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Boraschi P, Donati F, Cervelli R, Bani K, Morganti R, Furbetta N, Morelli L, Neri E. MR staging of rectal cancer: Comparison between the 2012 and 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guidelines. Eur J Radiol 2024; 181:111804. [PMID: 39471550 DOI: 10.1016/j.ejrad.2024.111804] [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: 06/06/2024] [Revised: 10/11/2024] [Accepted: 10/22/2024] [Indexed: 11/01/2024]
Abstract
PURPOSE To compare the adherence of the interpretation and reporting staging system, respectively proposed in the 2012 and 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guidelines for Magnetic Resonance Imaging (MRI) staging of rectal cancer, focusing on the improvement offered by the criteria introduced by 2016 ESGAR guidelines. METHOD Fifty-six patients affected by rectal cancer were included; 25/56 patients underwent upfront surgery; 31 underwent to neo-adjuvant chemo-radiotherapy before surgery. All patients underwent 3 T MRI examination for local staging. All MR exams were evaluated by two radiologists with 20- and 4-years' experience, who were blinded to each other; the T and N stages, the Mesorectal Fascia (MRF) status and the Extramural Vascular Invasion (EMVI) were assessed according to both 2012 and 2016 ESGAR guidelines. The correlation between radiological and pathological findings, as well as the MRI staging were evaluated. RESULTS As to the expert reviewer, no significant differences were found by comparing the MR T and N stages, T and N restaging, MRF status and EMVI according to 2012 and 2016 ESGAR guidelines. As to the 4-years' experience radiologist the MR staging agreement between 2012 and 2016 guidelines was "moderate" in N-stage evaluation and "fair" in T-restaging evaluation. No significant discrepancies were found for other parameters. CONCLUSIONS MRI is a reliable method in rectal cancer staging/restaging. The assessment of T-restaging is improved by adopting the 2016 ESGAR guidelines, especially for non-expert readers; this result could be justified by the introduction of diffusion-weighted imaging. On the contrary, the newest guidelines do not improve the diagnostic performance in assessing nodal staging and restaging.
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Affiliation(s)
- Piero Boraschi
- 2nd Unit of Radiology, Department of Radiological Nuclear and Laboratory Medicine, Pisa University Hospital, Via Paradisa 2, Pisa 56124, Italy.
| | - Francescamaria Donati
- 2nd Unit of Radiology, Department of Radiological Nuclear and Laboratory Medicine, Pisa University Hospital, Via Paradisa 2, Pisa 56124, Italy
| | - Rosa Cervelli
- Unit of Interventional Radiology, Department of Radiological Nuclear and Laboratory Medicine, Pisa University Hospital, Via Paradisa 2, Pisa 56124, Italy
| | - Kathrine Bani
- Academic Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, Pisa 56126, Italy
| | - Riccardo Morganti
- Departmental Section of Statistical Support for Clinical Trials, Pisa University Hospital, Via Roma 67, Pisa 56126, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, Pisa 56126, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, Pisa 56126, Italy
| | - Emanuele Neri
- Academic Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, Pisa 56126, Italy
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Opara CO, Khan FY, Kabiraj DG, Kauser H, Palakeel JJ, Ali M, Chaduvula P, Chhabra S, Lamsal Lamichhane S, Ramesh V, Mohammed L. The Value of Magnetic Resonance Imaging and Endorectal Ultrasound for the Accurate Preoperative T-staging of Rectal Cancer. Cureus 2022; 14:e30499. [DOI: 10.7759/cureus.30499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
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Abstract
With the changing lifestyle and the acceleration of aging in the Chinese population, the incidence and mortality of colorectal cancer (CRC) have risen in the last decades. On the contrary, the incidence and mortality of CRC have continued to decline in the USA since the 1980s, which is mainly attributed to early screening and standardized diagnosis and treatment. Rectal cancer accounts for the largest proportion of CRC in China, and its treatment regimens are complex. At present, surgical treatment is still the most important treatment for rectal cancer. Since the first Chinese guideline for diagnosis and treatment of CRC was issued in 2010, the fourth version has been revised in 2020. These guidelines have greatly promoted the standardization and internationalization of CRC diagnosis and treatment in China. And with the development of comprehensive treatment methods such as neoadjuvant chemoradiotherapy, targeted therapy, and immunotherapy, the post-operative quality of life and prognosis of patients with rectal cancer have improved. We believe that the inflection point of the rising incidence and mortality of rectal cancer will appear in the near future in China. This article reviewed the current status and research progress on surgical therapy of rectal cancer in China.
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Abreu SFM, Martins SFF. Preoperative staging of rectal cancer with MRI: correlation with pathologic staging. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2015.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Abstract
Introduction An accurate preoperative rectal cancer staging is crucial to the correct management of the disease. Despite great controversy around this issue, pelvic magnetic resonance (RM) is said to be the imagiologic standard modality. This work aimed to evaluate magnetic resonance accuracy in preoperative rectal cancer staging comparing with the anatomopathological results.
Methods We calculated sensibility, specificity, positive (VP positive) and negative (VP negative) predictive values for each T and N. We evaluated the concordance between both methods of staging using the Cohen weighted K (K
w), and through ROC curves, we evaluated magnetic resonance accuracy in rectal cancer staging.
Results 41 patients met the inclusion criteria. We achieved an efficacy of 43.9% for T and 61% for N staging. The respective sensibility, specificity, positive and negative predictive values are 33.3%, 94.7%, 33.3% and 94.7% for T1; 62.5%, 32%, 37.0% and 57.1% for T2; 31.8%, 79%, 63.6% and 50% for T3 and 27.8%, 87%, 62.5% and 60.6% for N. We obtained a poor concordance for T and N staging and the anatomopathological results. The ROC curves indicated that magnetic resonance is ineffective in rectal cancer staging.
Conclusion Magnetic resonance has a moderate efficacy in rectal cancer staging and the major difficulty is in differentiating T2 and T3.
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Affiliation(s)
- Soraia Filipa Macado Abreu
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Sandra Fátima Fernandes Martins
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
- Surgery Department, Hospitalar Center of Trás-os-Montes e Alto Douro, Distrito de Vila Real, Portugal
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Reginelli A, Clemente A, Sangiovanni A, Nardone V, Selvaggi F, Sciaudone G, Ciardiello F, Martinelli E, Grassi R, Cappabianca S. Endorectal Ultrasound and Magnetic Resonance Imaging for Rectal Cancer Staging: A Modern Multimodality Approach. J Clin Med 2021; 10:641. [PMID: 33567516 PMCID: PMC7915333 DOI: 10.3390/jcm10040641] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022] Open
Abstract
Preoperative staging represents a crucial point for the management, type of surgery, and candidacy for neoadjuvant therapy in patient with rectal cancer. The most recent clinical guidelines in oncology recommend an accurate preoperative evaluation in order to address early and advanced tumors to different therapeutic options. In particular, potential pitfalls may occur in the assessment of T3 tumors, which represents the most common stage at diagnosis. The depth of tumor invasion is known to be an important prognostic factor in rectal carcinoma; as a consequence, the T3 imaging classification has a substantial importance for treatment strategy and patient survival. However, the differentiation between tumor invasion of perirectal fat and mesorectal desmoplastic reactions remains a main goal for radiologists. Magnetic resonance imaging (MRI) is actually considered as the best imaging modality for rectal cancer staging. Although the endorectal ultrasound (ERUS) is the preferred staging method for early tumors, it could also be useful in identifying perirectal fat invasion. Moreover, the addiction of diffusion weighted imaging (DWI) improves the diagnostic performance of MRI in rectal cancer staging by adding functional information about rectal tumor and adjacent mesorectal tissues. This study investigated the diagnostic performance of conventional MRI alone, in combination with the DWI technique and ERUS in order to assess the best diagnostic imaging combination for rectal cancer staging.
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Affiliation(s)
- Alfonso Reginelli
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (A.R.); (A.S.); (R.G.); (S.C.)
| | - Alfredo Clemente
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (A.R.); (A.S.); (R.G.); (S.C.)
| | - Angelo Sangiovanni
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (A.R.); (A.S.); (R.G.); (S.C.)
| | - Valerio Nardone
- Unit of Radiation Oncology, Ospedale del Mare, 80147 Naples, Italy;
| | - Francesco Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (F.S.); (G.S.)
| | - Guido Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (F.S.); (G.S.)
| | - Fortunato Ciardiello
- Medical Oncology, Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (F.C.); (E.M.)
| | - Erika Martinelli
- Medical Oncology, Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (F.C.); (E.M.)
| | - Roberto Grassi
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (A.R.); (A.S.); (R.G.); (S.C.)
| | - Salvatore Cappabianca
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy; (A.R.); (A.S.); (R.G.); (S.C.)
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Tsai C, Hague C, Xiong W, Raval M, Karimuddin A, Brown C, Phang PT. Evaluation of endorectal ultrasound (ERUS) and MRI for prediction of circumferential resection margin (CRM) for rectal cancer. Am J Surg 2017; 213:936-942. [PMID: 28391975 DOI: 10.1016/j.amjsurg.2017.03.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/06/2017] [Accepted: 03/21/2017] [Indexed: 01/03/2023]
Abstract
ERUS and MRI are used for preoperative imaging of rectal cancer. Here, we compare ERUS and MRI for accuracy of CRM prediction at mid- and distal rectal locations. In retrospective review, 20 rectal cancer patients having TME surgery had both ERUS and MRI preoperatively: 8 mid rectum and 12 in distal rectum. Predicted CRM by ERUS and MRI were compared to TME pathology. Overall, predicted CRM was 6.5 ± 3.6 mm by ERUS, 7.7 ± 5.0 mm by MRI, and 6.0 ± 4.6 mm by pathology. Overall, correlation coefficients to pathology were 0.77 (p = 0.0004) for ERUS and 0.64 (p = 0.008) for MRI. In distal rectum, correlation coefficients were 0.71 (p = 0.02) for ERUS and -0.10 (p = 0.79) for MRI. In mid rectum, correlation coefficients were 0.92 (p = 0.01) for ERUS and 0.44 (p = 0.38) for MRI. While MRI is used routinely for preoperative rectal cancer imaging, ERUS can provide additional assessment of CRM for mid or distal rectal lesions. Further investigation is needed to support these preliminary ERUS CRM findings in mid and distal rectum.
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Affiliation(s)
- Catherine Tsai
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Cameron Hague
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Wei Xiong
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Manoj Raval
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Ahmer Karimuddin
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Carl Brown
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - P Terry Phang
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
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Purysko AS, Coppa CP, Kalady MF, Pai RK, Leão Filho HM, Thupili CR, Remer EM. Benign and malignant tumors of the rectum and perirectal region. ACTA ACUST UNITED AC 2016; 39:824-52. [PMID: 24663381 DOI: 10.1007/s00261-014-0119-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Although most rectal masses are histologically characterized as adenocarcinomas, the rectum and perirectal region can be affected by a wide variety of tumors and tumor-like conditions that can mimic the symptoms caused by rectal adenocarcinoma, including mucosal or submucosal rectal tumors such as lymphoma, gastrointestinal stromal tumor, leiomyosarcoma, neuroendocrine tumor, hemangioma, and melanoma, as well as tumors of the perirectal region such as developmental cyst, neurogenic tumor, osseous tumor, and other miscellaneous conditions. As a group, tumors of the rectum are considerably different from the group of tumors that arise in the perirectal region: they are most often neoplastic, symptomatic, and malignant, whereas tumors arising in the perirectal region are most commonly congenital, asymptomatic, and benign. Proctoscopy with biopsy is the most important method for the diagnosis of rectal tumors, but this procedure cannot determine the precise intramural extension of a rectal tumor and cannot accurately distinguish submucosal and intramural tumors from extramural tumors. Cross-sectional imaging, especially transrectal ultrasound and magnetic resonance imaging, allows evaluation of the entire bowel wall thickness and the perirectal tissues, helping further characterize these tumors. Recognition of the existence of these masses and their key clinical and imaging features is crucial for clinicians to accurately diagnose and appropriately manage these conditions.
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Affiliation(s)
- Andrei S Purysko
- Abdominal Imaging Section, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, JB3, Cleveland, OH, 44195, USA,
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Cote A, Graur F, Lebovici A, Mois E, Al Hajjar N, Mare C, Badea R, Iancu C. The accuracy of endorectal ultrasonography in rectal cancer staging. Med Pharm Rep 2015; 88:348-56. [PMID: 26609269 PMCID: PMC4632895 DOI: 10.15386/cjmed-481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 05/25/2015] [Accepted: 06/12/2015] [Indexed: 01/04/2023] Open
Abstract
Background and aims The incidence of rectal cancer in the European Union is about 35% of the total colorectal cancer incidence. Staging rectal cancer is important for planning treatment. It is essential for the management of rectal cancer to have adequate preoperative imaging, because accurate staging can influence the therapeutic strategy, type of resection, and candidacy for neoadjuvant therapy. The aim of this work is to evaluate the accuracy of endorectal ultrasound (ERUS) in rectal cancer staging. Methods A retrospective study was performed to assess the accuracy of ERUS by analyzing patients discharged from Regional Institute of Gastroenterology and Hepatology (IRGH) Cluj-Napoca, Romania, diagnosed with rectal cancer between 01 January 2011 and 31 December 2013. Patients who were preoperatively staged by other imaging methods and those who had ERUS performed in another service were excluded from the analysis. As inclusion criteria remained ERUS performed for patients with rectal cancer in IRGH Cluj-Napoca where they were also operated. We analyzed preoperative T stage obtained by ERUS and it was compared with the histopathology findings. Results The number of patients discharged with a diagnosis of rectal cancer were 200 (operated – 157) in 2011, 193 (operated – 151) in 2012, and 198 (operated – 142) in 2013. We analyzed a total of 51 cases diagnosed with rectal cancer who performed ERUS in IRGH Cluj-Napoca. The results according to the T stage obtained by ERUS and histopathology test were: Conclusions ERUS is a method of staging rectal cancer which is human dependent. ERUS is less accurate for T staging of stenotic tumours, but the accuracy may still be within acceptable limits. Surgeons use ERUS to adopt a treatment protocol, knowing the risk of under-staging and over-staging of this method. The accuracy of ERUS is higher in diagnosing rectal cancer in stages T1, T2 and even in stage T3 with malignant tumor which is not occlusive. ERUS is less accurate for T staging of locally advanced and stenotic tumours.
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Affiliation(s)
- Adrian Cote
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania ; Surgery Department, Prof. Dr. O. Fodor Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Florin Graur
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania ; Surgery Department, Prof. Dr. O. Fodor Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Andrei Lebovici
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania ; Radiology Department, Emergency County Hospital, Cluj-Napoca, Romania
| | - Emil Mois
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania ; Surgery Department, Prof. Dr. O. Fodor Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Nadim Al Hajjar
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania ; Surgery Department, Prof. Dr. O. Fodor Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Codruta Mare
- Department of Statistics-Forecasting-Mathematics, Faculty of Economics and Business Administration, Babes-Bolyai University, Cluj-Napoca, Romania
| | - Radu Badea
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania ; Ultrasonography Department, Prof. Dr. O. Fodor Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Cornel Iancu
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania ; Surgery Department, Prof. Dr. O. Fodor Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
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Restivo A, Zorcolo L, Marongiu L, Scintu F, Casula G. Limits of endorectal ultrasound in tailoring treatment of patients with rectal cancer. Dig Surg 2015; 32:129-34. [PMID: 25791387 DOI: 10.1159/000375537] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 01/25/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Endorectal ultrasound (ERUS) is considered reliable in staging rectal cancer, but recently some critics have questioned its accuracy. The aim of this study was to evaluate how often an ERUS-based decision leads to an appropriate treatment. METHODS Two hundred and twenty patients with rectal cancer staged with ERUS who underwent a surgical resection or a local excision without neoadjuvant therapy from 1997 to 2012 were included. According to ERUS, patients were divided into three groups of indication: (a) local excision (Tis-1 N0), (b) direct surgery (T2 N0), (c) preoperative chemoradiation (T3-4 or N+). Accuracy was explored by the correlation established with the final pathology. RESULTS Accuracy for T and N staging was 65 and 64%, respectively. Indication to local excision and to chemoradiation was correct in 97 and 88% of patients staged by ERUS. Accuracy of indication to direct surgery was poor (37%), and 21% of patients were overtreated in this group. CONCLUSIONS ERUS seems not able to fulfill all the needs of ideal tailored therapeutic strategies. T2 diagnosis needs to be confirmed by an excisional biopsy before a final decision is made because overstaging of early tumors may occur in a not-so-negligible proportion of patients.
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Affiliation(s)
- Angelo Restivo
- Department of Surgical Sciences, Colorectal Unit, University of Cagliari, Cagliari, Italy
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Patel RK, Sayers AE, Kumar P, Khulusi S, Razack A, Hunter IA. The Role of Endorectal Ultrasound and Magnetic Resonance Imaging in the Management of Early Rectal Lesions in a Tertiary Center. Clin Colorectal Cancer 2014; 13:245-50. [DOI: 10.1016/j.clcc.2014.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 09/10/2014] [Indexed: 01/06/2023]
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Kim MJ. Transrectal ultrasonography of anorectal diseases: advantages and disadvantages. Ultrasonography 2014; 34:19-31. [PMID: 25492891 PMCID: PMC4282231 DOI: 10.14366/usg.14051] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 11/17/2014] [Accepted: 11/19/2014] [Indexed: 12/17/2022] Open
Abstract
Transrectal ultrasonography (TRUS) has been widely accepted as a popular imaging modality for evaluating the lower rectum, anal sphincters, and pelvic floor in patients with various anorectal diseases. It provides excellent visualization of the layers of the rectal wall and of the anatomy of the anal canal. TRUS is an accurate tool for the staging of primary rectal cancer, especially for early stages. Although magnetic resonance imaging is a modality complementary to TRUS with advantages for evaluating the mesorectum, external sphincter, and deep pelvic inflammation, three-dimensional ultrasonography improves the detection and characterization of perianal fistulas and therefore plays a crucial role in optimal treatment planning. The operator should be familiar with the anatomy of the rectum and pelvic structures relevant to the preoperative evaluation of rectal cancer and other anal canal diseases, and should have technical proficiency in the use of TRUS combined with an awareness of its limitations compared to magnetic resonance imaging.
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Affiliation(s)
- Min Ju Kim
- Department of Radiology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
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Vignali A, Nardi PD. Multidisciplinary treatment of rectal cancer in 2014: where are we going? World J Gastroenterol 2014; 20:11249-11261. [PMID: 25170209 PMCID: PMC4145763 DOI: 10.3748/wjg.v20.i32.11249] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/08/2014] [Accepted: 05/25/2014] [Indexed: 02/06/2023] Open
Abstract
In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.
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Abstract
INTRODUCTION Minimally invasive surgery has many potential benefits, and the application of recently developed robotic technology to patients with colorectal diseases is rapidly gaining popularity. QUALITY AND OUTCOMES However, the literature evaluating such techniques, including the outcomes, risks, and costs, is limited. In this review, we evaluate and summarize the existing information, calling attention to areas where future investigation should occur.
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Affiliation(s)
- Carrie Y Peterson
- Colorectal Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Room C-1075, New York, NY, 10065, USA
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Paradigm-shifting new evidence for treatment of rectal cancer. J Gastrointest Surg 2014; 18:391-7. [PMID: 23888373 DOI: 10.1007/s11605-013-2297-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 07/16/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of rectal cancer has dramatically evolved during the last three decades shifting toward a tailored approach based on preoperative staging and response to neoadjuvant combined modality therapy (CMT). METHODS A literature search was performed using PubMed/Medline electronic databases. RESULTS Selected patients with T1 N0 rectal cancer are best treated with local excision by transanal endoscopic microsurgery (TEM). Satisfactory results have been reported after CMT and TEM for the treatment of highly selected T2 N0 rectal cancers. CMT followed by rectal resection and total mesorectal excision is considered the standard of care for the treatment of locally advanced rectal cancer. However, a subset of stage II and III patients may not require neoadjuvant radiation treatment. Finally, there are mounting data supporting a "watch and wait" approach or local excision in patients with complete clinical response after neoadjuvant CMT. CONCLUSIONS Current evidence shows that selected T1 N0 rectal cancers can be managed by TEM alone, while locally advanced cancers should be treated by CMT followed by radical surgery. Studies are underway to identify patients that do not benefit from neoadjuvant radiation therapy. A non-operative approach in case of complete clinical response must be validated by large prospective studies.
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van Gijn W, Brehm V, de Graaf E, Neijenhuis PA, Stassen LPS, Leijtens JWA, Van De Velde CJH, Doornebosch PG. Unexpected rectal cancer after TEM: outcome of completion surgery compared with primary TME. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2013; 39:1225-9. [PMID: 23972571 DOI: 10.1016/j.ejso.2013.08.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 07/27/2013] [Accepted: 08/05/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) has gained wide-spread acceptance as a safe and useful technique for the resection of rectal adenomas and selected T1 malignant lesions. If the lesion appears >T1 rectal cancer after resection with TEM, a completion TME resection is recommended. The aim of this study was to investigate the results of TME surgery after TEM for rectal cancer. METHODS In four tertiary referral hospitals for TEM, all patients with completion TME surgery after initial TEM were selected. All eligible patients who were treated with 5 × 5 Gy radiotherapy followed by TME surgery from the Dutch TME trial were selected as reference group. A multivariate logistic regression model was used to calculate odds ratio's (OR) for colostomies and for colo- and ileostomies combined. Local recurrence and survival rates were compared in hazard ratio's (HR) using the multivariate Cox proportional hazard model. RESULTS Fifty-nine patients were included in the TEM-COMPLETION group and 881 patients from the TME trial. In the TEM-COMPLETION group, 50.8% of the patients had a colostomy compared to 45.9% in the TME trial, OR 2.51 (p < 0.006). There is no significant difference when ileo- and colostomies are analyzed together. In the TEM-COMPLETION group, 10.2% developed a local recurrence compared to 5.2% in the TME trial, HR 6.8 (p < 0.0001). CONCLUSIONS Completion TME surgery after TEM for unexpected rectal adenocarcinoma results in more colostomies and higher local recurrence rates compared to one stage TME surgery preceded with preoperative 5 × 5 Gy radiotherapy. Pre-operative investigations must be optimized to distinguish malignant and benign lesions and prevent avoidable local recurrence and colostomies.
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Affiliation(s)
- W van Gijn
- Netherlands Cancer Institute, Surgery Department, The Netherlands.
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Swartling T, Kälebo P, Derwinger K, Gustavsson B, Kurlberg G. Stage and size using magnetic resonance imaging and endosonography in neoadjuvantly-treated rectal cancer. World J Gastroenterol 2013; 19:3263-3271. [PMID: 23745028 PMCID: PMC3671078 DOI: 10.3748/wjg.v19.i21.3263] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 02/14/2013] [Accepted: 04/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the stage and size of rectal tumours using 1.5 Tesla (1.5T) magnetic resonance imaging (MRI) and three-dimensional (3D) endosonography (ERUS).
METHODS: In this study, patients were recruited in a phase I/II trial of neoadjuvant chemotherapy for biopsy-proven rectal cancer planned for surgical resection with or without preoperative radiotherapy. The feasibility and accuracy of 1.5T MRI and 3D ERUS were compared with the histopathology of the fixed surgical specimen (pathology) to determine the stage and size of the rectal cancer before and after neoadjuvant chemotherapy. A Philips Intera 1.5T with a cardiac 5-channel synergy surface coil was used for the MRI, and a B-K Medical Falcon 2101 EXL 3D-Probe was used at 13 MHz for the ERUS. Our hypothesis was that the staging accuracy would be the same when using MRI, ERUS and a combination of MRI and ERUS. For the combination, MRI was chosen for the assessment of the lymph nodes, and ERUS was chosen for the assessment of perirectal tissue penetration. The stage was dichotomised into stage I and stage II or greater. The size was measured as the supero-inferior length and the maximal transaxial area of the tumour.
RESULTS: The staging feasibility was 37 of 37 for the MRI and 29 of 36 for the ERUS, with stenosis as a limiting factor. Complete sets of investigations were available in 18 patients for size and 23 patients for stage. The stage accuracy by MRI, ERUS and the combination of MRI and ERUS was 0.65, 0.70 and 0.74, respectively, before chemotherapy and 0.65, 0.78 and 0.83, respectively, after chemotherapy. The improvement of the post-chemotherapy staging using the combination of MRI and ERUS compared with the staging using MRI alone was significant (P = 0.046). The post-chemotherapy understaging frequency by MRI, ERUS and the combination of MRI and ERUS was 0.18, 0.14 and 0.045, respectively, and these differences were non-significant. The measurements of the supero-inferior length by ERUS compared with MRI were within 1.96 standard deviations of the difference between the methods (18 mm) for tumours smaller than 50 mm. The agreement with pathology was within 1.96 standard deviations of the difference between imaging and pathology for all tumours with MRI (15 mm) and for tumours that did not exceed 50 mm with ERUS (22 mm). Tumours exceeding 50 mm in length could not be reliably measured by ERUS due to the limit in the length of each recording.
CONCLUSION: MRI is preferable to use when assessing the size of large or stenotic rectal tumours. However, staging accuracy is improved by combining MRI with ERUS.
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Abstract
Thanks to major advances in the field of surgical techniques and neoadjuvant chemoradiation therapy, along with more accurate pre-operative staging tools and the widespread introduction of population-based screening programs, treatment of rectal cancer has been evolving over the past few decades, moving towards a more tailored approach. This has brought a shift in the treatment algorithm of benign rectal lesions and selected early rectal cancers, for which today transanal endoscopic microsurgery (TEM) is accepted as an effective alternative to abdominal surgery. In 2013, topics of controversy are the role of TEM in the treatment of more advanced rectal cancers, in cases of complete pathological response after chemoradiation therapy and the role of TEM as a platform for single-port surgery and NOTES. This article reviews the current indications for TEM and the future perspectives of this approach in the treatment of rectal tumors.
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Affiliation(s)
- Mario Morino
- Digestive, Colorectal, Oncologic and Minimally Invasive Surgery, Department of Surgical Sciences, University of Turin, Italy
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18
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Rafaelsen SR, Vagn-Hansen C, Sørensen T, Pløen J, Jakobsen A. Transrectal ultrasound and magnetic resonance imaging measurement of extramural tumor spread in rectal cancer. World J Gastroenterol 2012; 18:5021-6. [PMID: 23049209 PMCID: PMC3460327 DOI: 10.3748/wjg.v18.i36.5021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 07/26/2012] [Accepted: 07/29/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the agreement between transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI) in classification of ≥ T3 rectal tumors.
METHODS: From January 2010 to January 2012, 86 consecutive patients with ≥ T3 tumors were included in this study. The mean age of the patients was 66.4 years (range: 26-91 years). The tumors were all ≥ T3 on TRUS. The sub-classification was defined by the penetration of the rectal wall: a: 0 to 1 mm; b: 1-5 mm; c: 6-15; d: > 15 mm. Early tumors as ab (≤ 5 mm) and advanced tumors as cd (> 5 mm). All patients underwent TRUS using a 6.5 MHz transrectal transducer. The MRI was performed with a 1.5 T Philips unit. The TRUS findings were blinded to the radiologist performing the interpretation of the MRI images and measuring the depth of extramural tumor spread.
RESULTS: TRUS found 51 patients to have an early ≥ T3 tumors and 35 to have an advanced tumor, whereas MRI categorized 48 as early ≥ T3 tumors and 38 as advanced tumors. No patients with tumors classified as advanced by TRUS were found to be early on MRI. The kappa value in classifying early versus advanced T3 rectal tumors was 0.93 (95% CI: 0.85-1.00). We found a kappa value of 0.74 (95% CI: 0.63-0.86) for the total sub-classification between the two methods. The mean maximal tumor outgrowth measured by TRUS, 5.5 mm ± 5.63 mm and on MRI, 6.3 mm ± 6.18 mm, P = 0.004. In 19 of the 86 patients the following CT scan or surgery revealed distant metastases; of the 51 patients in the ultrasound ab group three (5.9%) had metastases, whereas 16 (45.7%) of 35 in the cd group harbored distant metastases, P = 0.00002. The odds ratio of having distant metastases in the ultrasound cd group compared to the ab group was 13.5 (95% CI: 3.5-51.6), P = 0.00002. The mean maximal ultrasound measured outgrowth was 4.3 mm (95% CI: 3.2-5.5 mm) in patients without distant metastases, while the mean maximal outgrowth was 9.5 mm (95% CI: 6.2-12.8 mm) in the patients with metastases, P = 0.00004. Using the MRI classification three (6.3%) of 48 in the MRI ab group had distant metastases, while 16 (42.1%) of the 38 in the MRI cd group, P = 0.00004. The MRI odds ratio was 10.9 (95% CI: 2.9-41.4), P = 0.00008. The mean maximal MRI measured outgrowth was 4.9 mm (95% CI: 3.7-6.1 mm) in patients without distant metastases, while the mean maximal outgrowth was 11.5 mm (95% CI: 7.8-15.2 mm) in the patients with metastases, P = 0.000006.
CONCLUSION: There is good agreement between TRUS and MRI in the pretreatment sub-classification of ≥ T3 tumors. Distant metastases are more frequent in the advanced group.
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Computer-aided colorectal tumor classification in NBI endoscopy using local features. Med Image Anal 2012; 17:78-100. [PMID: 23085199 DOI: 10.1016/j.media.2012.08.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 07/26/2012] [Accepted: 08/20/2012] [Indexed: 12/18/2022]
Abstract
An early detection of colorectal cancer through colorectal endoscopy is important and widely used in hospitals as a standard medical procedure. During colonoscopy, the lesions of colorectal tumors on the colon surface are visually inspected by a Narrow Band Imaging (NBI) zoom-videoendoscope. By using the visual appearance of colorectal tumors in endoscopic images, histological diagnosis is presumed based on classification schemes for NBI magnification findings. In this paper, we report on the performance of a recognition system for classifying NBI images of colorectal tumors into three types (A, B, and C3) based on the NBI magnification findings. To deal with the problem of computer-aided classification of NBI images, we explore a local feature-based recognition method, bag-of-visual-words (BoW), and provide extensive experiments on a variety of technical aspects. The proposed prototype system, used in the experiments, consists of a bag-of-visual-words representation of local features followed by Support Vector Machine (SVM) classifiers. A number of local features are extracted by using sampling schemes such as Difference-of-Gaussians and grid sampling. In addition, in this paper we propose a new combination of local features and sampling schemes. Extensive experiments with varying the parameters for each component are carried out, for the performance of the system is usually affected by those parameters, e.g. the sampling strategy for the local features, the representation of the local feature histograms, the kernel types of the SVM classifiers, the number of classes to be considered, etc. The recognition results are compared in terms of recognition rates, precision/recall, and F-measure for different numbers of visual words. The proposed system achieves a recognition rate of 96% for 10-fold cross validation on a real dataset of 908 NBI images collected during actual colonoscopy, and 93% for a separate test dataset.
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Koch M, Schölch S, Ulrich A, Weitz J, Büchler MW. Pelvic exenteration for advanced rectal cancer. COLORECTAL CANCER 2012. [DOI: 10.2217/crc.12.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY Advanced rectal cancer is defined by local tumor invasion into adjacent structures and organs in the pelvis. A curative multimodal therapy approach for patients with advanced rectal cancer includes neoadjuvant treatment with subsequent pelvic exenteration. Pelvic exenteration is associated with high perioperative morbidity as this surgical procedure includes an extensive resection of pelvic anatomical planes with en bloc removal of the tumor and surrounding organs and structures. Safe reconstruction of the large pelvic floor defect is very important. Quality of life and oncological outcome after pelvic exenteration for advanced rectal cancer are good. In this article, we highlight important clinical and surgical aspects of pelvic exenteration for advanced rectal cancer and review the recent literature.
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Affiliation(s)
- Moritz Koch
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Sebastian Schölch
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Alexis Ulrich
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Jürgen Weitz
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
| | - Markus W Büchler
- Department of Surgery, University Hospital Heidelberg, INF 110, 69120 Heidelberg, Germany
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