How reliable is current imaging in restaging rectal cancer after neoadjuvant therapy?

Abstract

In patients with advanced rectal cancer, neoadjuvant chemo radiotherapy provides tumor downstaging and downsizing and complete pathological response in up to 30% of cases. After proctectomy complete pathological response is associated with low rates of local recurrence and excellent long term survival. Several authors claim a less invasive surgery or a non operative policy in patients with partial or clinical complete response respectively, however to identify patients with true complete pathological response before surgical resection remains a challenge. Current imaging techniques have been reported to be highly accurate in the primary staging of rectal cancer, however neoadjuvant therapy course produces deep modifications on cancer tissue and on surrounding structures such as overgrowth fibrosis, deep stroma alteration, wall thickness, muscle disarrangement, tumor necrosis, calcification, and inflammatory infiltration. As a result, the same imaging techniques, when used for restaging, are far less accurate. Local tumor extent may be overestimated or underestimated. The diagnostic accuracy of clinical examination, rectal ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography using 18F-fluoro-2’-deoxy-D-glucose ranges between 25% and 75% being less than 60% in most studies, both for rectal wall invasion and for lymph nodes involvement. In particular the ability to predict complete pathological response, in order to tailor the surgical approach, remains low. Due to the radio-induced tissue modifications, combined with imaging technical aspects, low rate accuracy is achieved, making modern imaging techniques still unreliable in restaging rectal cancer after chemo-radiotherapy.

Keywords: Rectal cancer, Restaging, Neoadjuvant therapies, Diagnostic accuracy, Complete pathological response

Core tip: Neoadjuvant chemoradiotherapy has become the standard treatment for patients with advanced rectal cancer allowing reduction of local recurrences and increased sphincters’ preservation. New trends have proposed the possibility to change the planned surgical resection after neoadjuvant treatment, in case of extensive tumor response, and several Authors claim limited resection or non operative “wait and see” policy. In this setting restaging plays a crucial role in identifying patients with complete response. The diagnostic accuracy in predicting tumor response of the currently available imaging techniques is extensively reviewed in order to determine the reliability.