidence interval [CI], 1.15-2.98), PNI (HR 3.23, 95% CI, 1.85-5.72) and LVI (HR 2.04, 95% CI, 1.02-4.08) were independent prognosis factors and were associated with worse DFS. CONCLUSIONS Patients with MAC of the rectum are associated with a lower pCR rate and tumor downstaging rate, higher incidence of local recurrence, and poorer DFS with neoadjuvant treatment.
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PET/MRI Characterization of Mucinous Versus Nonmucinous Components of Rectal Adenocarcinoma: A Comparison of Tumor Metabolism and Cellularity. AJR Am J Roentgenol 2020; 216:376-383. [PMID: 33295813 DOI: 10.2214/ajr.19.22627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this study was to evaluate whether FDG PET/MRI can be used to differentiate the mucinous from the nonmucinous components of primary rectal tumors and to compare the glycolytic metabolism on PET with tumor cellularity on DWI in both components. SUBJECTS AND METHODS. Ninety-nine patients who underwent FDG PET/MRI for staging of primary rectal cancer were included in this prospective analysis. MRI depicted the mucin component through the tumor volume. Separate volumes of interest were drawn on both mucinous and nonmucinous components and propagated to PET and apparent diffusion coefficient (ADC) mapping. Maximum and mean standardized uptake values (SUVmax, SUVmean) and maximum, mean, and minimum ADC values (ADCmax, ADCmean, ADCmin) were recorded and compared between areas with mucinous and nonmucinous components. Whole-body PET/MRI was also used to evaluate for the presence of distant metastases. Nonparametric testing was used to compare the two groups of patients: those with tumors with a mucinous component and those with tumors without a mucinous component. Logistic regression analysis was performed to calculate the association risk between mucinous component and metastatic disease. RESULTS. Seventeen patients (17.2%) had a mucinous component within the tumor on T2-weighted MRI. Most of these patients had advanced disease, the mucinous component tumors being in significantly higher T categories than the tumors without a mucinous component (88.2% vs 61.0%; p = 0.032). SUVmax (7.4 vs 16.7; p = 0.002) and SUVmean (5.4 vs 13.4; p = 0.001) were significantly lower in tumors with a mucinous component than in those without a mucinous component. Tumor ADC measurements were not different between tumors with and those without a mucinous component (ADCmean, 1.4 vs 1.6; p = 0.361). There was no association between presence of a mucinous component within the primary rectal tumor and presence of synchronous metastases (odds ratio, 1.1 [0.4-3.0]; p = 0.904). Moreover, the occurrence of metastases in patients with mucinous component tumors (7/17 [41.2%]) was not different from that in patients with tumors without a mucinous component (28/82 [34.1%]) (p = 0.887). CONCLUSION. PET/MRI can be used to differentiate the mucinous and nonmucinous components within primary rectal adenocarcinoma on the basis of metabolic status. The FDG uptake is significantly lower in the mucinous component, but tumor cellularity based on MRI and DWI findings is not. Despite being associated with a higher T category in the sample of patients in this study, the presence of a mucinous component seems not to be associated with increased risk of synchronous metastases.
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11
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Childs DD, Rocha Lima CMSP, Zhou Y. Mucin-Containing Rectal Cancer: A Review of Unique Imaging, Pathology, and Therapeutic Response Features. Semin Roentgenol 2020; 56:186-200. [PMID: 33858645 DOI: 10.1053/j.ro.2020.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David D Childs
- Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC.
| | | | - Yi Zhou
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC
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12
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Gollub MJ, Lall C, Lalwani N, Rosenthal MH. Current controversy, confusion, and imprecision in the use and interpretation of rectal MRI. Abdom Radiol (NY) 2019; 44:3549-3558. [PMID: 31062058 DOI: 10.1007/s00261-019-01996-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There has been a rapid increase in the utilization of MRI in rectal cancer staging in the USA essentially replacing endorectal ultrasound and mimicking the trend in Europe seen in the 1990s and 2000s. Accompanying this trend, there is a demand, and recognized need, for greater precision and clarification of confusing, misunderstood and poorly understood concepts, facts, statements and nomenclature regarding rectal cancer and the use of pelvic MRI for diagnosis. As such, this Review, part evidence-based and part expert opinion, will attempt to elucidate and clarify several concepts the authors have encountered in 25 years of imaging rectal cancer, focusing on MRI.
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Affiliation(s)
- Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Chandana Lall
- Division of Abdominal and Body Imaging, Department of Radiology, University of Florida, Jacksonville, 32209, FL, USA
| | - Neeraj Lalwani
- Department of Radiology, Section of Abdominal Imaging, Wake Forest University and Baptist Medical Center, Winston Salem, 27103, NC, USA
| | - Michael H Rosenthal
- Harvard Medical School, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, 02215, MA, USA
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13
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Raposo Rodríguez L, Fernández García N, Tovar Salazar D, Gómez Illán R, Díaz Sánchez T. Imaging findings for mucinous tumors tumortumorof the abdomen and pelvis. RADIOLOGIA 2019. [DOI: 10.1016/j.rxeng.2019.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Díaz-Vico T, Fernández-Martínez D, García-Gutiérrez C, Suárez-Sánchez A, Cifrián-Canales I, Mendoza-Pacas GE, Sánchez-Farpón H, Truán-Alonso N. Mucinous adenocarcinoma arising from chronic perianal fistula-a multidisciplinary approach. J Gastrointest Oncol 2019; 10:589-596. [PMID: 31183213 DOI: 10.21037/jgo.2019.01.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Mucinous adenocarcinoma (MA) is a rare entity. Indeed, the pathogenesis of fistula-associated perianal MA is still controversial. Due to the lack of informed evidence regarding this malignancy, no guidelines have been established concerning diagnostic and treatment strategies. The aim of this article is to report our experience and outcomes after three cases of large perianal MA treated in our center. From our retrospective chart review, we identified three male patients with chronic perianal fistula-in-ano who progressively developed perianal MA, confirmed by pelvic magnetic resonance (MRI) and histopathological examination performed on biopsy. We hereby, in accordance with the Surgical CAse REport (SCARE) guidelines, describe the management and further follow-up of each patient. The three patients underwent preoperative chemoradiation therapy, followed by ischioanal abdominoperineal resection (APR). Perineal reconstruction was needed in every case, using a vertical rectus abdominis myocutaneous (VRAM) flap and, punctually, a left fasciocutaneous flap was used too. Also, two of three patients completed the treatment with adjuvant chemotherapy. Neither recurrences nor distant metastases have been observed during the follow-up in both cases that finished the multimodal treatment. MA arising from chronic perianal fistula has an indolent growth with locoregional aggressiveness and a high risk of local recurrence. Therefore, although an ischioanal APR remains the surgical treatment of choice, an aggressive multimodal approach combining preoperative chemoradiation and adjuvant chemotherapy may achieve favorable effectiveness and promising response rates.
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Affiliation(s)
- Tamara Díaz-Vico
- Department of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, Spain
| | - Daniel Fernández-Martínez
- Department of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, Spain
| | - Carmen García-Gutiérrez
- Department of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, Spain
| | - Aida Suárez-Sánchez
- Department of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, Spain
| | - Isabel Cifrián-Canales
- Department of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, Spain
| | | | - Herminio Sánchez-Farpón
- Department of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, Spain
| | - Nuria Truán-Alonso
- Department of General Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Asturias, Spain
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15
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Imaging findings for mucinous tumors of the abdomen and pelvis. RADIOLOGIA 2019; 61:370-387. [PMID: 31078302 DOI: 10.1016/j.rx.2019.03.003] [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: 10/13/2018] [Revised: 02/25/2019] [Accepted: 03/15/2019] [Indexed: 11/23/2022]
Abstract
This article aims to describe the imaging findings for mucinous tumors of the abdomen and pelvis, which have a similar appearance on imaging tests regardless of the organ in which they develop. Due to the high water content of mucus, the appearance of these tumors is generally similar to that of water on ultrasonography, computed tomography, and magnetic resonance imaging. Another common feature of mucin-producing tumors is that calcifications are often present. The rupture of these lesions and accumulation of mucinous material in the peritoneal cavity gives rise to pseudomyxoma peritonei. It is important to identify mucinous tumors because they have a different prognosis and clinical course than non-mucinous tumors and require different management. Depending on their anatomic location and their imaging characteristics, the treatment approach varies from follow-up to radical surgery together with chemotherapy or radiotherapy or both.
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16
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Luo C, Cen S, Ding G, Wu W. Mucinous colorectal adenocarcinoma: clinical pathology and treatment options. Cancer Commun (Lond) 2019; 39:13. [PMID: 30922401 PMCID: PMC6440160 DOI: 10.1186/s40880-019-0361-0] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 03/21/2019] [Indexed: 02/07/2023] Open
Abstract
Mucinous colorectal adenocarcinoma is a distinct subtype of colorectal cancer (CRC) characterized by the presence of abundant extracellular mucin which accounts for at least 50% of the tumor volume. Mucinous colorectal adenocarcinoma is found in 10%–20% of CRC patients and occurs more commonly in female and younger patients. Moreover, mucinous colorectal adenocarcinoma is more frequently located in the proximal colon and diagnosed at an advanced stage. Based on its molecular context, mucinous colorectal adenocarcinoma is associated with the overexpression of mucin 2 (MUC2) and mucin 5AC (MUC5AC) proteins. At the same time, it shows higher mutation rates in the fundamental genes of the RAS/MAPK and PI3K/Akt/mTOR pathways. Mucinous colorectal adenocarcinoma also shows higher rates of microsatellite instability (MSI) than non-mucinous colorectal adenocarcinoma which might correlate it with Lynch syndrome and the CpG island methylator phenotype. The prognosis of mucinous colorectal adenocarcinoma as to non-mucinous colorectal adenocarcinoma is debatable. Further, the impaired responses of mucinous colorectal adenocarcinoma to palliative or adjuvant chemotherapy warrant more studies to be performed for a specialized treatment for these patients. In this review, we discuss the molecular background and histopathology of mucinous colorectal adenocarcinoma, and provide an update on its prognosis and therapeutics from recent literatures.
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Affiliation(s)
- Cong Luo
- Department of Abdominal Oncology, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, P. R. China.
| | - Shuyi Cen
- School of Medicine, Zhejiang University, Hangzhou, 310058, Zhejiang, P. R. China
| | - Guojun Ding
- Department of Radiotherapy, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, P. R. China
| | - Wei Wu
- Department of Pathology, Zhejiang Cancer Hospital, Hangzhou, 310022, Zhejiang, P. R. China
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17
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Lambregts DMJ, Boellaard TN, Beets-Tan RGH. Response evaluation after neoadjuvant treatment for rectal cancer using modern MR imaging: a pictorial review. Insights Imaging 2019; 10:15. [PMID: 30758688 PMCID: PMC6375095 DOI: 10.1186/s13244-019-0706-x] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/24/2018] [Indexed: 01/02/2023] Open
Abstract
In recent years, neoadjuvant chemoradiotherapy (CRT) has become the standard of care for patients with locally advanced rectal cancer. Until recently, patients routinely proceeded to surgical resection after CRT, regardless of the response. Nowadays, treatment is tailored depending on the response to chemoradiotherapy. In patients that respond very well to CRT, organ-preserving treatments such as watch-and-wait are increasingly considered as an alternative to surgery. To facilitate such personalized treatment planning, there is now an increased demand for more detailed radiological response evaluation after chemoradiation. MRI is one of the main tools used to assess response, but has difficulties in assessing response within areas of post-radiation fibrosis. Hence, MR sequences such as diffusion-weighted imaging are increasingly adopted in clinical MR protocols to improve the differentiation between tumor and fibrosis. In this pictorial review, we discuss the strengths and weaknesses of modern MR imaging, including functional imaging sequences such as diffusion-weighted MRI, for response evaluation after chemoradiation treatment and provide the main pearls and pitfalls for image interpretation.
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Affiliation(s)
- Doenja M J Lambregts
- Department of Radiology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Thierry N Boellaard
- Department of Radiology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology, Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, The Netherlands.,GROW School for Oncology and Developmental Biology - Maastricht University, Maastricht, The Netherlands
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Wen Z, Chen Y, Yang X, Lu B, Liu Y, Shen B, Yu S. Application of magnetic resonance diffusion kurtosis imaging for distinguishing histopathologic subtypes and grades of rectal carcinoma. Cancer Imaging 2019; 19:8. [PMID: 30744694 PMCID: PMC6371623 DOI: 10.1186/s40644-019-0192-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 01/28/2019] [Indexed: 01/19/2023] Open
Abstract
Background To evaluate the diagnostic performance of diffusion kurtosis imaging (DKI) for distinguishing different histopathological subtypes and grades of rectal carcinoma and to compare DKI with conventional diffusion-weighted imaging (DWI). Methods This prospective study involved 132 patients with rectal carcinoma, comprising 116 with adenocarcinoma not otherwise specified (AC) and 16 with mucinous carcinoma (MC). High spatial resolution magnetic resonance (MR) and DKI sequences (b values of 0, 600, 1000, 1500 and 2000 s/mm2) were performed for pretreatment evaluation. The mean kurtosis (MK) and mean diffusivity (MD) from DKI and the apparent diffusion coefficient (ADC) from DWI were measured by two experienced radiologists. The Mann-Whitney U test was used to evaluate different histopathological subtypes and grades. Receiver operating characteristic (ROC) curve analyses were performed to compare the diagnostic ability of different quantitative parameters. Results The MD and ADC values were significantly higher for MC than for AC (1.94 ± 0.51 vs. 1.33 ± 0.02 and 1.26 ± 0.64 vs. 0.92 ± 0.01, respectively; P < 0.001). The MK values were significantly lower for MC than for AC (0.66 ± 0.02 vs. 0.93 ± 0.09, P < 0.001). The MK and MD values demonstrated higher sensitivity (94%, both) and specificity (96, 93%, respectively) than the ADC values. However, all the parameters derived from both DKI and DWI showed no significant differences between different histological grades. Conclusions DKI is a more valuable imaging biomarker than conventional DWI for differentiating MC from AC. However, it is still debatable whether DKI is useful for distinguishing different histological grades.
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Affiliation(s)
- Ziqiang Wen
- Department of Radiology, Sun Yat-sen University First Affiliated Hospital, No. 58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Yan Chen
- Department of Radiology, Sun Yat-sen University First Affiliated Hospital, No. 58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Xinyue Yang
- Department of Radiology, Southern Medical University Zhujiang Hospital, Guangzhou, 510282, China
| | - Baolan Lu
- Department of Radiology, Sun Yat-sen University First Affiliated Hospital, No. 58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Yiyan Liu
- Department of Radiology, Sun Yat-sen University First Affiliated Hospital, No. 58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Bingqi Shen
- Department of Radiology, Sun Yat-sen University First Affiliated Hospital, No. 58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China
| | - Shenping Yu
- Department of Radiology, Sun Yat-sen University First Affiliated Hospital, No. 58, Zhongshan Second Road, Yuexiu District, Guangzhou, 510080, China.
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Nishie A, Asayama Y, Ishigami K, Ushijima Y, Takayama Y, Okamoto D, Fujita N, Tsurumaru D, Togao O, Sagiyama K, Manabe T, Oki E, Kubo Y, Hida T, Hirahashi-Fujiwara M, Keupp J, Honda H. Amide proton transfer imaging to predict tumor response to neoadjuvant chemotherapy in locally advanced rectal cancer. J Gastroenterol Hepatol 2019; 34:140-146. [PMID: 29900583 DOI: 10.1111/jgh.14315] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/28/2018] [Accepted: 06/02/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The amount of proteins and peptides can be estimated with amide proton transfer (APT) imaging. Previous studies demonstrated the usefulness of APT imaging to predict tumor malignancy. We determined whether APT imaging can predict the tumor response to neoadjuvant chemotherapy (NAC) in patients with locally advanced rectal cancer (LARC). METHODS Seventeen patients with LARC who underwent a pretherapeutic magnetic resonance examination including APT imaging and NAC (at least two courses) were enrolled. The APT-weighted imaging (WI) signal intensity (SI) (%) was defined as magnetization transfer ratio asymmetry (MTRasym ) at the offset of 3.5 ppm. Each tumor was histologically evaluated for the degree of degeneration and necrosis and then classified as one of five histological Grades (0, none; 1a, less than 1/3; 1b, 1/3 to 2/3; 2, more than 2/3; 3, all). We compared the mean APTWI SIs of the tumors between the Grade 0/1a/1b (low-response group) and Grade 2/3 (high-response group) by Student's t-test. We used receiver operating characteristics curves to determine the diagnostic performance of the APTWI SI for predicting the tumor response. RESULTS The mean APTWI SI of the low-response group (n = 12; 3.05 ± 1.61%) was significantly higher than that of the high-response group (n = 5; 1.14 ± 1.13%) (P = 0.029). The area under the curve for predicting the tumor response using the APTWI SI was 0.87. When ≥2.75% was used as an indicator of low-response status, 75% sensitivity and 100% specificity of the APTWI SI were obtained. CONCLUSION Pretherapeutic APT imaging can predict the tumor response to NAC in patients with LARC.
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Affiliation(s)
- Akihiro Nishie
- Department of Clinical Radiology, Kyushu University, Fukuoka, Japan
| | - Yoshiki Asayama
- Department of Clinical Radiology, Kyushu University, Fukuoka, Japan
| | - Kousei Ishigami
- Department of Clinical Radiology, Kyushu University, Fukuoka, Japan
| | | | - Yukihisa Takayama
- Department of Radiology Informatics and Network, Kyushu University, Fukuoka, Japan
| | - Daisuke Okamoto
- Department of Clinical Radiology, Kyushu University, Fukuoka, Japan
| | - Nobuhiro Fujita
- Department of Clinical Radiology, Kyushu University, Fukuoka, Japan
| | | | - Osamu Togao
- Department of Clinical Radiology, Kyushu University, Fukuoka, Japan
| | - Koji Sagiyama
- Department of Clinical Radiology, Kyushu University, Fukuoka, Japan
| | - Tatsuya Manabe
- Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan
| | - Eiji Oki
- Department of Surgery and Science, Kyushu University, Fukuoka, Japan
| | - Yuichiro Kubo
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoyuki Hida
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Minako Hirahashi-Fujiwara
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Hiroshi Honda
- Department of Clinical Radiology, Kyushu University, Fukuoka, Japan
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20
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Khan M, Loree JM, Advani SM, Ning J, Li W, Pereira AAL, Lam M, Raghav K, Morris VK, Broaddus R, Maru D, Overman MJ, Kopetz S. Prognostic Implications of Mucinous Differentiation in Metastatic Colorectal Carcinoma Can Be Explained by Distinct Molecular and Clinicopathologic Characteristics. Clin Colorectal Cancer 2018; 17:e699-e709. [PMID: 30205948 PMCID: PMC6588353 DOI: 10.1016/j.clcc.2018.07.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/09/2018] [Accepted: 07/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The mucinous histologic subtype accounts for 5% to 20% of colorectal cancer (CRC) cases but remains poorly characterized. The present study characterized the baseline characteristics, mutational profile, and clinical outcomes of patients diagnosed with mucinous CRC. MATERIALS AND METHODS We identified 1877 patients with metastatic CRC with available histologic findings and molecular profiling and summarized the baseline clinical and pathologic characteristics and overall survival (OS) stratified by the histologic type. The data from separate cohorts with consensus molecular subtype (CMS) and CpG island methylator information were also summarized. RESULTS The mucinous histologic type was found in 277 of the 1877 patients (14.8%) and was associated with an increased prevalence of microsatellite instability (P < .001) and a right-sided primary (P < .001). An increased frequency of CMS1 (microsatellite instability immune) and lower rates of CMS2 (canonical) were identified, with mucinous compared with nonmucinous adenocarcinoma (P < .0001). Mutations in SMAD4 (P < .001), GNAS (P < .001), ERBB2 (P = .02), BRAF (P < .001), and KRAS (P < .001) occurred at greater frequencies in the mucinous CRC cases, and TP53 (P < .001), APC (P < .001), and NRAS mutations (P = .03) were less common. Univariate (hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.17-1.63; P < .001) and multivariate analysis (HR, 1.36; 95% CI, 1.12-1.64; P = .002) demonstrated that the mucinous histologic type is associated with worse OS. The features associated with the mucinous histologic subtype were independent predictors for shorter OS, including BRAF (HR, 1.74; 95% CI, 1.35-2.25; P < .001) and KRAS (HR, 1.42; 95% CI, 1.22-1.65; P < .001) mutations, right-sided location (HR, 1.20; 95% CI, 1.04-1.39; P = .01), and synchronous metastases (HR, 2.92; 95% CI, 2.49-3.42; P < .001). CONCLUSION Compared with nonmucinous adenocarcinoma, the mucinous histologic type is associated with a worse prognosis, even when controlling for known prognostic features. This unique biologic behavior should be considered in the treatment and prognostic assessment of patients with CRC.
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Affiliation(s)
- Maliha Khan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jonathan M Loree
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shailesh M Advani
- Department of Oncology, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wen Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Allan A L Pereira
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Lam
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kanwal Raghav
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Van K Morris
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Russell Broaddus
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dipen Maru
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Use of magnetic resonance imaging in rectal cancer patients: Society of Abdominal Radiology (SAR) rectal cancer disease-focused panel (DFP) recommendations 2017. Abdom Radiol (NY) 2018; 43:2893-2902. [PMID: 29785540 DOI: 10.1007/s00261-018-1642-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To propose guidelines based on an expert-panel-derived unified approach to the technical performance, interpretation, and reporting of MRI for baseline and post-treatment staging of rectal carcinoma. METHODS A consensus-based questionnaire adopted with permission and modified from the European Society of Gastrointestinal and Abdominal Radiologists was sent to a 17-member expert panel from the Rectal Cancer Disease-Focused Panel of the Society of Abdominal Radiology containing 268 question parts. Consensus on an answer was defined as ≥ 70% agreement. Answers not reaching consensus (< 70%) were noted. RESULTS Consensus was reached for 87% of items from which recommendations regarding patient preparation, technical performance, pulse sequence acquisition, and criteria for MRI assessment at initial staging and restaging exams and for MRI reporting were constructed. CONCLUSION These expert consensus recommendations can be used as guidelines for primary and post-treatment staging of rectal cancer using MRI.
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Stijns RCH, Tromp MSR, Hugen N, de Wilt JHW. Advances in organ preserving strategies in rectal cancer patients. Eur J Surg Oncol 2017; 44:209-219. [PMID: 29275912 DOI: 10.1016/j.ejso.2017.11.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/23/2017] [Accepted: 11/19/2017] [Indexed: 02/06/2023] Open
Abstract
Treatment of rectal cancer patients has been subjected to change over the past thirty years. Total mesorectal excision is considered the cornerstone of rectal cancer treatment, but is also associated with significant morbidity resulting in an impaired quality of life. The addition of neoadjuvant chemoradiotherapy to surgery has shown to improve survival and local control and may lead to a partial or even complete response (CR). This raises questions regarding the necessity for subsequent radical surgery. After careful patient selection local excision and wait-and-see approaches are explored, aiming to improve quality of life without compromising oncological outcome. A multimodality diagnostic approach for optimal staging is crucial in determining the appropriate neoadjuvant treatment regimen. Adequate endoscopic restaging of rectal tumours after multimodality treatment will aid in selecting patients who are eligible for an organ preserving approach. The role and accuracy of imaging in the detection of the primary tumour, residual rectal cancer or local recurrence seems vital. Alternative neoadjuvant regimens are currently explored to increase the rate of clinical CRs, which may support organ preserving approaches. This review aims to generate insight into the advances in diagnostics and treatment modalities in all stages of rectal cancer and will highlight future studies that may support further implementation of organ preservation treatment in rectal cancer.
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Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Mike-Stephen R Tromp
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Niek Hugen
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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ÇOLAKOĞLU ER H, ERDEN A. Mean ADC values discriminate rectal mucinous carcinomafrom rectal nonmucinous adenocarcinoma. Turk J Med Sci 2017; 47:1520-1525. [DOI: 10.3906/sag-1609-59] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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24
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Barbaro B, Leccisotti L, Vecchio FM, Di Matteo M, Serra T, Salsano M, Poscia A, Coco C, Persiani R, Alfieri S, Gambacorta MA, Valentini V, Giordano A, Bonomo L. The potential predictive value of MRI and PET-CT in mucinous and nonmucinous rectal cancer to identify patients at high risk of metastatic disease. Br J Radiol 2016; 90:20150836. [PMID: 27845566 DOI: 10.1259/bjr.20150836] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To correlate imaging parameters from baseline MRI diffusion-weighted imaging (DWI) and fludeoxyglucose (FDG) positron emission tomography (PET)-CT with synchronous and metachronous metastases in mucinous carcinoma (MC) and non-mucinous carcinoma (NMC) rectal cancer. METHODS 111 patients with extraperitoneal locally advanced rectal cancer, who underwent pelvic MRI, DWI and FDG PET-CT, were stratified into MC (n = 23) and NMC (n = 88). We correlated adverse morphologic features on MRI [mT4, mesorectal fascia involvement, extramural venous invasion (mEMVI), mN2] and quantitative imaging parameters [minimum apparent diffusion coefficient (ADCmin), maximum standardized uptake value, total lesion glycolysis, metabolic tumour volume, T2 weighted and DWI tumour volumes] with the presence of metastatic disease. All patients underwent pre-operative chemoradiation therapy (CRT); 100/111 patients underwent surgery after CRT and were classified as pathological complete response (PCR) and no PCR [tumour regression grade (TRG)1 vs TRG2-5] and as ypN0 and ypN1-2. Median follow-up time was 48 months. Metastases were confirmed on FDG PET-CT and contrast-enhanced multidetector CT. RESULTS The percentage of mucin measured by MRI correlates with that quantified by histology. On multivariate analysis, the synchronous metastases were correlated with mEMVI [odds ratio (OR) = 21.48, p < 0.01] and low ADCmin (OR = 0.04, p = 0.038) in NMC. The difference of metachronous recurrence between the MC group (10-90% mucin) and NMC group was significant (p < 0.01) (OR = 21.67, 95% confidence interval 3.8-120.5). Metachronous metastases were correlated with ypN2 (OR = 8.24, p = 0.01) in MC and in NMC. In NMC, mEMVI correlated with no PCR (p = 0.018) and ypN2 (p < 0.01). CONCLUSION mEMVI could identify patients with NMC, who are at high risk of synchronous metastases. The MC group is at a high risk of developing metachronous metastases. Advances in knowledge: Patients at high risk of metastases are more likely to benefit from more aggressive neoadjuvant therapy.
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Affiliation(s)
- Brunella Barbaro
- 1 Department of Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Lucia Leccisotti
- 1 Department of Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Fabio M Vecchio
- 2 Department of Pathology, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Marialuisa Di Matteo
- 1 Department of Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Teresa Serra
- 1 Department of Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Marco Salsano
- 1 Department of Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Andrea Poscia
- 4 Department of Hygiene, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Claudio Coco
- 3 Department of Surgery, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Roberto Persiani
- 3 Department of Surgery, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Sergio Alfieri
- 3 Department of Surgery, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Maria Antonietta Gambacorta
- 1 Department of Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Vincenzo Valentini
- 1 Department of Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Alessandro Giordano
- 1 Department of Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
| | - Lorenzo Bonomo
- 1 Department of Bioimaging and Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy
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Rectal adenocarcinoma in patients with anorectal malformations: report of two cases and a review of the literature. SPRINGERPLUS 2016; 5:1623. [PMID: 27722042 PMCID: PMC5030204 DOI: 10.1186/s40064-016-3263-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 09/07/2016] [Indexed: 01/05/2023]
Abstract
Aim Anorectal malformation (ARM) is a rare congenital disorder of the anus and rectum. In the last 30 years virtually all patients born with ARM have survived and surgeons from adult care may be called to deal with new and long-term sequelae, including tumors of the pulled-through anorectum. Two new cases of colorectal carcinoma in young adults born with ARM and a review of the literature is reported to emphasize the importance of a multidisciplinary follow-up. Methods A man and a woman, with previous history of ARM, presented at 34 years of age with symptoms of intestinal occlusion and a large pelvic mass. Both patients had no familial history of colorectal carcinoma. Results The patients underwent biopsies (mucinous rectal adenocarcinoma) and stadiation (T4N0M0). In one case the microsatellite instability showed a stable profile. Despite maximal treatments, including surgery, chemo- and radio-therapy, they both died a few years after diagnosis for progression of disease. Conclusion Case studies are too limited to suggest guidelines for prevention and treatment of such complications, but the life-long follow-up is mandatory in the framework of a well-established network between pediatric and adult surgeons. The risk of tumor development in these patients should not be neglected and colleagues from adult care should be aware of the possibility this occurs in their practice.
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Abstract
The optimal management of rectal cancer is achieved through a shared multidisciplinary decision making process with accurate staging by imaging being critical for treatment planning. Good quality, high-resolution MRI has become the imaging gold standard as it allows consistent staging and stratification of patients into distinct prognostic groups according to MR-findings. Imaging features other than T and N have been proven to influence patient outcomes, and increasingly these features are taken into consideration when determining treatment options: distance of tumour to the potential circumferential margin (CRM), presence of tumour within the extramural rectal vessels (EMVI), discontinuous tumour deposits (N1c), relationship to the intersphincteric plane in low rectal tumours and to pelvic compartments in advanced disease. The presence or absence of proven adverse MR features should be included in the MRI report and shared with the patient when treatment choices are offered. MRI enables the identification of high risk tumours where the use of neoadjuvant therapy is justified and is a robust method of identifying patients with a strong likelihood of complete response after preoperative treatment.
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Affiliation(s)
- Svetlana Balyasnikova
- />Colorectal Imaging Group, The Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT UK
- />Imperial College London, London, SW7 2AZ UK
- />The N. N. Blokhin Russian Cancer Research Center, Kashirskoye Shosse 24, Moscow, 15478 Russia
- />The State Scientific Center of Coloproctology, ul. Saliama Adilia 2, Moscow, 123423 Russia
| | - Gina Brown
- />Colorectal Imaging Group, The Royal Marsden Hospital, NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT UK
- />Imperial College London, London, SW7 2AZ UK
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Tarantino I, Hüttner FJ, Warschkow R, Schmied BM, Diener MK, Ulrich A. Prognostic Relevance of Mucinous Subtype in a Population-based Propensity Score Analysis of 40,083 Rectal Cancer Patients. Ann Surg Oncol 2015; 23:1576-86. [PMID: 26714956 DOI: 10.1245/s10434-015-5029-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND The prognostic relevance of mucinous histology in colorectal cancer remains unclear, especially for rectal neoplasms. The objective of this study was to evaluate if mucinous subtype has a relevant impact on overall survival (OS) and cancer-specific survival (CSS) of patients with adenocarcinomas of the rectum. METHODS On the basis of the data set of the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute of the United States, patients with rectal cancer between 2004 and 2011 were identified. Risk-adjusted Cox regression analysis and propensity score methods were used to assess OS and CSS. RESULTS In total, 40,083 patients with stage I-IV rectal cancer, of whom 2483 (6.2 %) had mucinous histology, were included in this study. In unadjusted analysis, the 5-year OS and CSS for patients with a mucinous adenocarcinoma was 54.3 % [95 % confidence interval (CI) 52.0-56.7] and 61.4 % (95 % CI 59.1-63.9) compared to 66.4 % (95 % CI 65.8-67.0) and 74.5 % (95 % CI 73.9-75.1) for patients with nonmucinous adenocarcinoma (P < 0.001). The survival disadvantage persisting in risk-adjusted Cox proportional hazard regression analysis [hazard ratio (HR) 1.23, 95 % CI 1.15-1.31, P < 0.001 and 1.25, 95 % CI 1.16-1.35, P < 0.001) disappeared after propensity score matching (OS: HR = 0.96, 95 % CI 0.76-1.21, P = 0.722; CSS: HR 1.06, 95 % CI 0.80-1.40, P = 0.693). CONCLUSIONS This population-based, propensity score matched analysis shows that mucinous histology itself does not constrain survival in rectal cancer patients. Therefore, treatment decisions should not be different according to mucinous histology.
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Affiliation(s)
- Ignazio Tarantino
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Felix J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Study Center of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - Rene Warschkow
- Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Bruno M Schmied
- Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.,Study Center of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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Is it safe to omit neoadjuvant chemo-radiation in mucinous rectal carcinoma? Int J Surg 2015; 23:120-7. [DOI: 10.1016/j.ijsu.2015.08.081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 08/08/2015] [Accepted: 08/27/2015] [Indexed: 01/15/2023]
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Yang CW, Tao MZ. Significance of expression of p53 and nm23 in mucous adenocarcinoma of the rectum. Shijie Huaren Xiaohua Zazhi 2014; 22:5385-5388. [DOI: 10.11569/wcjd.v22.i34.5385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the clinical significance of expression of p53 and nm23 in mucous adenocarcinoma (MUC) of the rectum.
METHODS: The expression of p53 and nm23 in 37 cases of MUC and 261 cases of non-MUC of the rectum was detected by using immunohistochemical streptavidin-peroxidase method.
RESULTS: The positive rates of high p53 and nm23 expression in MUC were significantly lower than those in non-MUC (16.2% vs 35.6%, 13.5% vs 29.9%, P < 0.05 for both). The expression of p53 and nm23 was not correlated with tumor size, gender, invasion depth, 1ymph node metastasis or TNM stage (P > 0.05 for all). Nm23 expression was not related to p53 expression.
CONCLUSION: The expression of p53 and nm23 is low in rectal MUC, and they may have no significant role in the development and progression of this malignancy.
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Chand M, Rasheed S, Bhangu A, Stamp GWH, Swift RI, Tekkis PP, Brown G. Adjuvant chemotherapy improves overall survival after TME surgery in mucinous carcinoma of the rectum. Eur J Surg Oncol 2013; 40:240-5. [PMID: 24286808 DOI: 10.1016/j.ejso.2013.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 10/01/2013] [Accepted: 11/04/2013] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Mucinous tumours of the rectum are characterised by an abundance of extracellular mucin within the tumour complex. They are known to have a poor prognosis compared to non-mucinous adenocarcinomas. The effect of adjuvant chemotherapy on the survival outcomes of patients with mucinous cancer remains unclear. This study evaluated the 5-year overall survival of patients with mucinous rectal cancer following optimal TME surgery to determine whether adjuvant chemotherapy conferred a survival benefit. METHODS An analysis of a prospectively-maintained database was conducted of patients presenting with mucinous rectal cancer between 2000 and 2010. Patients with mucinous tumours were identified from final pathology reports of the surgical resection specimens. The primary outcome was 5-year overall survival; univariate and multivariate analysis was performed using Cox proportional hazards regression models. RESULTS A total of 191 patients were included for analysis with mean age of presentation 64.6 years (36-88 ± 11). On the fully adjusted multivariate model, EMVI status (HR 1.853, 95% CI 1.081-3.175) and not being given adjuvant chemotherapy (HR 2.888, 95% CI 1.801-4.633) were significant for disease recurrence. The 5-year overall survival for patients that had undergone adjuvant chemotherapy was 66.1% compared with 35.2% (Mantel Cox log-rank test - p < 0.0001). CONCLUSION This study demonstrates that adjuvant chemotherapy is an independent factor for improvement in overall survival in patients with mucinous adenocarcinoma. Therefore, patients who have undergone TME surgery for mucinous carcinoma of the rectum should be offered adjuvant chemotherapy even in the absence of other high-risk features for poor outcomes.
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Affiliation(s)
- M Chand
- Royal Marsden Hospital, Fulham Road, London, United Kingdom; Croydon University Hospital, London Road, Croydon, United Kingdom; Imperial College, Department of Cancer and Surgery, London, United Kingdom.
| | - S Rasheed
- Royal Marsden Hospital, Fulham Road, London, United Kingdom; Imperial College, Department of Cancer and Surgery, London, United Kingdom.
| | - A Bhangu
- Royal Marsden Hospital, Fulham Road, London, United Kingdom; Imperial College, Department of Cancer and Surgery, London, United Kingdom.
| | - G W H Stamp
- Royal Marsden Hospital, Fulham Road, London, United Kingdom; Imperial College, Department of Cancer and Surgery, London, United Kingdom.
| | - R I Swift
- Croydon University Hospital, London Road, Croydon, United Kingdom.
| | - P P Tekkis
- Royal Marsden Hospital, Fulham Road, London, United Kingdom; Imperial College, Department of Cancer and Surgery, London, United Kingdom.
| | - G Brown
- Royal Marsden Hospital, Fulham Road, London, United Kingdom.
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