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Doroudian S, Osterman E, Glimelius B. Risk Factors for Recurrence After Surgery for Rectal Cancer in a Modern, Nationwide Population-Based Cohort. Ann Surg Oncol 2024; 31:5570-5584. [PMID: 38853216 PMCID: PMC11300512 DOI: 10.1245/s10434-024-15552-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/16/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND The success of modern multimodal treatment in rectal cancer is dependent on risk prediction. Better knowledge of the risk of locoregional and distant recurrence, in relation to preoperative treatment, pathological stage, and commonly used risk factors, is needed when deciding on adjuvant therapy and surveillance. METHODS The Swedish ColoRectal Cancer Registry was used to identify patients diagnosed with rectal adenocarcinoma between 2011 and 2018. Readily available variables, including patient, tumor, and treatment factors were exposures. Cox proportional hazard models were used to identify important risk factors for recurrence and calculate recurrence risks. RESULTS A total of 9428 curatively resected patients were included and followed for a median of 72 months. Eighteen percent had distal recurrence and 3% had locoregional recurrence at 5 years. Risk factors with major impact on distal recurrence were pT4a (hazard ratio [HR] 5.1, 95% confidence interval [CI] 3.3-8.0), pN2b (HR 3.4, 95% CI 2.7-4.2), tumor deposit (HR 1.7, 95% CI 1.5-1.9), lymph node yield (HR 1.5, 95% CI 1.3-1.8), and tumor level 0-5 cm (HR 1.5, 95% CI 1.3-1.8). Pathologic stage and number of risk factors identified groups with markedly different recurrence risks in all neoadjuvant treatment groups. CONCLUSIONS Readily available risk factors, as a complement to stage, are still valid and robust in all neoadjuvant treatment groups. Tumor deposit is important, while circumferential resection margin might no longer be important with improved oncological treatments and high-quality TME surgery. Tailored surveillance is possible in selected groups using risk stratification based on stage and risk factors.
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Affiliation(s)
- Sepehr Doroudian
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
- Center for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden.
- Department of Surgery, Gävle County Hospital, Gävle, Sweden.
| | - Erik Osterman
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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Zhou M, Huang H, Bao D, Chen M, Lu F. Assessment of prognostic indicators and KRAS mutations in rectal cancer using a fractional-order calculus MR diffusion model: whole tumor histogram analysis. Abdom Radiol (NY) 2024:10.1007/s00261-024-04523-1. [PMID: 39152230 DOI: 10.1007/s00261-024-04523-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/04/2024] [Accepted: 08/10/2024] [Indexed: 08/19/2024]
Abstract
PURPOSE This study aims to explore the relationship between apparent diffusion coefficient (ADC) and fractional-order calculus (FROC)-specific parameters with prognostic indicators and Kirsten rat sarcoma viral oncogene homologue (KRAS) mutation status in rectal cancer. METHODS One hundred fifty-eight patients with rectal cancer were retrospectively enrolled. Histogram measurements of ADC, diffusion coefficient (D), intravoxel diffusion heterogeneity (β), and a microstructural quantity (μ) were estimated for the whole-tumor volume. The relationships between histogram measurements and prognostic indicators were evaluated. The efficacy of histogram measurements, both conducted singly and in conjunction, for evaluating different KRAS mutation statuses was also assessed. The performance of mean and median histogram measurements in evaluating various KRAS mutation statuses was assessed using Receiver Operating Characteristic (ROC) curve analysis. A p-value of less than 0.05 was considered statistically significant. RESULTS The histogram measurements of ADC, D, β, and μ differed significantly between well-moderately differentiated groups and poorly differentiated groups, T1-2 and T3-4 subgroups, lymph node metastasis (LNM)-negative and LNM-positive subgroups, extranodal extension (ENE)-negative and ENE-positive subgroups, tumor deposit (TD)-negative and TD-positive subgroups, and lymphovascular invasion (LVI)-negative and LVI-positive subgroups. The combination of Dmean, βmean, and μmean achieved the highest performance [The area under the ROC curve (AUC) = 0.904] in evaluating the KRAS mutation status. CONCLUSION When assessing parameters from the FROC model as potential biomarkers through histograms, they surpass traditional ADC values in distinguishing prognostic indicators and determining KRAS mutation status in rectal cancer.
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Affiliation(s)
- Mi Zhou
- Department of Radiology, Sichuan Provincial Orthpaedics Hospital, Chengdu, 610041, People's Republic of China.
| | - Hongyun Huang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, People's Republic of China
| | - Deying Bao
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, People's Republic of China
| | - Meining Chen
- Department of MR Scientific Marketing, Siemens Healthineers, Shanghai, 200135, China
| | - Fulin Lu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, People's Republic of China
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Kim EJ, Kim CW, Lee JL, Yoon YS, Park IJ, Lim SB, Yu CS, Kim JC. Partial mesorectal excision can be a primary option for middle rectal cancer: a propensity score-matched retrospective analysis. Ann Coloproctol 2024; 40:253-267. [PMID: 36999173 PMCID: PMC11362759 DOI: 10.3393/ac.2022.00689.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/15/2022] [Accepted: 11/23/2022] [Indexed: 04/01/2023] Open
Abstract
PURPOSE Although partial mesorectal excision (PME) and total mesorectal excision (TME) is primarily indicated for the upper and lower rectal cancer, respectively, few studies have evaluated whether PME or TME is more optimal for middle rectal cancer. METHODS This study included 671 patients with middle and upper rectal cancer who underwent robot-assisted PME or TME. The 2 groups were optimized by propensity score matching of sex, age, clinical stage, tumor location, and neoadjuvant treatment. RESULTS Complete mesorectal excision was achieved in 617 of 671 patients (92.0%), without showing a difference between the PME and TME groups. Local recurrence rate (5.3% vs. 4.3%, P>0.999) and systemic recurrence rate (8.5% vs. 16.0%, P=0.181) also did not differ between the 2 groups, in patients with middle and upper rectal cancer. The 5-year disease-free survival (81.4% vs. 74.0%, P=0.537) and overall survival (88.0% vs. 81.1%, P=0.847) also did not differ between the PME and TME groups, confined to middle rectal cancer. Moreover, 5-year recurrence and survival rates were not affected by distal resection margins of 2 cm (P=0.112) to 4 cm (P>0.999), regardless of pathological stages. Postoperative complication rate was higher in the TME than in the PME group (21.4% vs. 14.5%, P=0.027). Incontinence was independently associated with TME (odds ratio [OR], 2.009; 95% confidence interval, 1.015-3.975; P=0.045), along with older age (OR, 4.366, P<0.001) and prolonged operation time (OR, 2.196; P=0.500). CONCLUSION PME can be primarily recommended for patients with middle rectal cancer with lower margin of >5 cm from the anal verge.
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Affiliation(s)
- Ee Jin Kim
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Wook Kim
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Lyul Lee
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Eberhardt SC. Detection of Extranodal Extension at Pretreatment Rectal Cancer MRI: Promising for Staging and Prognosis. Radiology 2024; 310:e240582. [PMID: 38530177 DOI: 10.1148/radiol.240582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Affiliation(s)
- Steven C Eberhardt
- From the Department of Radiology, University of New Mexico, MSC10 5530, 1 University of New Mexico, Albuquerque, NM 87131
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Li H, Chai L, Pu H, Yin LL, Li M, Zhang X, Liu YS, Pang MH, Lu T. T2WI-based MRI radiomics for the prediction of preoperative extranodal extension and prognosis in resectable rectal cancer. Insights Imaging 2024; 15:57. [PMID: 38411722 PMCID: PMC10899552 DOI: 10.1186/s13244-024-01625-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/18/2024] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVE To investigate whether T2-weighted imaging (T2WI)-based intratumoral and peritumoral radiomics can predict extranodal extension (ENE) and prognosis in patients with resectable rectal cancer. METHODS One hundred sixty-seven patients with resectable rectal cancer including T3T4N + cases were prospectively included. Radiomics features were extracted from intratumoral, peritumoral 3 mm, and peritumoral-mesorectal fat on T2WI images. Least absolute shrinkage and selection operator regression were used for feature selection. A radiomics signature score (Radscore) was built with logistic regression analysis. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of each Radscore. A clinical-radiomics nomogram was constructed by the most predictive radiomics signature and clinical risk factors. A prognostic model was constructed by Cox regression analysis to identify 3-year recurrence-free survival (RFS). RESULTS Age, cT stage, and lymph node-irregular border and/or adjacent fat invasion were identified as independent clinical risk factors to construct a clinical model. The nomogram incorporating intratumoral and peritumoral 3 mm Radscore and independent clinical risk factors achieved a better AUC than the clinical model in the training (0.799 vs. 0.736) and validation cohorts (0.723 vs. 0.667). Nomogram-based ENE (hazard ratio [HR] = 2.625, 95% CI = 1.233-5.586, p = 0.012) and extramural vascular invasion (EMVI) (HR = 2.523, 95% CI = 1.247-5.106, p = 0.010) were independent risk factors for predicting 3-year RFS. The prognostic model constructed by these two indicators showed good performance for predicting 3-year RFS in the training (AUC = 0.761) and validation cohorts (AUC = 0.710). CONCLUSION The nomogram incorporating intratumoral and peritumoral 3 mm Radscore and clinical risk factors could predict preoperative ENE. Combining nomogram-based ENE and MRI-reported EMVI may be useful in predicting 3-year RFS. CRITICAL RELEVANCE STATEMENT A clinical-radiomics nomogram could help preoperative predict ENE, and a prognostic model constructed by the nomogram-based ENE and MRI-reported EMVI could predict 3-year RFS in patients with resectable rectal cancer. KEY POINTS • Intratumoral and peritumoral 3 mm Radscore showed the most capability for predicting ENE. • Clinical-radiomics nomogram achieved the best predictive performance for predicting ENE. • Combining clinical-radiomics based-ENE and EMVI showed good performance for 3-year RFS.
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Affiliation(s)
- Hang Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# Second Section of First Ring Road, Qingyang District, Chengdu, Sichuan, 610070, China
| | - Li Chai
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong Pu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# Second Section of First Ring Road, Qingyang District, Chengdu, Sichuan, 610070, China
| | - Long-Lin Yin
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# Second Section of First Ring Road, Qingyang District, Chengdu, Sichuan, 610070, China
- Institute of Radiation Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Mou Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# Second Section of First Ring Road, Qingyang District, Chengdu, Sichuan, 610070, China
| | - Xin Zhang
- Pharmaceutical Diagnostic Team, GE Healthcare, Beijing, 100176, China
| | - Yi-Sha Liu
- Department of Pathology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# Second Section of First Ring Road, Qingyang District, Chengdu, Sichuan, 610070, China
| | - Ming-Hui Pang
- Department of Geriatric Surgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# Second Section of First Ring Road, Qingyang District, Chengdu, Sichuan, 610070, China
| | - Tao Lu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# Second Section of First Ring Road, Qingyang District, Chengdu, Sichuan, 610070, China.
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Aldilaijan AF, Kim YI, Kim CW, Yoon YS, Park IJ, Lim SB, Kim J, Ro JS, Kim JC. Clinical implication of tissue carcinoembryonic antigen expression in association with serum carcinoembryonic antigen in colorectal cancer. Sci Rep 2023; 13:7616. [PMID: 37165043 PMCID: PMC10172318 DOI: 10.1038/s41598-023-34855-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 05/09/2023] [Indexed: 05/12/2023] Open
Abstract
This study aimed to evaluate the prognostic significance of carcinoembryonic antigen (CEA) expression in tumor tissues of patients with colorectal cancer (CRC). The cohort included 7,412 patients with CRC from January 2010 to December 2015. Survival outcomes were assessed based on tissue CEA (t-CEA) patterns and intensities. Three-year (76.7% versus 81.3%) and 5-year (71.7% versus 77.6%, p < 0.001) disease-free survival (DFS) rates were significantly (p < 0.001) poorer in patients with a diffuse-cytoplasmic pattern than an apicoluminal pattern. Three-year (79% versus 86.6%) and 5-year (74.6% versus 84.7%) DFS rates were also significantly (p < 0.001) poorer in patients with high than low t-CEA intensity. Three-year (84.6% versus 88.4%) and 5-year (77.3% versus 82.6%) overall survival (OS) rates were significantly (p < 0.001) poorer in patients with diffuse-cytoplasmic than apicoluminal pattern of CEA expression, and both 3-year (86.7% versus 91.2%) and 5-year (80.1% versus 87.7%) OS rates were significantly (p < 0.001) poorer in patients with high than low t-CEA intensity. Multivariate analyses showed that high-intensity t-CEA was independently associated with DFS (p = 0.02; hazard ratio [HR] = 1.233) and OS (p = 0.032; HR = 1.228). Therefore, high-intensity t-CEA is a significant prognostic factor in CRC, independent of serum CEA (s-CEA), and can complement s-CEA in predicting survival outcomes after CRC resection.
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Affiliation(s)
- Abdulmohsin Fawzi Aldilaijan
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Young Il Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Chan Wook Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
| | - Yong Sik Yoon
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Seok-Byung Lim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jihun Kim
- Department of Pathology, Institute of Innovative Cancer Research, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Soo Ro
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin Cheon Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
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Hyperfractionation versus Conventional Fractionation of Preoperative Intensity-Modulated Radiotherapy with Oral Capecitabine in Locally Advanced Mid-Low Rectal Cancer: A Propensity Score Matching Study. JOURNAL OF ONCOLOGY 2022; 2022:9119245. [PMID: 35444702 PMCID: PMC9015848 DOI: 10.1155/2022/9119245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/24/2021] [Accepted: 03/17/2022] [Indexed: 11/26/2022]
Abstract
Purpose In theory, the hyperfractionated radiotherapy can enhance biological effect dose against tumor and alleviate normal tissue toxicity. This study is to assess the efficacy and safety of preoperative hyperfractionated intensity-modulated radiotherapy (IMRT) with oral capecitabine in patients with locally advanced rectal cancer (LARC). Methods We retrospectively screened patients with LARC from January 2015 to June 2016. Patients that received hyperfractionated IMRT or conventional fractionated IMRT were eligible in the hyperfractionation (HF) group or conventional fractionation (CF) group, respectively. The primary outcome was the complete response rate. Secondary outcomes included toxicity, postoperative complications, anus-reservation operation rate, local recurrence and distant metastases rate, overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). Results 335 patients were included in the analysis. The complete response rate for the hyperfractionated and conventional fractionated IMRT was 20.41% vs. 23.47% (P = 0.583). The anus-reservation operation rate was 68.37% vs. 65.31% (P = 0.649). There were no cases of grade 4 toxicity during radiotherapy; the rate of grade 3 toxicity and postoperative complications was both comparable between groups. However, in the CF group, more patients had a second operation due to complications (0.0% vs. 5.68%, P = 0.011). The cumulative local regional recurrence and distant metastases rates of the HF group and CF group were 5.10% vs. 9.18% (P = 0.267) and 22.45% vs. 24.49% (P = 0.736), respectively. The 5-year OS, CSS, and DFS in the HF group and CF group were 86.45% vs. 73.30% (P = 0.503), 87.34% vs. 75.23% (P = 0.634), and 70.80% vs. 68.11% (P = 0.891), respectively. Conclusions The preoperative hyperfractionated IMRT with oral capecitabine, with an acceptable toxicity and favorable response and survival, could reduce the rate of secondary surgery.
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The application of apparent diffusion coefficients derived from intratumoral and peritumoral zones for assessing pathologic prognostic factors in rectal cancer. Eur Radiol 2022; 32:5106-5118. [PMID: 35320412 DOI: 10.1007/s00330-022-08717-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 02/12/2022] [Accepted: 03/05/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the diagnostic performance of the apparent diffusion coefficient (ADC) derived from intratumoral and peritumoral zones for assessing pathologic prognostic factors in rectal cancer. MATERIALS AND METHODS One hundred forty-six patients with rectal cancer who underwent preoperative MRI were prospectively enrolled. Two radiologists independently placed free-hand regions of interest (ROIs) in the largest tumor cross section and three small ROIs on the peritumoral zone adjacent to the tumor contour. Maximum values of tumor ADC (ADCtmax), minimum values of tumor ADC (ADCtmin), mean values of tumor ADC (ADCtmean), mean values of peritumor ADC (ADCpmean), and ADCpmean/ADCtmean (ADC ratio) were obtained on ADC maps and correlated with prognostic factors using uni- and multivariate logistic regression, and receiver operating characteristic curve (ROC) analysis. RESULTS Interobserver agreement was excellent for ADCtmax and ADCtmean (intraclass correlation coefficient [ICC], 0.915-0.958), and were good for ADCtmin, ADCpmean, and ADC ratio (ICC, 0.774-0.878). The ADC ratio was significantly higher in the poor differentiation, T3-4 stage, lymph node metastasis (LNM)-positive, extranodal extension (ENE)-positive, tumor deposit (TD)-positive, and lymphovascular invasion (LVI)-positive groups than that in the well-moderate differentiation, T1-2 stage, LNM-negative, ENE-negative, TD-negative, and LVI-negative groups (p = 0.008, < 0.001, < 0.001, 0.001, < 0.001, and < 0.001, respectively). The area under the ROC curve (AUC) of the ADC ratio was the highest for assessing poor differentiation (0.700), T3-4 stage (0.707), LNM-positive (0.776), TD-positive (0.848), and LVI-positive (0.778). Both the ADC ratio (AUC = 0.677) and ADCpmean (AUC = 0.686) showed higher diagnostic performance for assessing ENE. CONCLUSION The ADC ratio could provide better predictive performance for assessing preoperative prognostic factors in resectable rectal cancer. KEY POINTS • Both the peritumor/tumor ADC ratio and ADCpmean are correlated with important prognostic factors of resectable rectal cancer. • Both peritumor ADC and peritumor/tumor ADC ratio had higher diagnostic performance than tumor ADC for assessment of prognostic factors in resectable rectal cancer. • Peritumor/tumor ADC ratio showed the most capability for the assessment of prognostic factors in resectable rectal cancer.
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