Curative chemoradiation for low rectal cancer: Primary clinical outcomes from a multicenter phase II trial

LBA3514

Background: Organ preserving treatment strategies based on chemoradiotherapy may spare rectal cancer patients of major surgery and stoma. We suggest substantially improved tumor control by increasing the radiotherapy dose, without significant increase in the rate of late effects. We designed a prospective phase II trial to test high-dose radiotherapy of low rectal cancer for organ preservation in a multicenter setting. Methods: We enrolled patients with localized T1-3 N0-1 M0 rectal cancer within 6 cm from the anal verge and in performance status 0-2. Any N1-nodes had to be at the level of the tumor and included in the primary tumor-volume. Radiotherapy consisted of 62 Gy to the tumor and 50.4 Gy to the regional lymph nodes, delivered in 28 fractions using intensity modulated radiation therapy and daily image guidance. Capecitabine 825 mg/m2 BID. Patients with clinical complete response (cCR) 6–12 weeks after end of treatment were allocated to follow-up. Surgery was offered only in case of residual cancer or later re-growth. The primary endpoint was the proportion of patients with locoregional tumor control after two years by chemoradiation alone. Secondary endpoints included long-term side effects (CTCAE grading), cCR, rate of distant metastases, and overall survival. Results: Three Danish centers enrolled 107 patients between 2015 and 2019. Baseline classifications were T1/T2/T3 and N1 in 15%/54%/31% and 29%, respectively. The median age was 71 years and 64% were male. 92 (86.0%) had cCR and were allocated to observation. Four patients drew consent or died leaving 103 observed for at least 2 years. 23 had regrowth after cCR, five of whom had organ preserving transanal endoscopic microsurgery, 15 other curative surgery, and three palliation. 63 had no locoregional regrowth. Thus 61% (63/103) of patients with 2 years of follow-up had locoregional tumor control with chemoradiation alone. The actuarial estimate of locoregional control at 2 years from start of observation was 73.8% (95%CI 63.2-81.8). Calculated from time of enrollment, metastasis-free and overall survival at 30 months was 85.4% (95%CI 76.5-91.1) and 94.8% (95%CI 87.8-97.8). In the 63 patients with complete response at 2 years, ‘Low Anterior Resection Syndrome-score’ was None=37%, Minor=28%, and Major=35%. The most severe toxicity was erectile dysfunction grade 3 (n=3), grade 2 (n=4), grade 1 (n=6), and grade 0 (n=26). Grade 2 diarrhea, constipation, fecal incontinence, rectal bleeding and decreased libido were each reported in one case, while urinary frequency grade 2 was seen in four patients. Conclusions: The vast majority of patients with low rectal cancer can be cured by modern radiotherapy 62 Gy in 28 fractions with excellent patient-reported outcomes, toxicity, tumor control, and survival. The treatment is feasible in a multicenter setting. We suggest this approach as a standard of care option. Clinical trial information: NCT02438839.

Functional precision medicine in colorectal cancer based on patient-derived tumoroids and in-vitro sensitivity drug testing

e15567

Background: Precision oncology based on in-vitro, functional assays has potential advantages compared to the much more common molecular approach, but the clinical benefit is unknown. We here report the results from the largest prospective interventional clinical trial testing the clinical outcome in colorectal cancer patients treated with drugs showing cytotoxic effect in matched patient-derived tumoroids. Methods: This single-center, phase II trial included patients with metastatic colorectal cancer previously exposed to all standard therapies. Specimens from one to three 18-16 G core needle biopsies were manually dissected, enzymatically treated, cultivated, and incubated to form 3D spherical microtumors, i.e. tumoroids. In the assay for in-vitro sensitivity testing, the tumoroids were challenged with single drugs and combinations thereof to determine patient-specific responses. Using tumoroid screening technology (IndiTreat, 2cureX, Copenhagen, Denmark), results were generated by comparing the sensitivity of the individual patient’s tumoroids with a reference panel from other patients. The testing included standard cytostatics and drugs with proven effect in previous early-phase clinical trials, a total of 15 drugs. The primary endpoint was the fraction of patients with progression-free survival (PFS) at two months. Based on placebo arms in randomized last-line trials, a minimal relevant difference of 20% (20% to 40%) was stated. Using Simon's two-stage design, a sample size of 45 patients was calculated with at least 14 PFS at two months (significance 5%, power 90%). Results: Ninety patients were enrolled from 9/2017 to 9/2020. Biopsies from 82 patients were obtained and sent for tumoroid formation of which 44 (54%, 95% CI 42-65) were successful and at least one treatment was suggested. Thirty-four patients initiated treatment according to the response obtained in the drug assays within a median of 51 days from inclusion (IQR 39-63). The primary endpoint, PFS at two months, was met in 17 of 34 patients (50%, 95%CI 32-68). There were no radiological responses. Median PFS was 81 days (95% CI 51-112) and median OS was 189 days (95% CI 103-277). Conclusions: Precision oncology using a functional approach with patient-derived tumoroids and in-vitro drug sensitivity testing seems feasible. The approach is limited by the fraction of patients with successful tumoroid development. The primary endpoint was met, as half of the patients were without progression at two months. Further clinical studies are justified. Clinical trial information: NCT03251612.

ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis

Objectives

To develop imaging guidelines for patients with fistula-in-ano and other causes of anal sepsis.

Methods

An expert group of 13 members of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) used a modified Delphi process to vote on a series of consensus statements relating to the imaging of patients with potential anal sepsis. Participants first completed a questionnaire to gather practice information and to help frame the statements posed.

Results

In the first round of voting, the expert group scored 51 statements of which 45 (88%) achieved immediate consensus. The remaining 6 statements were redrafted following input from the expert group and consensus achieved for all during a second round of voting, including an additional statement drafted. No statement was rejected due to a lack of consensus. After redrafting to improve clarity, 53 individual statements were presented.

Conclusion

These expert consensus statements can be used to guide appropriate indication, acquisition, interpretation and reporting of medical imaging for patients with potential fistula-in-ano and other causes of anal sepsis.

Key Points

• Medical imaging, notably magnetic resonance imaging, is used widely for the diagnosis and monitoring of fistula-in-ano and other causes of anal and perianal sepsis.

• While the indexed medical literature is clear that diagnostic accuracy is potentially excellent, this depends on competent image acquisition and interpretation.

• In order to facilitate this, the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) has produced expert consensus guidelines regarding the imaging of fistula-in-ano and related conditions.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06826-5) contains supplementary material, which is available to authorized users.

The impact of mismatch repair status to the preoperative staging of local colon cancer: Implications for clinical management

16

Background: Computed tomography (CT) scan is standard in preoperative local staging of colon cancer. Tumours with a deficient mismatch repair (dMMR) system are characterised by unique clinical and pathophysiologic aspects that may impact on the accuracy of the preoperative CT staging. Methods: Data from the Danish Colorectal Cancer Group national clinical database addressing a cohort of patients operated for stage I-III colon cancer in 2010-15 was analysed. The analyses of MMR status had been conducted consecutively through means of immunohistochemistry. All CT scans were blindly assessed by a certified radiologist. Results: Data from 590 patients, operated at a specialised cancer centre were available for analyses. A dMMR phenotype was detected in 135 (22.9%) of the patients. The overall correlation of the clinical and pathological T-category was significant for both groups. There was inferior correlation between cN and pN (p > 0.05) in pMMR cancers with a higher degree of over-staging assessed by CT-scan, compared to a significant correlation between cN and pN stage in pMMR cancers (p < 0.01). Of the 91 dMMR tumours judged node-positive by the preoperative CT scan, 59 (64.8%) showed no sign of metastatic involvement at the postoperative assessment. Conclusions: The accuracy of preoperative CT lymph node staging in colon cancer seems to differ depending on MMR status and may impact the clinical management including the neoadjuvant setting.

Long-term outcomes after high-dose chemoradiotherapy for non-surgical management of distal rectal cancer

3611

Background: Surgery is standard treatment for rectal cancer, but neoadjuvant chemoradiotherapy (CRT) may result in clinical complete response (cCR) in selected patients, allowing for non-surgical management (NSM). Prospective studies of NSM strategies are sparse however, and long-term data on quality of life (QoL) are limited. We conducted a single-arm phase II trial of high-dose CRT for NSM of distal rectal cancer; we report secondary long-term patient-reported outcomes (PROs), local regrowth and overall survival (OS) in patients managed non-surgically. Methods: Fifty-one patients with resectable, T2 or T3, N0–N1, low adenocarcinoma received 65Gy (IMRT, brachytherapy boost) and oral tegafur-uracil. Patients with cCR 6 weeks after treatment (clinical examination, MRI, biopsy) were referred for observation, and followed closely with clinical examinations, endoscopies, PET-CTs, and PROs for 5 years. Overall colorectal cancer specific QoL and specific symptom scores were compared between timepoints using paired Wilcoxon tests. Local regrowth was estimated using cumulative incidence; overall survival using Kaplan-Meier estimates. Results: Forty patients achieved cCR after treatment; 28 were in follow-up at 24m, 21 at 36m, 18 at 60m. Patients left the trial due to local tumor regrowth (n=12), distant metastases (n=3), new primary cancers (n=6) and loss to follow-up (n=1). Average QoL score did not differ between baseline (median 11.1) and 24m (13.7), 48m (11.1,) or 60m (6.9). See Table for individual scores; only rectal bleeding deteriorated from baseline (significantly worse at 24m). At median follow-up of 5.0 years, local regrowth rate and OS were 31% (95 CI 15%-47%) and 85% (95 CI 75%-97%), respectively. Conclusions: Long term follow-up after NSM of early rectal cancer showed excellent general colorectal cancer QoL and local symptom scores. (NCT00952926). EORTC QLQ – CR 29. Proportion reporting ‘quite a bit’ or ‘very much’ on symptom scales. Clinical trial information: NCT00952926. [Table: see text]

Characteristics of symptomatic men with testicular microlithiasis - A Danish cross-sectional questionnaire study

Testicular microlithiasis (TML) is an incidental finding at ultrasonography of the scrotum. A link between testicular microlithiasis and testicular cancer has been suggested. However, the majority of studies are retrospective using ultrasonography with minor data on health status and life style characteristics. Our objective was to investigate if lifestyle and health are associated with TML. In 2014, we conducted a self‐administered questionnaire survey including 1538 men, who all due to testicular/scrotal symptoms had an ultrasound investigation of the scrotum during 2004–2013. The men were divided into men with TML and men without. The 23‐items questionnaire included items on age, height, weight, lifestyle (alcohol consumptions, smoking habits, workload, exercise and food), previous diseases in the testicles, pain and consumption of analgesics. The prevalence of TML was 12.8%. Overall, lifestyle factors did not vary between men with or without TML. However, men with TML did consume more crisp than men without. Development of TML was not associated to classic life style factors such as alcohol consumption, smoking habits, or mothers smoking during pregnancy. Also, age and height could not be linked to presence of TML. We did find, however, that men with TML experienced less physical activity and consumed more crisp than men without TML. Since ingestion of crisps has potential carcinogenic effect (acrylamide), this finding needs confirmation in a separate study.

Testicular Microlithiasis: Patient Compliance in a Two-Year Follow-Up Program

Introduction: We present a retrospective 2-year follow-up cohort of 103 men with testicular microlithiasis (TML) and discuss patient compliance and the value of surveillance. Methods: A retrospective analysis of patients examined with scrotal ultrasonography (US) in the period from 2008 through 2010 was performed. A total of 103 men with TML were diagnosed and offered US follow-up every 6 months for 2 years. They were retrospectively analyzed regarding demographics and follow-up details, including the development of any kind of malignancy until March 2015, using the Danish Electronic Pathology Registry. Results: The prevalence of TML was 10.3%. Of the 103 men with TML, 23 (22.3%) had TML in the left testicle, 38 (36.9%) in the right (p=0.002), and 42 (40.8%) had bilateral TML. Patient compliance was low with 11.7% participating in all US follow-up examinations. 5 men presented risk factors (testicular atrophy (N=1) and previous testicular cancer (N=4)), but no cases of testicular malignancy were found in the follow-up period. Conclusion: The low patient compliance conflicts with the ESUR Scrotal Imaging Subcommittee guidelines that recommend scrotal US follow-up annually for TML until the age of 55 years. The fact that no cancers were found during follow-up using the pathology registry calls the value of follow-up into question.

Strain Elastography Evaluation of Rectal Tumors: Inter- and Intraobserver Reproducibility

PURPOSE

Elastography is a promising method for the identification and differentiation of malignant tissue in several organ systems. The primary aim was to evaluate the inter- and intraobserver reproducibility of endorectal strain elastography differentiation of adenomas and adenocarcinomas. The secondary aim was to compare the performance of strain elastography to endorectal ultrasonography (ERUS) examinations.

MATERIALS AND METHODS

Consecutive inclusion of 95 ERUS examinations and 110 elastography video loops with ERUS overlay mode. Video loops were randomized and evaluated by eight observers on two separate occasions. Observers were blinded to all clinical information except the circumferential location of the tumor. A continuous visual analog scale (VAS) and a categorical scale (W-score) were used for elastography evaluation. ERUS loops were T-staged according to the TNM classification system. Histopathological evaluation of surgical resection specimen was used as the reference standard.

RESULTS

Strain elastography visual evaluation yielded intraobserver variability from 0.86 to 0.97 and interobserver variability of 0.99. VAS strain elastography differentiation of adenomas (pT0) and adenocarcinomas (pT1 - 4) yielded sensitivity, specificity, accuracy, positive and negative predictive values of 0.94, 0.71, 0.89, 0.92 and 0.78, respectively. The corresponding ERUS values were 0.83, 0.64, 0.79, 0.88 and 0.54, respectively.

CONCLUSION

Visual evaluation of elastography loops is highly reproducible in an offline setting with blinded observers, and correlates significantly with pT-stages. Strain elastography performs better than ERUS and might consequently improve staging.

Ultrasound elastography in patients with rectal cancer treated with chemoradiation

OBJECTIVE

The current literature has described several predictive markers in rectal cancer patients treated with chemoradiation, but so far none of them have been validated for clinical use. The purpose of the present study was to compare quantitative elastography based on ultrasound measurements in the course of chemoradiation with tumor response based on T stage classification and the Mandard tumor regression grading (TRG).

MATERIALS AND METHODS

We prospectively examined 31 patients with rectal cancer planned for high dose radiochemotherapy. The tumor and the mesorectal fat elasticity were measured using the Acoustic Radiation Force Impulse to generate information on the mechanical properties of the tissue. The objective quantitative elastography shear wave velocity was compared to the T stage classification and TRG.

RESULTS

The baseline mean tumor elasticity was 3.13 m/s. Two and six weeks after the start of chemoradiation the velocities were 2.17 m/s and 2.11 m/s, respectively. The difference between baseline velocity and velocities during the treatment course was statistically significant, (p<0.0001). Patients with tumor confined to the rectal wall at histopathology (ypT1-2) had a mean elasticity measurement after two weeks of treatment of 1.95 m/s, whereas tumors invading the mesorectal fat (ypT3-4) had a velocity of 2.47 m/s, (p<0.05). The mean elasticity tended to be lower (1.99m/s) after two weeks in patients with TRG 1-2 responses in contrast to 2.24 m/s in those with TRG 3-4.

CONCLUSION

Ultrasound elastography after two weeks of chemoradiation seems to hold early predictive information to the pathological T stage.

Contrast-enhanced ultrasound vs multidetector-computed tomography for detecting liver metastases in colorectal cancer: a prospective, blinded, patient-by-patient analysis

AIM

This study compared the sensitivity and specificity of contrast-enhanced ultrasound (CEUS) and multidetector-computed tomography (MDCT) in the detection of liver metastases in patients with colorectal cancer.

METHOD

Between September 2004 and December 2008, 271 consecutive patients (146 men and 125 women; median age 68 years, range: 34-91 years) with primary colorectal cancer were evaluated. All underwent combined liver ultrasound and CEUS following intravenous injection of 2.4 ml of SonoVue(TM). The interval from injection to arrival time in the hepatic vein (ATHV) was noted. Contrast-enhanced MDCT in the portal phase was performed and interpreted blindly. In all patients, intra-operative ultrasound was used as the reference point. In addition, magnetic resonance imaging (MRI) or biopsy was performed on all suspicious lesions or if there was inconsistency in the results.

RESULTS

Liver metastases were detected in 21 (8%) patients. Both CEUS and MDCT had a sensitivity of 85.7%, with respective specificities of 97.6% and 95.6%, and positive predictive values of 75%vs 62%. The negative predictive value of both methods was 99%. In patients with and without liver metastases, ATHV was 18 and 22 s, respectively (P < 0.05).

CONCLUSION

CEUS has potential as a diagnostic alternative to MDCT in the detection of liver metastases. ATHV was shorter in patients with liver metastases.

Ultrasound imaging of flow patterns in liver metastases from colorectal cancer

BACKGROUND

The ability of colour Doppler, power Doppler and echo-enhanced Doppler imaging to detect the blood flow in liver metastases from colorectal cancer was investigated. An evaluation was then made to determine whether the flow pattern could be used as an indication of disease elsewhere.

METHODS

Forty-two patients with hepatic metastases from colorectal cancer were examined, 8 of whom had local recurrence of their colorectal cancer. Seventy-seven liver metastases were evaluated with colour Doppler and power Doppler, and the presence or absence of a Doppler signal in the halo or centre was noted. Forty-three of these metastases were further examined after contrast media echo-enhancement.

RESULTS

Signals from the peripheral halo were detected by colour Doppler imaging in 34% of the metastases, and in 77% by power Doppler (P < 0.001). Use of contrast media enhanced the power Doppler detection rate to 98% (P < 0.005). Central signals were detected by power Doppler in 12 patients, 8 (66%) of whom also had local recurrence. Thirty patients had neither local recurrence nor central signals, as detected by power Doppler (P < 0.001).

CONCLUSION

The results indicate that the halo in liver metastases corresponds to the vascular flow. There seems to be an association between metastases showing a central power Doppler flow and local tumour recurrence.

Cost-effectiveness of endoscopic ultrasonography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in patients suspected of pancreaticobiliary disease

BACKGROUND

It is not known whether initial endoscopic ultrasonography (EUS) or magnetic resonance cholangiopancreatography (MRCP) is more cost effective than endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A cost-effectiveness analysis of EUS, MRCP and ERCP was performed on 163 patients. The effectiveness of an investigation was defined as the percentage of patients with no need for further evaluation after the investigation in question had been performed. Costs were assumed from the budget-holder's point of view.

RESULTS

MRCP, EUS and ERCP had a total accuracy of 0.91, 0.93 and 0.92, respectively. Eighty-four (52%) patients needed endoscopic therapy in combination with ERCP, giving an effectiveness of MRCP, EUS, and ERCP of 0.44, 0.45 and 0.92, respectively. The cost-effectiveness of MRCP, EUS, and ERCP was 6622, 7353 and 4246 Danish Kroner (DKK) per fully investigated and treated patient (1 DKK=0.14 EUR).

CONCLUSION

Within a patient population with a probability of therapeutic ERCP in 50% of the patients, ERCP was the most cost-effective strategy.

Is there a difference in diagnostic accuracy and clinical impact between endoscopic ultrasonography and magnetic resonance cholangiopancreatography?

BACKGROUND AND STUDY AIMS

It is still unknown whether there is a difference in diagnostic accuracy and clinical impact between endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography (MRCP).

PATIENTS AND METHODS

The test performance and potential clinical impact of EUS and MRCP, had each investigation been performed as the first examination method, were compared prospectively in 163 patients admitted for and examined by endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

The accuracies of EUS and MRCP were 0.93 and 0.91, respectively (no significant difference, P > 0.05). Had EUS or MRCP been performed as the first investigation in the 75 patients who had a presumed high probability for needing therapeutic ERCP, only 15 and nine patients, respectively, would have avoided ERCP. In this group of patients, one patient needed other diagnostic investigations following EUS compared with 11 patients following MRCP ( P = 0.004). For the 57 patients with an intermediate probability of needing endoscopic therapy, EUS and MRCP would have spared 37 and 38 patients, respectively, from the need to have an ERCP. In 31 patients with a presumed low risk of needing endoscopic therapy, 30 and 29 patients would have been spared from ERCP had EUS and MRCP, respectively, been performed initially.

CONCLUSIONS

There was no difference in the diagnostic accuracy and clinical impact between EUS and MRCP in the majority of the patients. The impact of EUS or MRCP on the ERCP workload was highly dependent on the presumed probability of needing endoscopic therapy.

[Brain metastases from colorectal cancer]

Brain metastases from colorectal cancer are rare. The prognosis for patients with even a single resectable brain metastasis is poor. A case of surgically treated cerebral metastasis from a rectal carcinoma is reported. The brain tumour was radically resected. However, cerebral, as well as extracerebral, disease recurred 12 months after diagnosis. Surgical removal of colorectal metastatic brain lesions in selected cases results in a longer survival time.

[Intraoperative ultrasonography in colorectal cancer. A prospective, blind study]

This study was designed to compare diagnostic accuracies of measuring liver enzymes, preoperative ultrasonography, surgical examination, and intraoperative ultrasonography for detection of liver metastases from colorectal cancer. A blind prospective comparison between the diagnostic examinations mentioned above were performed in 295 consecutive patients with colorectal cancer. An experienced ultrasonologist performed the preoperative examinations and the results were not known to the other experienced ultrasonologist, who did the intraoperative examinations. The latter was also unaware of the findings by the surgeon. The presence of metastases was further assessed by ultrasonography three months postoperatively, as well as surgery and liver biopsy in some of the patients. The sensitivity of intraoperative ultrasonography (62/64) was significantly superior to that of surgical exploration (54/64), and that of preoperative ultrasonography (45/64). The lowest sensitivity was presented by liver enzymes. "Bilobar" metastases were detected in 42 of 46 patients by intraoperative ultrasonography, but in no more than 33 by the surgeon. Intraoperative ultrasonography demonstrated the highest specificity of all examinations. Intraoperative ultrasonography reduces the number of patients with liver metastases being subjected to superfluous or even harmful liver surgery and it may increase the number in whom liver surgery will prolong life.

Comparison of two techniques of transrectal ultrasonography for the assessment of local extent of polypoid tumours of the rectum

The capability of transrectal ultrasonography (TRUS) to differentiate between benign and malignant rectal polyps was evaluated. Digital palpation and sigmoidoscopy were followed by TRUS with a 7.5-MHz linear-array transducer, in a blinded design. In the second part of the study the procedure was extended with an acoustic window system (AWS), preventing compression of the polyp. Pathological examination after surgical resection was used for definitive diagnosis in 110 polyps. Digital examination detected 10 of 22 carcinomas with adenomas, compared with 19 by TRUS (P < 0.01). However, TRUS falsely indicated 20 of 49 adenomas to be carcinomas, compared with 4 out of 49 by digital examination (P < 0.001). TRUS combined with AWS detected 23 of 24 carcinomas, and gave a false positive result in only 3 of 26 benign polyps. The results suggest that the best way to discriminate between benign and malignant rectal polyps is to combine TRUS with AWS.

Intraoperative ultrasonography in detection of hepatic metastases from colorectal cancer

PURPOSE

This study was designed to compare diagnostic accuracies of measuring liver enzymes, preoperative ultrasonography, surgical examination, and intraoperative ultrasonography for detection of liver metastases from colorectal cancer.

METHODS

Blind, prospective comparisons of diagnostic examinations mentioned above were performed in 295 consecutive patients with colorectal cancer. An experienced ultrasonologist performed the preoperative examinations, and results were unknown to the other experienced ultrasonologist who performed the intraoperative examinations. The latter, also was unaware of the findings by the surgeon. The presence of metastases was further assessed by ultrasonography three months postoperatively, as well as additional surgery and liver biopsy in some of the patients.

RESULTS

The sensitivity of intraoperative ultrasonography (62/64) was significantly superior to that of surgical exploration (54/64) and that of preoperative ultrasonography (45/64). The lowest sensitivity was presented by liver enzymes. Bilobar metastases were detected in 42 of 46 patients by intraoperative ultrasonography but in only 33 patients by the surgeon. Intraoperative ultrasonography demonstrated the highest specificity of all examinations.

CONCLUSIONS

Intraoperative ultrasonography reduces the number of patients with liver metastases from being subjected to superfluous or even harmful liver surgery, and it may increase the number in whom liver surgery will prolong life.

[Rectal exploration and transrectal ultrasound scanning of rectal cancer. A prospective, blind study]

Staging of rectal carcinoma before surgical treatment was performed in a prospective blind study, comparing digital rectal exploration and transrectal linear ultrasonography (TRUS) with the resulting pathological examination. TRUS underestimated the depth of penetration in three of 33 patients and overestimated it in nine of 74. The figures for digital examination were five of 18 and 20 of 76, respectively. Penetration of the rectal wall was correctly identified in 56 of 61 patients by digital rectal examination and in 59 of 61 by TRUS. Specimens without penetration of the rectal wall were identified in 26 of 33 patients by TRUS, but in no more than 13 of 33 by digital examination. Regional lymph node metastases were present in 19 patients; none were diagnosed by digital examination, but TRUS identified 11 of the 19. It is concluded that TRUS will result in more patients being given the possibility of curative local surgery.

Digital rectal examination and transrectal ultrasonography in staging of rectal cancer. A prospective, blind study

Staging of rectal carcinoma before surgical treatment was performed in a prospective blind study, comparing digital rectal exploration and transrectal linear ultrasonography (TRUS) with the resulting pathological examination. TRUS underestimated depth of penetration in 3 of 33 patients and overestimation resulted in 9 of 74. The figures for digital examination were 5 of 18 and 20 of 76, respectively. Penetration of the rectal wall was correctly identified in 56 of 61 patients by digital examination and in 59 of 61 by TRUS. Specimens without penetration of the rectal wall were identified in 26 of 33 patients by TRUS, but in not more than 13 of 33 by digital examination. Regional lymph node metastases were present in 19 patients; none were diagnosed by digital examination, but TRUS identified 11 of the 19. It is concluded that TRUS will result in more patients having the possibility of local surgery for cure.

Echo pattern of lymph nodes in colorectal cancer: an in vitro study

Surgical specimens from 75 patients with colorectal cancer were examined within 15 min of removal with a 7.5 MHz linear-array transducer. The echo pattern of 139 lymph nodes was analysed to evaluate previous criteria of malignancy and to establish other possible criteria, which could be tested in vivo. The pathologist examined each node without knowledge of the sonographic finding. Malignant nodes were larger than benign nodes. Of 21 nodes less than 5 mm in diameter, 20 were benign. Round nodes were malignant more often (45/78) than ovoid nodes (6/61). A homogeneous echo pattern was associated with malignancy in 39 of 82 nodes in contrast to 12 of 57 with a heterogeneous pattern. Thirty-one nodes were ovoid as well as heterogeneous and all of these were benign. A hyperechoic centre was found in 14 nodes of which two were malignant. The highest predictive value for malignancy (59%) was obtained by combining the discriminative properties of shape, homogeneity and echogenicity.