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Troester AM, Gaertner WB. Contemporary management of rectal cancer. Surg Open Sci 2024; 18:17-22. [PMID: 38312301 PMCID: PMC10832461 DOI: 10.1016/j.sopen.2024.01.009] [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: 11/20/2023] [Accepted: 01/02/2024] [Indexed: 02/06/2024] Open
Abstract
The management of rectal cancer has undergone significant changes over the past 50 years, and this has been associated with major improvements in overall outcomes and quality of life. From standardization of total mesorectal excision to refinements in radiation delivery and shifting of chemoradiotherapy treatment to favor a neoadjuvant approach, as well as the development of targeted chemotherapeutics, these management strategies have continually aimed to achieve locoregional and systemic control while limiting adverse effects and enhance overall survival. This article highlights evolving aspects of rectal cancer therapy including improved staging modalities, total neoadjuvant therapy, the role of short-course and more selective radiotherapy strategies, as well as organ preservation. We also discuss the evolving role of minimally invasive surgery and comment on lateral pelvic lymph node dissection. Key message Rectal cancer management is constantly evolving through refinements in radiation timing and delivery, modification of chemoradiotherapy treatment schedules, and increasing utilization of minimally invasive surgical techniques and organ preservation strategies. This manuscript aims to provide a synopsis of recent changes in the management of rectal cancer, highlighting contemporary modifications in neoadjuvant approaches and surgical management to enhance the knowledge of surgeons who care for this challenging population.
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Affiliation(s)
- Alexander M. Troester
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
| | - Wolfgang B. Gaertner
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
- Division of Colon & Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, United States of America
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Peng W, Qiao H, Mo L, Guo Y. Progress in the diagnosis of lymph node metastasis in rectal cancer: a review. Front Oncol 2023; 13:1167289. [PMID: 37519802 PMCID: PMC10374255 DOI: 10.3389/fonc.2023.1167289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Historically, the chief focus of lymph node metastasis research has been molecular and clinical studies of a few essential pathways and genes. Recent years have seen a rapid accumulation of massive omics and imaging data catalyzed by the rapid development of advanced technologies. This rapid increase in data has driven improvements in the accuracy of diagnosis of lymph node metastasis, and its analysis further demands new methods and the opportunity to provide novel insights for basic research. In fact, the combination of omics data, imaging data, clinical medicine, and diagnostic methods has led to notable advances in our basic understanding and transformation of lymph node metastases in rectal cancer. Higher levels of integration will require a concerted effort among data scientists and clinicians. Herein, we review the current state and future challenges to advance the diagnosis of lymph node metastases in rectal cancer.
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Affiliation(s)
- Wei Peng
- Medical Big Data and Bioinformatics Research Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- School of Public Health and Health Management, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Huimin Qiao
- Medical Big Data and Bioinformatics Research Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- School of Public Health and Health Management, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Linfeng Mo
- School of Health and Medicine, Guangzhou Huashang Vocational College, Guangzhou, Guangdong, China
| | - You Guo
- Medical Big Data and Bioinformatics Research Centre, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
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Ishizaki T, Mazaki J, Kasahara K, Udo R, Tago T, Nagakawa Y. Robotic versus laparoscopic approach for minimally invasive lateral pelvic lymph node dissection of advanced lower rectal cancer: a retrospective study comparing short-term outcomes. Tech Coloproctol 2023:10.1007/s10151-023-02818-x. [PMID: 37157049 DOI: 10.1007/s10151-023-02818-x] [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: 10/01/2022] [Accepted: 04/27/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE The importance of lateral pelvic lymph node dissection (LLND) for advanced low rectal cancer is gradually being recognized in Europe and the USA, where some patients were affected by uncontrolled lateral pelvic lymph node (LLNs) metastasis, even after total mesorectal excision (TME) with neoadjuvant chemoradiotherapy (CRT). The purpose of this study was thus to compare robotic LLND (R-LLND) with laparoscopic (L-LLND) to clarify the safety and advantages of R-LLND. METHODS Sixty patients were included in this single-institution retrospective study between January 2013 and July 2022. We compared the short-term outcomes of 27 patients who underwent R-LLND and 33 patients who underwent L-LLND. RESULTS En bloc LLND was performed in significantly more patients in the R-LLND than in the L-LLND group (48.1% vs. 15.2%; p = 0.006). The numbers of LLNs on the distal side of the internal iliac region (LN 263D) harvested were significantly higher in the R-LLND than in the L-LLND group (2 [0-9] vs. 1 [0-6]; p = 0.023). The total operative time was significantly longer in the R-LLND than in the L-LLND group (587 [460-876] vs. 544 [398-859]; p = 0.003); however, the LLND time was not significantly different between groups (p = 0.718). Postoperative complications were not significantly different between the two groups. CONCLUSION The present study clarified the safety and technical feasibility of R-LLND with respect to L-LLND. Our findings suggest that the robotic approach offers a key advantage, allowing significantly more LLNs to be harvested from the distal side of the internal iliac region (LN 263D). Prospective clinical trials examining the oncological superiority of R-LLND are thus necessary in the near future.
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Affiliation(s)
- Tetsuo Ishizaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan.
| | - Junichi Mazaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
| | - Kenta Kasahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
| | - Ryutaro Udo
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
| | - Tomoya Tago
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
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Determinants of Pre-Surgical Treatment in Primary Rectal Cancer: A Population-Based Study. Cancers (Basel) 2023; 15:cancers15041154. [PMID: 36831497 PMCID: PMC9954598 DOI: 10.3390/cancers15041154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023] Open
Abstract
When preoperative radiotherapy (RT) is best used in rectal cancer is subject to discussions and guidelines differ. To understand the selection mechanisms, we analysed treatment decisions in all patients diagnosed between 2010-2020 in two Swedish regions (Uppsala with a RT department and Dalarna without). Information on staging and treatment (direct surgery, short-course RT, or combinations of RT/chemotherapy) in the Swedish Colorectal Cancer Registry were used. Staging magnetic resonance imaging (MRI) permitted a division into risk groups, according to national guidelines. Logistic regression explored associations between baseline characteristics and treatment, while Cohen's kappa tested congruence between clinical and pathologic stages. A total of 1150 patients without synchronous metastases were analysed. Patients from Dalarna were older, had less advanced tumours and were pre-treated less often (52% vs. 63%, p < 0.001). All MRI characteristics (T-/N-stage, MRF, EMVI) and tumour levels were important for treatment choice. Age affected if chemotherapy was added. The correlation between clinical and pathological T-stage was fair/moderate and poor for N-stage. The MRI-based risk grouping influenced treatment choice the most. Since the risk grouping was modified to diminish the pre-treated proportion, fewer patients were irradiated with time. MRI staging is far from optimal. A stronger wish to decrease irradiation may explain why fewer patients from Dalarna were irradiated, but inequality in health care cannot be ruled out.
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Emile SH, Silva-Alvarenga E, Horesh N, Freund MR, Garoufalia Z, Wexner SD. Concordance between clinical and pathologic assessment of T and N stages of rectal adenocarcinoma patients who underwent surgery without neoadjuvant therapy: A National Cancer Database analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:426-432. [PMID: 36257901 DOI: 10.1016/j.ejso.2022.09.014] [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: 06/27/2022] [Revised: 09/01/2022] [Accepted: 09/21/2022] [Indexed: 10/07/2022]
Abstract
BACKGROUND Clinical assessment of T and N stages in rectal cancer is important to guide decision-making. The present study aimed to assess the accuracy of the clinical T and N staging of rectal cancer compared to the pathological staging and their overall agreement in a large cohort of patients. METHODS This retrospective study used data from the National Cancer Database (NCDB) between 2004 and 2017. Patients with non-metastatic rectal adenocarcinoma who did not receive neoadjuvant therapy were reviewed and the clinical T and N stages were compared to their pathologic counterparts. The overall concordance between clinical and pathologic assessments was calculated using Kappa coefficient. RESULTS The study included 8929 patients (57.3% male) with a mean age of 64 years. Clinical T stage and N stage were identical to pathologic stages in 70.3% and 77.6% of patients, respectively. Sensitivity and specificity of the clinical assessment of N stage was 35.2% and 95.5%, respectively. Concordance between the clinical and pathologic stages was moderate for the T stage (kappa = 0.575) and fair for the N stage (kappa = 0.346). Pathologic T4 stage (OR: 2.12, p < 0.0001), poorly differentiated adenocarcinoma (OR: 1.45, p = 0.026), lymphovascular invasion (OR: 4.5, p < 0.001), and longer time from diagnosis to first treatment (OR = 0.996, p = 0.046) were the independent predictors of N stage discrepancy. CONCLUSIONS There was a moderate agreement between the clinical and pathologic T stages and a fair agreement between the clinical and pathologic N stages. The clinical assessment of the N stage was highly specific yet had low sensitivity.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA; Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Emanuela Silva-Alvarenga
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA; Department of Surgery and Transplantation, Sheba Medical Center, Ramat Gan, Tel Aviv University, Tel Aviv, Israel
| | - Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA; Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA.
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Li Z, Huang S, He Y, van Wijnbergen JW, Zhang Y, Cottrell RD, Smith SG, Hammond PT, Chen DZ, Padera TP, Belcher AM. A new label-free optical imaging method for the lymphatic system enhanced by deep learning. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.01.13.523938. [PMID: 36711668 PMCID: PMC9882203 DOI: 10.1101/2023.01.13.523938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Our understanding of the lymphatic vascular system lags far behind that of the blood vascular system, limited by available imaging technologies. We present a label-free optical imaging method that visualizes the lymphatic system with high contrast. We developed an orthogonal polarization imaging (OPI) in the shortwave infrared range (SWIR) and imaged both lymph nodes and lymphatic vessels of mice and rats in vivo through intact skin, as well as human mesenteric lymph nodes in colectomy specimens. By integrating SWIR-OPI with U-Net, a deep learning image segmentation algorithm, we automated the lymph node size measurement process. Changes in lymph nodes in response to cancer progression were monitored in two separate mouse cancer models, through which we obtained insights into pre-metastatic niches and correlation between lymph node masses and many important biomarkers. In a human pilot study, we demonstrated the effectiveness of SWIR-OPI to detect human lymph nodes in real time with clinical colectomy specimens. One Sentence Summary We develop a real-time high contrast optical technique for imaging the lymphatic system, and apply it to anatomical pathology gross examination in a clinical setting, as well as real-time monitoring of tumor microenvironment in animal studies.
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Zhang C, Cui M, Xing J, Yang H, Yao Z, Zhang N, Tan F, Liu M, Xu K, Su X. Effect of lateral lymph nodes without malignant characteristics on the prognosis of patients with rectal cancer. Future Oncol 2022; 18:3509-3518. [PMID: 36317561 DOI: 10.2217/fon-2022-0476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Lateral lymph node (LLN) metastasis is a poor prognostic factor for rectal cancer patients. However, the effect of LLNs without malignant characteristics on the prognosis of rectal cancer patients has been uncertain. Methods: Consecutive patients who underwent laparoscopic-assisted low anterior resection were included. Patients with MRI-detected LLNs, but without malignant characteristics, were compared with patients with no MRI-detected LLNs. Results: The local recurrence rate was higher in the LLN-present group than in the LLN-absent group (9.8% vs 2.5%; p = 0.056). The overall survival of patients with no MRI-detected LLNs was significantly better than that of patients with MRI-detected LLNs (p = 0.021). Conclusion: The presence of LLNs, even without malignant features, may lead to worse local control and overall survival.
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Affiliation(s)
- Chenghai Zhang
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Ming Cui
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Jiadi Xing
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Hong Yang
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Zhendan Yao
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Nan Zhang
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Fei Tan
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Maoxing Liu
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Kai Xu
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
| | - Xiangqian Su
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital & Institute, 52 Fu-Cheng Road, Hai-Dian District, Beijing, 100142, China
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Song G, Li P, Wu R, Jia Y, Hong Y, He R, Li J, Zhang R, Li A. Development and validation of a high-resolution T2WI-based radiomic signature for the diagnosis of lymph node status within the mesorectum in rectal cancer. Front Oncol 2022; 12:945559. [PMID: 36185279 PMCID: PMC9523667 DOI: 10.3389/fonc.2022.945559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose The aim of this study was to explore the feasibility of a high-resolution T2-weighted imaging (HR-T2WI)-based radiomics prediction model for diagnosing metastatic lymph nodes (LNs) within the mesorectum in rectal cancer. Method A total of 604 LNs (306 metastatic and 298 non-metastatic) from 166 patients were obtained. All patients underwent HR-T2WI examination and total mesorectal excision (TME) surgery. Four kinds of segmentation methods were used to select region of interest (ROI), including method 1 along the border of LNs; method 2 along the expanded border of LNs with an additional 2–3 mm; method 3 covering the border of LNs only; and method 4, a circle region only within LNs. A total of 1,409 features were extracted for each method. Variance threshold method, Select K Best, and Lasso algorithm were used to reduce the dimension. All LNs were divided into training and test sets. Fivefold cross-validation was used to build the logistic model, which was evaluated by the receiver operating characteristic (ROC) with four indicators, including area under the curve (AUC), accuracy (ACC), sensitivity (SE), and specificity (SP). Three radiologists with different working experience in diagnosing rectal diseases assessed LN metastasis respectively. The diagnostic efficiencies with each of four segmentation methods and three radiologists were compared to each other. Results For the test set, the AUCs of four segmentation methods were 0.820, 0.799, 0.764, and 0.741; the ACCs were 0.725, 0.704, 0.709, and 0.670; the SEs were 0.756, 0.634, 0.700, and 0.589; and the SPs were 0.696, 0.772, 0.717, and 0.750, respectively. There was no statistically significant difference in AUC between the four methods (p > 0.05). Method 1 had the highest values of AUC, ACC, and SE. For three radiologists, the overall diagnostic efficiency was moderate. The corresponding AUCs were 0.604, 0.634, and 0.671; the ACCs were 0.601, 0.632, and 0.667; the SEs were 0.366, 0.552, and 0.392; and the SPs were 0.842, 0.715, and 0.950, respectively. Conclusions The proposed HR-T2WI-based radiomic signature exhibited a robust performance on predicting mesorectal LN status and could potentially be used for clinicians in order to determine the status of metastatic LNs in rectal cancer patients.
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Affiliation(s)
- Gesheng Song
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Panpan Li
- Department of Radiology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Rui Wu
- Department of Radiology, Shandong University, Jinan, China
| | - Yuping Jia
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yu Hong
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Rong He
- Department of Radiology, The Shandong First Medical University, Jinan, China
| | - Jinye Li
- Department of Radiology, Shandong Provincial ENT Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ran Zhang
- Marketing, Medical Technology Co., Ltd., Beijing, China
| | - Aiyin Li
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
- *Correspondence: Aiyin Li,
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Zhuang Z, Ma X, Zhang Y, Yang X, Wei M, Deng X, Wang Z. Establishment and validation of nomograms for predicting mesorectal lymph node staging and restaging. Int J Colorectal Dis 2022; 37:2069-2083. [PMID: 36028723 DOI: 10.1007/s00384-022-04244-1] [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] [Accepted: 08/15/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Preoperative determination of lymph node (LN) status is crucial in treatment planning for rectal cancer. This study prospectively evaluated the risk factors for lymph node metastasis (LNM) at staging and restaging based on a node-by-node pairing between MRI imaging findings and histopathology and constructed nomograms to evaluate its diagnostic value. METHODS From July 2021 to July 2022, patients with histopathologically verified rectal cancer who underwent MRI before surgery were prospectively enrolled. Histological examination of each LN status in the surgical specimens and anatomical matching with preoperative imaging. Taking histopathological results as the gold standard, federating clinical features from patients and LN imaging features on MRI-T2WI. Risk factors for LN metastasis were identified by multivariate logistic regression analysis and used to create a nomogram. The performance of the nomograms was assessed with calibration plots and bootstrapped-concordance index and validated using validation cohorts. RESULTS A total of 500 target LNs in 120 patients were successfully matched with node-by-node comparisons. A total of 353 LNs did not receive neoadjuvant therapy and 147 LNs received neoadjuvant chemoradiotherapy (neoCRT). Characterization of LNs not receiving neoadjuvant therapy and multivariate regression showed that the short diameter, preoperative CEA level, mrT-stage, border contour, and signal intensity were associated with a high risk of LN metastasis (P < 0.05). The nomogram predicted that the area under the curve was 0.855 (95% CI, 0.794-0.916) and 0.854 (95% CI, 0.727-0.980) in the training and validation cohorts, respectively. In the neoadjuvant therapy group, short diameter, ymrT-stage, internal signal, and MRI-EMVI were associated with LN positivity (P < 0.05), and the area under the curves using the nomogram was 0.912 (95% CI, 0.856-0.968) and 0.915 (95% CI, 0.817-1.000) in two cohorts. The calibration curves demonstrate good agreement between the predicted and actual probabilities for both the training and validation cohorts. CONCLUSION Our nomograms combined with preoperative clinical and imaging biomarkers have the potential to improve the prediction of nodal involvement, which can be used as an essential reference for preoperative N staging and restaging of rectal cancer.
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Affiliation(s)
- Zixuan Zhuang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xueqin Ma
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Zhang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xuyang Yang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Mingtian Wei
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiangbing Deng
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China.
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Ishizaki T, Mazaki J, Enomoto M, Udo R, Tago T, Kasahara K, Kuwabara H, Katsumata K, Nagakawa Y. A new technique for robotic lateral pelvic lymph node dissection for advanced low rectal cancer with emphasis on en bloc resection and inferior vesical vessel preservation. Surg Endosc 2022; 36:7789-7793. [DOI: 10.1007/s00464-022-09275-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/09/2022] [Indexed: 11/24/2022]
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Ogawa S, Itabashi M, Inoue Y, Ohki T, Bamba Y, Koshino K, Nakagawa R, Tani K, Aihara H, Kondo H, Yamaguchi S, Yamamoto M. Lateral pelvic lymph nodes for rectal cancer: A review of diagnosis and management. World J Gastrointest Oncol 2021; 13:1412-1424. [PMID: 34721774 PMCID: PMC8529924 DOI: 10.4251/wjgo.v13.i10.1412] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/21/2021] [Accepted: 08/24/2021] [Indexed: 02/06/2023] Open
Abstract
The current status and future prospects for diagnosis and treatment of lateral pelvic lymph node (LPLN) metastasis of rectal cancer are described in this review. Magnetic resonance imaging (MRI) is recommended for the diagnosis of LPLN metastasis. A LPLN-positive status on MRI is a strong risk factor for metastasis, and evaluation by MRI is important for deciding treatment strategy. LPLN dissection (LPLD) has an advantage of reducing recurrence in the lateral pelvis but also has a disadvantage of complications; therefore, LPLD may not be appropriate for cases that are less likely to have LPLN metastasis. Radiation therapy (RT) and chemoradiation therapy (CRT) have limited effects in cases with suspected LPLN metastasis, but a combination of preoperative CRT and LPLD may improve the treatment outcome. Thus, RT and CRT plus selective LPLD may be a rational strategy to omit unnecessary LPLD and produce a favorable treatment outcome.
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Affiliation(s)
- Shimpei Ogawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Michio Itabashi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Yuji Inoue
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Takeshi Ohki
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Yoshiko Bamba
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Kurodo Koshino
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Ryosuke Nakagawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Kimitaka Tani
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Hisako Aihara
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Hiroka Kondo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Shigeki Yamaguchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
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Zhuang Z, Zhang Y, Wei M, Yang X, Wang Z. Magnetic Resonance Imaging Evaluation of the Accuracy of Various Lymph Node Staging Criteria in Rectal Cancer: A Systematic Review and Meta-Analysis. Front Oncol 2021; 11:709070. [PMID: 34327144 PMCID: PMC8315047 DOI: 10.3389/fonc.2021.709070] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/22/2021] [Indexed: 02/05/2023] Open
Abstract
Background Magnetic resonance imaging (MRI)-based lymph node staging remains a significant challenge in the treatment of rectal cancer. Pretreatment evaluation of lymph node metastasis guides the formulation of treatment plans. This systematic review aimed to evaluate the diagnostic performance of MRI in lymph node staging using various morphological criteria. Methods A systematic search of the EMBASE, Medline, and Cochrane databases was performed. Original articles published between 2000 and January 2021 that used MRI for lymph node staging in rectal cancer were eligible. The included studies were assessed using the QUADAS-2 tool. A bivariate random-effects model was used to conduct a meta-analysis of diagnostic test accuracy. Results Thirty-seven studies were eligible for this meta-analysis. The pooled sensitivity, specificity, and diagnostic odds ratio of preoperative MRI for the lymph node stage were 0.73 (95% confidence interval [CI], 0.68–0.77), 0.74 (95% CI, 0.68–0.80), and 7.85 (95% CI, 5.78–10.66), respectively. Criteria for positive mesorectal lymph node metastasis included (A) a short-axis diameter of 5 mm, (B) morphological standard, including an irregular border and mixed-signal intensity within the lymph node, (C) a short-axis diameter of 5 mm with the morphological standard, (D) a short-axis diameter of 8 mm with the morphological standard, and (E) a short-axis diameter of 10 mm with the morphological standard. The pooled sensitivity/specificity for these criteria were 75%/64%, 81%/67%, 74%/79%, 72%/66%, and 62%/91%, respectively. There was no significant difference among the criteria in sensitivity/specificity. The area under the receiver operating characteristic (ROC) curve values of the fitted summary ROC indicated a diagnostic accuracy rate of 0.75–0.81. Conclusion MRI scans have minimal accuracy as a reference index for pretreatment staging of various lymph node staging criteria in rectal cancer. Multiple types of evidence should be used in clinical decision-making.
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Affiliation(s)
- Zixuan Zhuang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yang Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Mingtian Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xuyang Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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13
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Tsukamoto S, Fujita S, Ota M, Mizusawa J, Shida D, Kanemitsu Y, Ito M, Shiomi A, Komori K, Ohue M, Akazai Y, Shiozawa M, Yamaguchi T, Bando H, Tsuchida A, Okamura S, Akagi Y, Takiguchi N, Saida Y, Akasu T, Moriya Y. Long-term follow-up of the randomized trial of mesorectal excision with or without lateral lymph node dissection in rectal cancer (JCOG0212). Br J Surg 2020; 107:586-594. [PMID: 32162301 DOI: 10.1002/bjs.11513] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/29/2019] [Accepted: 12/18/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Japan Clinical Oncology Group (JCOG) 0212 (ClinicalTrials.gov NCT00190541) was a non-inferiority phase III trial of patients with clinical stage II-III rectal cancer without lateral pelvic lymph node enlargement. The trial compared mesorectal excision (ME) with ME and lateral lymph node dissection (LLND), with a primary endpoint of recurrence-free survival (RFS). The planned primary analysis at 5 years failed to confirm the non-inferiority of ME alone compared with ME and LLND. The present study aimed to compare ME alone and ME with LLND using long-term follow-up data from JCOG0212. METHODS Patients with clinical stage II-III rectal cancer below the peritoneal reflection and no lateral pelvic lymph node enlargement were included in this study. After surgeons confirmed R0 resection by ME, patients were randomized to receive ME alone or ME with LLND. The primary endpoint was RFS. RESULTS A total of 701 patients from 33 institutions were assigned to ME with LLND (351) or ME alone (350) between June 2003 and August 2010. The 7-year RFS rate was 71.1 per cent for ME with LLND and 70·7 per cent for ME alone (hazard ratio (HR) 1·09, 95 per cent c.i. 0·84 to 1·42; non-inferiority P = 0·064). Subgroup analysis showed improved RFS among patients with clinical stage III disease who underwent ME with LLND compared with ME alone (HR 1·49, 1·02 to 2·17). CONCLUSION Long-term follow-up data did not support the non-inferiority of ME alone compared with ME and LLND. ME with LLND is recommended for patients with clinical stage III disease, whereas LLND could be omitted in those with clinical stage II tumours.
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Affiliation(s)
- S Tsukamoto
- Department of Colorectal Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - S Fujita
- Department of Surgery, Tochigi Cancer Centre, Tochigi, Japan
| | - M Ota
- Department of Surgery, Yokohama City University Medical Centre, Kanagawa, Japan
| | - J Mizusawa
- Japan Clinical Oncology Group Data Centre and Operations Office, National Cancer Centre Hospital, Tokyo Medical University Hospital, Tokyo, Japan
| | - D Shida
- Department of Colorectal Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Y Kanemitsu
- Department of Colorectal Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - M Ito
- Colorectal Surgery Division, National Cancer Centre Hospital East, Chiba, Japan
| | - A Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Centre Hospital, Shizuoka, Japan
| | - K Komori
- Department of Surgery, Aichi Cancer Centre Hospital, Aichi, Japan
| | - M Ohue
- Department of Gastroenterological Surgery, Suita Municipal Hospital, Osaka International Cancer Institute, Japan
| | - Y Akazai
- Department of Surgery, Okayama Saiseikai General Hospital, Okayama, Japan
| | - M Shiozawa
- Department of Surgery, Kanagawa Cancer Centre, Kanagawa, Japan
| | - T Yamaguchi
- Department of Surgery, Kyoto Medical Centre, Kyoto, Japan
| | - H Bando
- Department of Surgery, Ishikawa Prefectural Central Hospital, Ishikawa, Japan
| | - A Tsuchida
- Department of Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - S Okamura
- Department of Surgery, Suita Municipal Hospital, Osaka, Japan
| | - Y Akagi
- Department of Surgery, Kurume University, Fukuoka, Japan
| | - N Takiguchi
- Department of Gastrointestinal Surgery, Chiba Cancer Centre, Chiba, Japan
| | - Y Saida
- Department of Surgery, Toho University Ohashi Medical Centre, Tokyo, Japan
| | - T Akasu
- Hospital of the Imperial Household, Tokyo, Japan
| | - Y Moriya
- Department of Surgery, Miki Hospital, Iwate, Japan
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14
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Abstract
The imaging of rectal cancer has evolved noticeably over the past 2 decades, paralleling the advances in therapy. The methods for imaging rectal cancer are increasingly used in clinical practice with the purpose of helping to detect, characterize and stage rectal cancer. In this setting, MR imaging emerged as the most useful imaging method for primary staging of rectal cancer; the present review focuses on the role of MR imaging in this regard.
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16
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Yap KSK, Mehta OH, Lau WFE, Akhurst T, Warrier S, Heriot A, Hicks RJ. Does addition of a diagnostic contrast-enhanced CT to a contemporaneous PET/CT provide incremental value in patients for restaging of colorectal carcinoma? Eur J Hybrid Imaging 2018. [DOI: 10.1186/s41824-018-0046-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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17
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von den Grün JM, Hartmann A, Fietkau R, Ghadimi M, Liersch T, Hohenberger W, Weitz J, Sauer R, Wittekind C, Ströbel P, Rödel C, Fokas E. Can clinicopathological parameters predict for lymph node metastases in ypT0-2 rectal carcinoma? Results of the CAO/ARO/AIO-94 and CAO/ARO/AIO-04 phase 3 trials. Radiother Oncol 2018; 128:557-563. [PMID: 29929861 DOI: 10.1016/j.radonc.2018.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/29/2018] [Accepted: 06/04/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The advent of less radical surgical approaches has generated concern about leaving locoregional lymph node metastases (LNM) unresected that could lead to adverse outcome. We examined the prognostic role of clinicopathological factors for ypN-positivity in patients with ypT0-2 rectal carcinoma treated within the CAO/ARO/AIO-94 and CAO/ARO/AIO-04 randomized phase 3 trials. METHODS The correlation of clinicopathological factors with ypN-status (ypN0 vs ypN1/2) was examined in n = 776 patients with ypT0-2 rectal carcinoma after preoperative CRT and total mesorectal excision surgery using Pearson's Chi-squared test for categorical variables and Kruskal-Wallis' test for continuous variables. Multivariable analysis was performed using binary logistic regression to identify independent prognosticators for ypN-positivity. RESULTS Residual LNM (ypN+) were found in 6%, 20.8% and 21.4% of patients with ypT0, ypT1 and ypT2 carcinomas, respectively. Independent prognosticators for LNM were advanced ypT category (p = 0.002) and lymphatic invasion (p = 0.020). In a separate multivariable analysis performed upon exclusion of ypT-category due to multicollinearity with residual tumor diameter (RTD), lymphatic invasion (p = 0.015) and RTD ≥10 mm (p = 0.005) demonstrated strong correlation with LNM. CONCLUSION Advanced ypT-stage, lymphatic invasion and RTD ≥10 mm were prognostic factors for LNM in patients ypT0-2 rectal carcinoma treated with CRT and surgery within both phase 3 trials. The high incidence of LNM in the ypT1-2 group needs to be taken into consideration in the context of oncological safety and indicate that LE should be advocated with great caution in this patient subgroup. The prognostic pathological factor identified here could help guide decision of LE vs TME after standard CRT.
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Affiliation(s)
| | - Arndt Hartmann
- Institute of Pathology, University of Erlangen, Nürnberg, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology and Radiotherapy, University of Erlangen, Nürnberg, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Torsten Liersch
- Department of General, Visceral and Pediatric Surgery, University Medical Center, Göttingen, Germany
| | - Werner Hohenberger
- Department of General and Visceral and Pediatric Surgery, University of Erlangen, Nürnberg, Germany
| | - Jürgen Weitz
- Department of General and Visceral and Pediatric Surgery, University of Dresden, Germany
| | - Rolf Sauer
- Department of Radiation Oncology and Radiotherapy, University of Erlangen, Nürnberg, Germany
| | | | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, Germany
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany
| | - Emmanouil Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Germany.
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Abstract
PUPRPOSE Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options. METHODS A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum. RESULTS Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery. CONCLUSION Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.
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Liu Y, Wang R, Ding Y, Tu S, Liu Y, Qian Y, Xu L, Tong T, Cai S, Peng J. A predictive nomogram improved diagnostic accuracy and interobserver agreement of perirectal lymph nodes metastases in rectal cancer. Oncotarget 2018; 7:14755-64. [PMID: 26910373 PMCID: PMC4924749 DOI: 10.18632/oncotarget.7548] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/29/2016] [Indexed: 12/19/2022] Open
Abstract
Objective To develop a predictive nomogram to improve the diagnostic accuracy and interobserver agreement of pre-therapeutic lymph nodes metastases in patients with rectal cancer. Materials and Methods An institutional database of 411 patients with rectal cancer was used to develop a nomogram to predict perirectal lymph nodes metastases. Patients' clinicopathological and MRI-assessed imaging variables were included in the multivariate logistic regression analysis. The model was externally validated and the performance was assessed by area under curve (AUC) of the receiver operator characteristics (ROC) curves. The interobserver agreement was measured between two independent radiologists. Results The diagnostic accuracy of the conventional MRI-assessed cN stage was 68%; 14.2% of the patients were over-staged and 17.8% of the patients were under-staged. A total of 35.1% of the patients had disagreed diagnosis for the cN stage between the two radiologists, with a kappa value of 0.295. A nomogram for predicting pathological lymph nodes metastases was successfully developed, with an AUC of 0.78 on the training data and 0.71 on the validation data. The predictors included in the nomogram were MRI cT stage, CRM involvement, preoperative CEA, tumor grade and lymph node size category. This nomogram yielded improved prediction in cN stage than the conventional MRI-based assessment. Conclusions By incorporating clinicopathological and MRI imaging features, we established a nomogram that improved the diagnostic accuracy and remarkably minimized the interobserver disagreement in predicting lymph nodes metastases in rectal cancers.
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Affiliation(s)
- Yongfeng Liu
- Institute of Health Sciences, Shanghai Jiao Tong University School of Medicine (SJTUSM) and Shanghai Institutes for Biological Sciences (SIBS), Chinese Academy of Sciences (CAS), Shanghai, China
| | - Renjie Wang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ying Ding
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shanshan Tu
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yi Liu
- Department of Statistics, Ohio State University, Columbus, OH, USA
| | - Youcun Qian
- Institute of Health Sciences, Shanghai Jiao Tong University School of Medicine (SJTUSM) and Shanghai Institutes for Biological Sciences (SIBS), Chinese Academy of Sciences (CAS), Shanghai, China
| | - Linghui Xu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Tong Tong
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Sanjun Cai
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Junjie Peng
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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20
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Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer. Int J Colorectal Dis 2017; 32:1631-1637. [PMID: 28762190 DOI: 10.1007/s00384-017-2873-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to identify the size criteria of lateral lymph node metastasis in lower rectal cancer both in patients who underwent preoperative CRT and those who did not. METHODS This study enrolled 150 patients who underwent resection for primary lower rectal adenocarcinoma with lateral lymph node dissection between 2013 and 2015. Patients were divided into two groups: the CRT group, treated with preoperative chemoradiotherapy before surgery, and the non-CRT group, treated with surgery alone. The short-axis diameter of each dissected lateral lymph node was measured. Receiver-operating characteristic curves were generated to reveal the optimal cutoff values for determining lateral lymph node metastasis in both groups. RESULTS In the non-CRT group (n = 131), the ROC curve demonstrated that the optimal cutoff value for determining metastasis was 6.0 mm, with a sensitivity of 78.5% and specificity of 82.9%, and the AUC was 0.845. In comparison, in the CRT group (n = 19), the optimal cutoff value was 5.0 mm, with a sensitivity of 71.4% and specificity of 85.3% and an AUC of 0.836. CONCLUSION The cutoff size for determining lateral lymph node metastasis was smaller in the CRT group than in the non-CRT group.
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21
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Prediction of lateral pelvic lymph node metastasis from lower rectal cancer using magnetic resonance imaging and risk factors for metastasis: Multicenter study of the Lymph Node Committee of the Japanese Society for Cancer of the Colon and Rectum. Int J Colorectal Dis 2017; 32:1479-1487. [PMID: 28762189 DOI: 10.1007/s00384-017-2874-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The goal of the study was to examine prediction of lateral pelvic lymph node (LPLN) metastasis from lower rectal cancer using a logistic model including risk factors for LPLN metastasis and magnetic resonance imaging (MRI) clinical LPLN (cLPLN) status, compared to prediction based on MRI alone. METHODS The subjects were 272 patients with lower rectal cancer who underwent MRI prior to mesorectal excision combined with LPLN dissection (LPLD) at six institutes. No patients received neoadjuvant therapy. Prediction models for right and left pathological LPLN (pLPLN) metastasis were developed using cLPLN status, histopathological grade, and perirectal lymph node (PRLN) status. For evaluation, data for patients with left LPLD were substituted into the right-side equation and vice versa. RESULTS Left LPLN metastasis was predicted using the right-side model with accuracy of 86.5%, sensitivity 56.4%, specificity 92.7%, positive predictive value (PPV) 61.1%, and negative predictive value (NPV) 91.2%, while these data using MRI cLPLN status alone were 80.4, 76.9, 81.2, 45.5, and 94.5%, respectively. Similarly, right LPLN metastasis was predicted using the left-side equation with accuracy of 83.8%, sensitivity 57.8%, specificity 90.4%, PPV 60.5%, and NPV 89.4%, and the equivalent data using MRI alone were 78.4, 68.9, 80.8, 47.7, and 91.1%, respectively. The AUCs for the right- and left-side equations were significantly higher than the equivalent AUCs for MRI cLPLN status alone. CONCLUSIONS A logistic model including risk factors for LPLN metastasis and MRI findings had significantly better performance for prediction of LPLN metastasis compared with a model based on MRI findings alone.
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Balyasnikova S, Read J, Wotherspoon A, Rasheed S, Tekkis P, Tait D, Cunningham D, Brown G. Diagnostic accuracy of high-resolution MRI as a method to predict potentially safe endoscopic and surgical planes in patients with early rectal cancer. BMJ Open Gastroenterol 2017; 4:e000151. [PMID: 29259791 PMCID: PMC5730880 DOI: 10.1136/bmjgast-2017-000151] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/08/2017] [Accepted: 06/19/2017] [Indexed: 12/26/2022] Open
Abstract
Introduction Early rectal cancer (ERC) assessment should include prediction of the potential excision plane to safely remove lesions with clear deep margins and feasibility of organ preservation. Method MRI accuracy for differentiating ≤T1sm2 (partially preserved submucosa) or ≤T2 (partially preserved muscularis) versus >T2 tumours was compared with the gold standard of pT stage T1sm1/2 versus ≤pT2 versus >pT2. N stage was also compared. The MRI protocol employed a standard surface phased array coil with a high resolution (0.6×0.6×3 mm resolution). The staging data were analysed from a prospectively recorded database of all ERC (≤mrT3b) treated by primary surgery. Results Of 65 <mrT3b tumours, 45 were ≤pT2 and 14 were ≤pT1sm2. MRI accuracy for ≤T1sm2 was 89% (95% CI 63% to 87%), positive predictive value (PPV) 77% and negative predictive value (NPV) 92%, and for ≤T2 89% (95% CI 79% to 95%), PPV 93% and NPV 81%. Interobserver agreement between two experienced radiologists was >0.7 suggesting good agreement. 44 out of 65 patients underwent radical surgery and 22 out of 44 were ≤mrT2. MRI accuracy to predict lymph node status was 84% (95% CI 70% to 92%), PPV 71% and NPV 90%. Among the 21 out of 65 (32%) patients undergoing local excision or TEM, 20 out of 21 were staged as MR≤T2 and confirmed as such by pathology. On follow-up, none had relapse. If the decision had been made to offer local excision on MRI TN staging rather than clinical assessment, a significant increase in organ preservation surgery from 32% to 60% would have been observed (difference 23%, 95% CI 9% to 35%). Conclusions MRI is a useful tool for multidisciplinary teams (MDTs) wishing to optimise treatment options for ERC; these study findings will be validated in a prospective multicentre trial.
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Affiliation(s)
- Svetlana Balyasnikova
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, Surrey, UK.,Imperial College London, London, UK.,The State Scientific Center of Coloproctology, Moscow, Russia
| | - James Read
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, Surrey, UK.,Imperial College London, London, UK.,Croydon University Hospital, Croydon, Surrey, UK
| | | | - S Rasheed
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, Surrey, UK
| | - Paris Tekkis
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, Surrey, UK.,Imperial College London, London, UK
| | - Diana Tait
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, Surrey, UK
| | - David Cunningham
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, Surrey, UK
| | - G Brown
- The Royal Marsden Hospital, NHS Foundation Trust, Sutton, Surrey, UK.,Imperial College London, London, UK
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The More the Better-Lower Rate of Stage Migration and Better Survival in Patients With Retrieval of 20 or More Regional Lymph Nodes in Pancreatic Cancer: A Population-Based Propensity Score Matched and Trend SEER Analysis. Pancreas 2017; 46:648-657. [PMID: 28196023 DOI: 10.1097/mpa.0000000000000784] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to assess the influence of regional lymph node (RLN) retrieval on stage migration and survival in pancreatic cancer. METHODS A total of 7685 stage I and II pancreatic cancer patients were identified in the Surveillance, Epidemiology, and End Results database in 2004-2011. The impact of RLN was assessed using Cox regression, propensity score methods, and joinpoint regression. RESULTS In 3079 patients, 1 to 10 RLNs were retrieved; in 2799 patients, 11 to 19 RLNs, and in 1807 patients, 20+ RLNs. The rate of node-positive pancreatic cancer increased with the number of retrieved RLN. This trend continued beyond 10 retrieved RLN (P < 0.001). In unadjusted analysis, retrieval of RLN did not influence survival (P = 0.178). When adjusting for significant bias in staging variables (P < 0.001), retrieval of 20+ RLNs compared to 11 to 19 RLNs was associated with an increased survival in node-negative (hazard ratio, 0.78; 95% confidence interval, 0.62-0.98; P = 0.033) and node-positive cancer (hazard ratio, 0.83; 95% confidence interval, 0.74-0.93; P = 0.002). CONCLUSIONS This population-based propensity score-adjusted investigation demonstrated that more retrieved RLNs in pancreatic cancer decreases the rate of stage migration and improves the oncological outcome in node-negative and positive cancer. Contradictory results may be explained by a bias in the cancer characteristics for a different extent of RLN retrieval.
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24
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Lee DH, Lee JM. Whole-body PET/MRI for colorectal cancer staging: Is it the way forward? J Magn Reson Imaging 2016; 45:21-35. [DOI: 10.1002/jmri.25337] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/24/2016] [Indexed: 12/22/2022] Open
Affiliation(s)
- Dong Ho Lee
- Department of Radiology; Seoul National University Hospital; Seoul Korea
- Seoul National University College of Medicine; Seoul Korea
| | - Jeong Min Lee
- Department of Radiology; Seoul National University Hospital; Seoul Korea
- Seoul National University College of Medicine; Seoul Korea
- Institute of Radiation Medicine; Seoul National University Medical Research Center; Seoul Korea
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25
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Yiqun S, Tong T, Fangqi L, Sanjun C, Chao X, Yajia G, Ye X. Recognition of Anterior Peritoneal Reflections and Their Relationship With Rectal Tumors Using Rectal Magnetic Resonance Imaging. Medicine (Baltimore) 2016; 95:e2889. [PMID: 26945377 PMCID: PMC4782861 DOI: 10.1097/md.0000000000002889] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Our goal was to explore the factors influencing the visualization of anterior peritoneal reflections (APRs) using rectal MRI. We evaluated the usefulness of rectal MRI in measuring the distance from the anal verge to the APR and determining the relationship between the APR and the rectal tumor. Clinical and imaging data from 319 patients who underwent surgery after MRI examination between October 2010 and December 2013 were retrospectively analyzed. The distance from the anal verge to the APR and the relationship between the APR and the location of the rectal tumor was evaluated. analysis of variance, logistic regression, independent samples t tests, and Kappa tests were used for statistical analysis. The APR was visible in 283 of 319 cases using rectal MRI. The APR was more readily observed in patients who were older than 58 years (P = 0.046), in patients whose subcutaneous fat thicknesses were >22.2 mm (P = 0.004), in patients with nondistended bladders (P = 0.001), and in those with an anteversion of the uterus (P = 0.001). There was a significant difference between the distance from the anal verge to the APR between females (10.4 ± 1.1 cm) and males (10.0 ± 1.2 cm; P = 0.014). The accuracy in predicting tumor location with respect to the APR was 70%, 50%, 98.2%, respectively for patients with tumors located above, at, and below the APR (compared with the location determined during surgery). Most of the APRs were visible using rectal MRI, whereas certain internal factors influence visualization. Rectal MRI could be a useful tool for evaluating the distance from the anal verge to the APR and relationship between rectal tumors and the APR.
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Affiliation(s)
- Sun Yiqun
- From the Department of Radiology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University (SY, TT, XC, GY); and Department of Colorectal Surgery, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University (LF, CS, XY), Shanghai, China
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Brunner W, Widmann B, Marti L, Tarantino I, Schmied BM, Warschkow R. Predictors for regional lymph node metastasis in T1 rectal cancer: a population-based SEER analysis. Surg Endosc 2016; 30:4405-15. [PMID: 26895892 DOI: 10.1007/s00464-016-4759-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 01/11/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Local resection of early-stage rectal cancer significantly reduces perioperative morbidity compared with radical resection. Identifying patients at risk of regional lymph node metastasis (LNM) is crucial for long-term survival after local resection. METHODS Patients after oncological resection of T1 rectal cancer were identified in the Surveillance, Epidemiology, and End Results register 2004-2012. Potential predictors of LNM and its impact on cancer-specific survival were assessed in logistic and Cox regression with and without multivariable adjustment. RESULTS In total, 1593 patients with radical resection of T1 rectal cancer and a minimum of 12 retrieved regional lymph nodes were identified. The overall LNM rate was 16.3 % (N = 260). A low risk of LNM was observed for small tumor size (P = 0.002), low tumor grade (P = 0.002) and higher age (P = 0.012) in multivariable analysis. The odds ratio for a tumor size exceeding 1.5 cm was 1.49 [95 % confidence interval (CI) 1.06-2.13], for G2 and G3/G4 carcinomas 1.69 (95 % CI 1.07-2.82) and 2.72 (95 % CI 1.50-5.03), and for 65- to 79-year-old and over 80-year-old patients 0.65 (95 % CI 0.43-0.96) and 0.39 (95 % CI 0.18-0.77), respectively. Five-year cancer-specific survival for patients with LNM was 90.0 % (95 % CI 85.3-95.0 %) and for patients without LNM 97.1 % (95 % CI 95.9-98.2 %, hazard ratio = 3.21, 95 % CI 1.82-5.69, P < 0.001). CONCLUSIONS In this population-based analysis, favorable cancer-specific survival rates were observed in nodal-negative and nodal-positive T1 rectal cancer patients after primary radical resection. The predictive value of tumor size, grading and age for LNM should be considered in medical decision making about local resection.
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Affiliation(s)
- Walter Brunner
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Bernhard Widmann
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland.
| | - Lukas Marti
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Ignazio Tarantino
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland.,Department of General, Abdominal and Transplant Surgery, University of Heidelberg, 69120, Heidelberg, Germany
| | - Bruno M Schmied
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland
| | - Rene Warschkow
- Department of General, Visceral, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland.,Institute of Medical Biometry and Informatics, University of Heidelberg, 69120, Heidelberg, Germany
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Osaki T, Yokoe I, Ogura S, Takahashi K, Murakami K, Inoue K, Ishizuka M, Tanaka T, Li L, Sugiyama A, Azuma K, Murahata Y, Tsuka T, Ito N, Imagawa T, Okamoto Y. Photodynamic detection of canine mammary gland tumours after oral administration of 5-aminolevulinic acid. Vet Comp Oncol 2016; 15:731-739. [DOI: 10.1111/vco.12213] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 10/17/2015] [Accepted: 12/20/2015] [Indexed: 01/08/2023]
Affiliation(s)
- T. Osaki
- Joint Department of Veterinary Clinical Medicine, Faculty of Agriculture; Tottori University; Tottori Japan
| | - I. Yokoe
- Joint Department of Veterinary Clinical Medicine, Faculty of Agriculture; Tottori University; Tottori Japan
| | - S. Ogura
- Department of Bioengineering; Tokyo Institute of Technology; Yokohama Japan
| | | | | | - K Inoue
- SBI Pharmaceuticals Co., Ltd.; Tokyo Japan
| | | | - T. Tanaka
- SBI Pharmaceuticals Co., Ltd.; Tokyo Japan
| | - L. Li
- Department of Bio- and Material Photonics; Chitose Institute of Science and Technology; Chitose Japan
| | - A. Sugiyama
- Joint Department of Veterinary Clinical Medicine, Faculty of Agriculture; Tottori University; Tottori Japan
| | - K. Azuma
- Joint Department of Veterinary Clinical Medicine, Faculty of Agriculture; Tottori University; Tottori Japan
| | - Y. Murahata
- Joint Department of Veterinary Clinical Medicine, Faculty of Agriculture; Tottori University; Tottori Japan
| | - T. Tsuka
- Joint Department of Veterinary Clinical Medicine, Faculty of Agriculture; Tottori University; Tottori Japan
| | - N. Ito
- Joint Department of Veterinary Clinical Medicine, Faculty of Agriculture; Tottori University; Tottori Japan
| | - T. Imagawa
- Joint Department of Veterinary Clinical Medicine, Faculty of Agriculture; Tottori University; Tottori Japan
| | - Y. Okamoto
- Joint Department of Veterinary Clinical Medicine, Faculty of Agriculture; Tottori University; Tottori Japan
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Ogawa S, Hida JI, Ike H, Kinugasa T, Ota M, Shinto E, Itabashi M, Kameoka S, Sugihara K. Selection of Lymph Node-Positive Cases Based on Perirectal and Lateral Pelvic Lymph Nodes Using Magnetic Resonance Imaging: Study of the Japanese Society for Cancer of the Colon and Rectum. Ann Surg Oncol 2015; 23:1187-94. [PMID: 26671038 DOI: 10.1245/s10434-015-5021-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE To investigate the optimum cutoff for lymph node size to identify cases positive for perirectal lymph node (PRLN) and lateral lymph node (LPLN) metastasis of lower rectal cancer on magnetic resonance imaging (MRI). METHODS The subjects were 449 patients who underwent preoperative MRI. Mesorectal excision was performed in all patients (combined with lateral pelvic lymph node [LN] dissection in 324) between 2004 and 2013 at 6 institutes. Cases were classified as cN positive and cN negative on the basis of the short axis of the largest LN being greater than or equal to a cutoff or less than a cutoff, respectively. PRLN and LPLN diagnoses using 5 and 10 mm cutoffs were compared with histologic diagnoses. Of the 449 patients, 55 received preoperative chemoradiotherapy. MRI was only performed after this therapy in all of these patients. RESULTS For PRLNs, 5 and 10 mm cutoffs gave area under the curve (AUC) values of 0.6364 and 0.5794, respectively. The 5 mm cutoff gave a significantly higher AUC value (P = 0.0152), with an accuracy of 63.7 %, sensitivity of 72.6 %, and specificity of 54.7 %. For right LPLNs, the respective AUC values were 0.7418 and 0.6326 (P = 0.0034), and the variables (5 mm cutoff) were 77.6, 68.6, and 79.7 %. For left LPLNs, AUC values were 0.7593 and 0.6559, respectively (P = 0.0057), and the variables (5 mm cutoff) were 79.3, 70.8, and 81.0 %. CONCLUSIONS Identification of LN-positive cases on the basis of PRLN and LPLN sizes was superior at a short-axis 5 mm cutoff. Size-based diagnosis of LN metastasis is simple and useful, but further investigation is needed to clarify whether it is superior to diagnosis based on morphology, such as shape, border, and signal intensity.
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Affiliation(s)
- Shimpei Ogawa
- Department of Surgery II, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.
| | - Jin-Ichi Hida
- Department of Surgery, Kindai University School of Medicine, Osaka-Sayama, Osaka, Japan.
| | - Hideyuki Ike
- Department of Surgery, Saiseikai Yokohama City Nanbu Hospital, Yokohama, Japan
| | - Tetsushi Kinugasa
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Mitsuyoshi Ota
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Eiji Shinto
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Michio Itabashi
- Department of Surgery II, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Shingo Kameoka
- Department of Surgery II, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kenichi Sugihara
- Department of Surgical Oncology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Kono Y, Togashi K, Utano K, Horie H, Miyakura Y, Fukushima N, Lefor AT, Yasuda Y. Lymph Node Size Alone is Not an Accurate Predictor of Metastases in Rectal Cancer: A Node-for-Node Comparative Study of Specimens and Histology. Am Surg 2015. [DOI: 10.1177/000313481508101230] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although size criteria have been proposed to identify lymph node metastases in patients with rectal cancer, size may not be an accurate predictor. Specimens from consecutive rectal cancer patients who underwent curative-intent radical surgery were examined. The long and short axes of lymph nodes were measured on the glass slides using micrometer calipers. The pathologic diagnosis was used as the reference. The diagnostic accuracy of metastatic status according to lymph node size was evaluated. Overall, 1283 lymph nodes from 78 patients were reviewed. The metastatic rate correlates with the length of both the long and short axes. However, metastases were present even in 1-mm lymph nodes, and the metastatic rate exceeds 5 per cent in lymph nodes measuring 3 mm along both axes. Cutoff values of ≥4 mm and ≥3 mm for the long and short axes result in a sensitivity of 76 per cent and 79 per cent, and a specificity of 36 per cent and 33 per cent, respectively, for each axis. Size criteria alone do not accurately predict the N-stage of rectal cancer. Diminutive lymph nodes, which are not seen on imaging studies, can contain metastatic disease.
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Affiliation(s)
- Yoshihiko Kono
- Departments of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
| | - Kazutomo Togashi
- Departments of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
| | - Kenichi Utano
- Departments of Radiology, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
| | - Hisanaga Horie
- Departments of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
| | - Yasuyuki Miyakura
- Departments of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
| | - Noriyoshi Fukushima
- Departments of Pathology, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
| | - Alan T. Lefor
- Departments of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
| | - Yoshikazu Yasuda
- Departments of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, Japan
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Tapan U, Ozbayrak M, Tatlı S. MRI in local staging of rectal cancer: an update. Diagn Interv Radiol 2015; 20:390-8. [PMID: 25010367 DOI: 10.5152/dir.2014.13265] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Preoperative imaging for staging of rectal cancer has become an important aspect of current approach to rectal cancer management, because it helps to select suitable patients for neoadjuvant chemoradiotherapy and determine the appropriate surgical technique. Imaging modalities such as endoscopic ultrasonography, computed tomography, and magnetic resonance imaging (MRI) play an important role in assessing the depth of tumor penetration, lymph node involvement, mesorectal fascia and anal sphincter invasion, and presence of distant metastatic diseases. Currently, there is no consensus on a preferred imaging technique for preoperative staging of rectal cancer. However, high-resolution phased-array MRI is recommended as a standard imaging modality for preoperative local staging of rectal cancer, with excellent soft tissue contrast, multiplanar capability, and absence of ionizing radiation. This review will mainly focus on the role of MRI in preoperative local staging of rectal cancer and discuss recent advancements in MRI technique such as diffusion-weighted imaging and dynamic contrast-enhanced MRI.
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Affiliation(s)
- Umit Tapan
- Department of Hematology/Oncology, Boston University Medical Center, Boston, Massachusetts, USA.
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31
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Kwon GH, Kim KA, Hwang SS, Park SY, Kim HA, Choi SY, Kim JW. Efficiency of Non-Contrast-Enhanced Liver Imaging Sequences Added to Initial Rectal MRI in Rectal Cancer Patients. PLoS One 2015; 10:e0137320. [PMID: 26348217 PMCID: PMC4562629 DOI: 10.1371/journal.pone.0137320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 07/23/2015] [Indexed: 01/26/2023] Open
Abstract
Purpose The purpose of this study was to estimate the value of addition of liver imaging to initial rectal magnetic resonance imaging (MRI) for detection of liver metastasis and evaluate imaging predictors of a high risk of liver metastasis on rectal MRI. Methods We enrolled 144 patients who from October 2010 to May 2013 underwent rectal MRI with T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI) (b values = 50, 500, and 900 s/mm2) of the liver and abdominopelvic computed tomography (APCT) for the initial staging of rectal cancer. Two reviewers scored the possibility of liver metastasis on different sets of liver images (T2WI, DWI, and combined T2WI and DWI) and APCT and reached a conclusion by consensus for different analytic results. Imaging features from rectal MRI were also analyzed. The diagnostic performances of CT and an additional liver scan to detect liver metastasis were compared. Multivariate logistic regression to determine independent predictors of liver metastasis among rectal MRI features and tumor markers was performed. This retrospective study was approved by the Institutional Review Board, and the requirement for informed consent was waived. Results All sets of liver images were more effective than APCT for detecting liver metastasis, and DWI was the most effective. Perivascular stranding and anal sphincter invasion were statistically significant for liver metastasis (p = 0.0077 and p = 0.0471), while extramural vascular invasion based on MRI (mrEMVI) was marginally significant (p = 0.0534). Conclusion The addition of non-contrast-enhanced liver imaging, particularly DWI, to initial rectal MRI in rectal cancer patients could facilitate detection of liver metastasis without APCT. Perivascular stranding, anal sphincter invasion, and mrEMVI detected on rectal MRI were important imaging predictors of liver metastasis.
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Affiliation(s)
- Gene-hyuk Kwon
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyung Ah Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- * E-mail:
| | - Seong Su Hwang
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo Youn Park
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun A. Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Young Choi
- Department of Radiology and Medical Research Institute, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Ji Woong Kim
- Department of Chiropractic, Graduate School of Health promotion, Hanseo University, Seosan-Si, Korea
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Kim IY, Cha SW, Ahn JH, Kim YW. Factors affecting the restaging accuracy of magnetic resonance imaging after preoperative chemoradiation in patients with rectal cancer. Eur J Surg Oncol 2015; 41:493-8. [PMID: 25648465 DOI: 10.1016/j.ejso.2014.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 12/26/2014] [Indexed: 01/11/2023] Open
Abstract
PURPOSES We evaluated patient or tumor factors associated with the preoperative restaging accuracy of magnetic resonance imaging (MRI) for determining T and N stages as well as circumferential resection margin (CRM) involvement after chemoradiation (CRT) in patients with locally advanced rectal cancer. METHODS Seventy-seven patients with rectal cancer that were treated with preoperative CRT (50.4 Gy) followed by radical resection were included. Post-CRT MRI was performed approximately 4 weeks after preoperative CRT. RESULTS The median tumor distance from the anal verge was 6 cm, 48 (62%) of which were anterior and 29 (38%) posterior. The median tumor diameter was 3 cm. A stage-by-stage comparison showed that correct staging occurred in 62%, 43%, and 86% of patients for T staging, N staging, and CRM prediction, respectively. Shorter distance to the anal verge (<5 cm), smaller tumor diameter (<1 cm), and anterior tumor location were associated with incorrect T staging. There were no significant variables in terms of N staging accuracy. Shorter tumor distance and anterior tumor location were associated with incorrect CRM prediction. CONCLUSIONS Our findings suggest that specific tumor factors such as small, distal, or anterior rectal tumors are closely associated with the accuracy of MRI after preoperative CRT.
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Affiliation(s)
- I Y Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - S W Cha
- Department of Radiology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - J H Ahn
- Department of Radiology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Y W Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea.
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Zhao Q, Liu L, Wang Q, Liang Z, Shi G. Preoperative diagnosis and staging of rectal cancer using diffusion-weighted and water imaging combined with dynamic contrast-enhanced scanning. Oncol Lett 2014; 8:2734-2740. [PMID: 25360178 PMCID: PMC4214399 DOI: 10.3892/ol.2014.2590] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 03/20/2014] [Indexed: 01/24/2023] Open
Abstract
The aim of the present study was to evaluate the value of diffusion-weighted imaging (DWI) and water imaging combined with dynamic contrast-enhanced scanning for the preoperative diagnosis and staging of rectal cancer. In total, 72 patients with pathologically confirmed rectal cancer were selected for examination using magnetic resonance imaging (MRI) with phased-array coils, DWI, water imaging and dynamic contrast-enhanced scanning. The patients were divided into two groups, experimental (simple enhanced scanning plus diffusion combined with water imaging) and control (simple enhanced scanning), for the pathological observations. The sensitivity, specificity and accuracy for the T staging of the carcinomas using scan enhancement with DWI and the evaluation of cancer using water imaging were 98.5% (65/66), 66.7% (4/6) and 95.8% (69/72), respectively, and the accuracy for N staging was 89%. Whereas, the sensitivity, specificity and accuracy for the T staging of the carcinomas using simple scan enhancement were 85.7% (42/49), 78.3% (18/23) and 83.3% (60/72), respectively, and the accuracy for N staging was 61%. Therefore, the combination of multiple MRI techniques may be of high value for the early diagnosis and exact staging of rectal cancer.
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Affiliation(s)
- Qili Zhao
- Department of Magnetic Resonance and Computed Tomography, The People's Hospital of Langfang City, Langfang, Hebei 065000, P.R. China
| | - Lijian Liu
- Department of Magnetic Resonance and Computed Tomography, The People's Hospital of Langfang City, Langfang, Hebei 065000, P.R. China
| | - Qiuyan Wang
- Department of Magnetic Resonance and Computed Tomography, The People's Hospital of Langfang City, Langfang, Hebei 065000, P.R. China
| | - Zexia Liang
- Department of Magnetic Resonance and Computed Tomography, The People's Hospital of Langfang City, Langfang, Hebei 065000, P.R. China
| | - Gaofeng Shi
- Department of Magnetic Resonance and Computed Tomography, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei 050019, P.R. China
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Charlton ME, Mattingly-Wells LR, Marcet JE, McMahon Waldschmidt BC, Cromwell JW. Association between surgeon characteristics and their preferences for guideline-concordant staging and treatment for rectal cancer. Am J Surg 2014; 208:817-823. [PMID: 24997492 DOI: 10.1016/j.amjsurg.2014.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 03/19/2014] [Accepted: 03/21/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Rectal cancer guidelines recommend transrectal ultrasound or magnetic resonance imaging for locoregional staging and neoadjuvant chemoradiation therapy (CRT) for Stage II/III disease, but studies show these are underutilized. We examined how surgeon preferences align with guidelines or vary by training. METHODS Questionnaires on training, years of practice, and staging/treatment preferences were sent to surgeons practicing in Florida. RESULTS Of 759 surveys distributed, 321 (42%) responded; 158 were excluded because they were trainees, not treating rectal cancer, or not board certified/eligible. Among the remaining 163, 71% were general surgeons, 18% colorectal surgeons, and 11% surgical oncologists. Colorectal surgeons and surgical oncologists were more likely than general surgeons to prefer transrectal ultrasound/magnetic resonance imaging (79% vs 50%; P < .01), and neoadjuvant CRT (71% vs 45%; P < .01). Differences remained significant after adjusting for years in practice. CONCLUSION Increased focus on appropriate use of staging procedures and neoadjuvant CRT within general surgery training/educational programs is warranted.
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Affiliation(s)
- Mary E Charlton
- Department of Epidemiology, University of Iowa College of Public Health, 145 N Riverside Drive, Iowa City, IA 52242, USA; VA Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.
| | | | - Jorge E Marcet
- Division of Colon and Rectal Surgery, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Brenna C McMahon Waldschmidt
- Department of Epidemiology, University of Iowa College of Public Health, 145 N Riverside Drive, Iowa City, IA 52242, USA
| | - John W Cromwell
- Division of Gastrointestinal Surgery, Minimally Invasive and Bariatric Surgery, Department of Surgery, University of Iowa College of Medicine, Iowa City, IA, USA
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Williams JG, Pullan RD, Hill J, Horgan PG, Salmo E, Buchanan GN, Rasheed S, McGee SG, Haboubi N. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis 2013; 15 Suppl 2:1-38. [PMID: 23848492 DOI: 10.1111/codi.12262] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- J G Williams
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK.
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Uçar A, Obuz F, Sökmen S, Terzi C, Sağol O, Sarıoğlu S, Füzün M. Efficacy of high resolution magnetic resonance imaging in preoperative local staging of rectal cancer. Mol Imaging Radionucl Ther 2013; 22:42-8. [PMID: 24003396 PMCID: PMC3759308 DOI: 10.4274/mirt.43153] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 04/13/2013] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To assess the efficacy of high-resolution magnetic resonance imaging (HRMRI) for preoperative local staging in patients with rectal cancer who did not receive preoperative radiochemotherapy. METHODS In this retrospective study, 30 patients with biopsy proved primary rectal cancer were evaluated by HRMRI. Two observers independently scored the tumour and lymph node stages, and circumferential resection margin (CRM) involvement. The sensitivity, specificity, the negative predictive value and the positive predictive value of HRMRI findings were calculated within the 95% confidence interval. The area under the curve was measured for each result. Agreement between two observers was assessed by means of the Kappa test. RESULTS In T staging the accuracy rate of HRMRI was 47-67%, overstaging was 10-21%, and understaging was 13-43%. In the prediction of extramural invasion with HRMRI, the sensitivity was 79-89%, the specificity was 72-100%, the PPV was 85-100%, the NPV was 73-86%, and the area under the curve was 0.81-0.89. In the prediction of lymph node metastasis, the sensitivity was 58-58%, the specificity was 50-55%, the PPV was 43-46%, and the NPV was 64-66%. The area under the curve was 0.54-0.57. When the cut off value was selected as 1 mm, the sensitivity of HRMRI was 38-42%, the specificity was 73-82%, the PPV was 33-42%, and NPV was 79-81% in the prediction of the CRM involvement. The correlation between the two observers was moderate for tumour staging, substantial for lymph node staging and predicting of CRM involvement. CONCLUSION Preoperative HRMRI provides good predictive data for extramural invasion but poor prediction of lymph node status and CRM involvement. CONFLICT OF INTEREST None declared.
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Affiliation(s)
- Aysun Uçar
- Dokuz Eylül University, Department of Radiology, İzmir, Turkey
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Hartman RI, Chang CY, Wo JY, Eisenberg JD, Hong TS, Harisinghani MG, Gazelle GS, Pandharipande PV. Optimizing adjuvant treatment decisions for stage t2 rectal cancer based on mesorectal node size: a decision analysis. Acad Radiol 2013; 20:79-89. [PMID: 22947271 DOI: 10.1016/j.acra.2012.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 07/18/2012] [Accepted: 07/20/2012] [Indexed: 12/23/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to optimize treatment decisions for patients with suspected stage T2 rectal cancer on the basis of mesorectal lymph node size at magnetic resonance imaging. MATERIALS AND METHODS A decision-analytic model was developed to predict outcomes for patients with stage T2 rectal cancer at magnetic resonance imaging. Node-positive patients were assumed to benefit from chemoradiation prior to surgery. Imperfect magnetic resonance imaging performance for primary cancer and mesorectal nodal staging was incorporated. Five triage strategies were considered for administering preoperative chemoradiation: treat all patients; treat for any mesorectal node >3, >5, and >7 mm in size; and treat no patients. If nodal metastases or unsuspected stage T3 disease went untreated preoperatively, postoperative chemoradiation was needed, resulting in poorer outcomes. For each strategy, rates of acute and long-term chemoradiation toxicity and of 5-year local recurrence were computed. Effects of input parameter uncertainty were evaluated in sensitivity analysis. RESULTS The optimal strategy depended on the outcome prioritized. Acute and long-term chemoradiation toxicity rates were minimized by triaging only patients with nodes >7 mm to preoperative chemoradiation (18.9% and 10.8%, respectively). A treat-all strategy minimized the 5-year local recurrence rate (5.6%). A 7-mm nodal triage threshold increased the 5-year local recurrence rate to 8.0%; when no patients were treated preoperatively, the local recurrence rate was 10.1%. With improved primary tumor staging, all outcomes could be further optimized. CONCLUSIONS Mesorectal nodal size thresholds for preoperative chemoradiation should depend on the outcome prioritized: higher size thresholds reduce chemoradiation toxicity but increase recurrence rates. Improvements in nodal staging will have greater impact if primary tumor staging can be improved.
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Maas M, Lambregts DMJ, Lahaye MJ, Beets GL, Backes W, Vliegen RFA, Osinga-de Jong M, Wildberger JE, Beets-Tan RGH. T-staging of rectal cancer: accuracy of 3.0 Tesla MRI compared with 1.5 Tesla. ACTA ACUST UNITED AC 2012; 37:475-81. [PMID: 21674192 PMCID: PMC3345180 DOI: 10.1007/s00261-011-9770-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Objectives Magnetic resonance imaging (MRI) is not accurate in discriminating T1-2 from borderline T3 rectal tumors. Higher resolution on 3 Tesla-(3T)-MRI could improve diagnostic performance for T-staging. The aim of this study was to determine whether 3T-MRI compared with 1.5 Tesla-(1.5T)-MRI improves the accuracy for the discrimination between T1-2 and borderline T3 rectal tumors and to evaluate reproducibility. Methods 13 patients with non-locally advanced rectal cancer underwent imaging with both 1.5T and 3T-MRI. Three readers with different expertise evaluated the images and predicted T-stage with a confidence level score. Receiver operator characteristics curves with areas under the curve (AUC) and diagnostic parameters were calculated. Inter- and intra-observer agreements were calculated with quadratic kappa-weighting. Histology was the reference standard. Results Seven patients had pT1-2 tumors and six had pT3 tumors. AUCs ranged from 0.66 to 0.87 at 1.5T vs. 0.52–0.82 at 3T. Mean overstaging rate was 43% at 1.5T and 57% at 3T (P = 0.23). Inter-observer agreement was κ 0.50–0.71 at 1.5T vs. 0.15–0.68 at 3T. Intra-observer agreement was κ 0.71 at 1.5T and 0.76 at 3T. Conclusions This is the first study to compare 3T with 1.5T MRI for T-staging of rectal cancer within the same patients. Our results showed no difference between 3T and 1.5T-MRI for the distinction between T1-2 and borderline T3 tumors, regardless of expertise. The higher resolution at 3T-MRI did not aid in the distinction between desmoplasia in T1-2-tumors and tumor stranding in T3-tumors. Larger studies are needed to acknowledge these findings.
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Affiliation(s)
- Monique Maas
- Department of Radiology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Postbus 616, 6200 MD Maastricht, The Netherlands
| | - Doenja M. J. Lambregts
- Department of Radiology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Postbus 616, 6200 MD Maastricht, The Netherlands
| | - Max J. Lahaye
- Department of Radiology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Geerard L. Beets
- Department of Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Postbus 616, 6200 MD Maastricht, The Netherlands
| | - Walter Backes
- Department of Radiology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Roy F. A. Vliegen
- Department of Radiology, Atrium Medical Center, Postbus 4446, 6401 CX Heerlen, The Netherlands
| | - Margreet Osinga-de Jong
- Department of Radiology, Orbis Medical Center, Postbus 5500, 6130 MB Sittard, The Netherlands
| | - Joachim E. Wildberger
- Department of Radiology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Postbus 616, 6200 MD Maastricht, The Netherlands
| | - Regina G. H. Beets-Tan
- Department of Radiology, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Postbus 616, 6200 MD Maastricht, The Netherlands
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Tiernan JP, Ansari I, Hirst NA, Millner PA, Hughes TA, Jayne DG. Intra-operative tumour detection and staging in colorectal cancer surgery. Colorectal Dis 2012; 14:e510-20. [PMID: 22564278 DOI: 10.1111/j.1463-1318.2012.03078.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM Surgical resection for colorectal cancer involves segmental resection and regional lymphadenectomy. The appropriateness of this 'one-size-fits-all' strategy is questioned as bowel cancer screening programmes result in a shift to earlier stage disease. Currently, the nodal status of a colorectal cancer can only be reliably determined by histopathological examination of the resected specimen. New methods of intra-operative staging are required to allow surgical resection to be tailored to the stage of the disease. METHOD A literature search was performed of PubMed and Embase databases using the terms 'colon' OR 'colorectal' AND 'intra-operative detection' OR 'intra-operative staging' OR 'intra-operative detection' OR 'radioimmunoguided surgery'. Articles published between January 1980 and January 2012 were included. Technologies that have the potential to allow intra-operative staging and treatment stratification were identified and further searches performed. RESULTS Established techniques such as sentinel lymph node mapping and radioimmunoguided surgery have benefited from combination with other technologies to allow real-time intra-operative staging. Intra-operative fluorescence, using naturally fluorescent biomarkers or fluorescent tumour probes, probably offers the most practical means of intra-operative lymph node staging and may be facilitated using nanotechnology. Optical coherence tomography and real-time elastography have the potential to provide an in vivo'virtual biopsy'. CONCLUSION Technological advances may allow accurate intra-operative lymph node staging to facilitate tailored surgical resection. This may become the next paradigm shift in colorectal cancer surgery.
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Affiliation(s)
- J P Tiernan
- Section of Translational Anaesthetic and Surgical Sciences, Leeds Institute of Molecular Medicine, St James's University Hospital, Leeds, UK.
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Kuo LJ, Chiou JF, Tai CJ, Chang CC, Kung CH, Lin SE, Hung CS, Wang W, Tam KW, Lee HC, Liang HH, Chang YJ, Wei PL. Can we predict pathologic complete response before surgery for locally advanced rectal cancer treated with preoperative chemoradiation therapy? Int J Colorectal Dis 2012; 27:613-21. [PMID: 22080392 DOI: 10.1007/s00384-011-1348-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pathologic complete response has been proven to have oncological benefits for locally advanced rectal cancer treated with chemoradiation therapy. The aims of this study are to analyze and determine the factors to predict pathologic complete response for patients treated with preoperative neoadjuvant therapy. METHODS Patients with biopsy-proven, locally advanced rectal cancer were treated neoadjuvantly followed by radical surgical resection. Tumors were re-assessed after completing chemoradiation, including pelvic magnetic resonance images, colonoscopic examination, and re-biopsy. The results of examination were compared with the final pathologic status. RESULTS A retrospective chart review of 166 patients was conducted. Twenty-five patients (15.1%) had pathologic complete response after chemoradiation. The 5-year overall survival rates were better in the complete response group than the residual tumor group (91.1% vs. 70.8%; P = 0.047), and there were also significant differences in the 5-year disease-free survival rates between these two groups (91.1% vs. 70.2%; P = 0.027). The prediction rates for pathologic complete response by re-biopsy, magnetic resonance images, and colonoscopy were 21.4%, 33.3%, and 53.8%, respectively. In addition, when we further combine the results of colonoscopic findings and re-biopsy, the prediction rate for pathologic complete response reached 77.8% (P = 0.009). CONCLUSIONS Combining the results of the re-biopsy and post-treatment colonoscopic findings, we can achieve a good prediction rate for pathologic complete response. Post-treatment magnetic resonance images are not useful tools in predicting tumor clearance following chemoradiation.
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Affiliation(s)
- Li-Jen Kuo
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Minsky BD. Progress in the Treatment of Locally Advanced Clinically Resectable Rectal Cancer. Clin Colorectal Cancer 2011; 10:227-37. [DOI: 10.1016/j.clcc.2011.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 06/21/2011] [Indexed: 12/11/2022]
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The role of lateral lymph node dissection in the management of lower rectal cancer. Langenbecks Arch Surg 2011; 397:353-61. [PMID: 22105772 DOI: 10.1007/s00423-011-0864-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 10/10/2011] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Lateral lymph node involvement is a problem encountered in patients with low rectal cancers. This has been documented in both anatomical and pathological studies. Currently, the vast majority of centers have concentrated on the use of chemoradiation to obtain better local control and manage these nodes indirectly. In Japan, extended nodal dissection for the control of pelvic nodal disease has seen further advancement. This paper discusses the key issues involved in the management of pelvic lateral nodes in low rectal cancers. METHODS A review of available literature and critical appraisal of the entity of lateral nodes in low rectal cancers, the treatment options, and oncological and functional results were performed. RESULTS There are good data showing that the entity of pelvic lateral nodes in low rectal cancers should not be ignored. Recent data have emerged showing that radiotherapy is associated with significant long-term functional side effects. Refinement of the technique, lateral node dissection, has led to good local control as well as good functional outcomes. CONCLUSION In this context, there needs to be a reevaluation of the role of chemoradiation as the sole treatment for lateral nodal disease in centers outside of Japan. Individualization of the treatment of rectal cancer may require all centers to be able to offer both modalities.
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Gleeson FC, Clain JE, Rajan E, Topazian MD, Wang KK, Levy MJ. EUS-FNA assessment of extramesenteric lymph node status in primary rectal cancer. Gastrointest Endosc 2011; 74:897-905. [PMID: 21839439 DOI: 10.1016/j.gie.2011.05.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 05/21/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Preoperative staging is an essential factor in the multidisciplinary management of rectal cancer. The accuracy of imaging alone with CT, magnetic resonance imaging, or rigid endorectal US is poor. The addition of EUS-FNA may enhance extramesenteric lymph node metastases detection (M1 disease) and overall staging accuracy. OBJECTIVE To evaluate the frequency of extramesenteric lymph node visualization by EUS and the rate of extramesenteric lymph node metastases by FNA. Secondary goals were to evaluate the clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases, disease progression, and overall mortality. DESIGN Retrospective cohort study. SETTINGS Tertiary referral center. RESULTS Forty-one of 316 patients (13%) with primary rectal cancer over a 6-year period had M1 disease by EUS-FNA. Significant clinical, endoscopic, and sonographic features associated with extramesenteric lymph node metastases included the serum carcinoembryonic antigen level, tumor length 4 cm and longer, annularity 50% or more, sessile morphology, and lymph node size. The sensitivity and specificity of CT for extramesenteric lymph node metastases were 44% and 89%, respectively. Twenty-three of 316 rectal cancer endosonographic procedures (7.3%) were up-staged by FNA, which established extramesenteric lymph node metastases. Over a 4-year follow-up, disease progression and overall mortality of patients with extramesenteric lymph node metastases was observed in 6 patients (14.6%) and 14 patients (34%), respectively. CONCLUSIONS Preoperative EUS-FNA identification of extramesenteric lymph node metastases outside of standard radiation fields or total mesorectal excision resection margins could affect medical and surgical planning.
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Affiliation(s)
- Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Abstract
In the past two decades, substantial progress has been made in the adjuvant management of colorectal cancer. Chemotherapy has improved overall survival in patients with node-positive (N+) disease. In contrast with colon cancer, which has a low incidence of local recurrence, patients with rectal cancer have a higher incidence requiring the addition of pelvic radiation therapy (chemoradiation). Patients with rectal cancer have a number of unique management considerations: for example, the role of short-course radiation, whether postoperative adjuvant chemotherapy is necessary for all patients, and if the type of surgery following chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation as well as modify the need for pelvic radiation? This review will address these and other controversies specific to patients with rectal cancer.
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Affiliation(s)
- Bruce D Minsky
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, IL 60637, USA.
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Minsky BD. Counterpoint: Long-Course Chemoradiation Is Preferable in the Neoadjuvant Treatment of Rectal Cancer. Semin Radiat Oncol 2011; 21:228-33. [DOI: 10.1016/j.semradonc.2011.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Min BS, Kim NK, Pyo JY, Kim H, Seong J, Keum KC, Sohn SK, Cho CH. Clinical impact of tumor regression grade after preoperative chemoradiation for locally advanced rectal cancer: subset analyses in lymph node negative patients. JOURNAL OF THE KOREAN SOCIETY OF COLOPROCTOLOGY 2011; 27:31-40. [PMID: 21431095 PMCID: PMC3053500 DOI: 10.3393/jksc.2011.27.1.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 12/07/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND We investigated the prognostic significance of tumor regression grade (TRG) after preoperative chemoradiation therapy (preop-CRT) for locally advanced rectal cancer especially in the patients without lymph node metastasis. METHODS One-hundred seventy-eight patients who had cT3/4 tumors were given 5,040 cGy preoperative radiation with 5-fluorouracil/leucovorin chemotherapy. A total mesorectal excision was performed 4-6 weeks after preop-CRT. TRG was defined as follows: grade 1 as no cancer cells remaining; grade 2 as cancer cells outgrown by fibrosis; grade 3 as a minimal presence or absence of regression. The prognostic significance of TRG in comparison with histopathologic staging was analyzed. RESULTS Seventeen patients (9.6%) showed TRG1. TRG was found to be significantly associated with cancer-specific survival (CSS; P = 0.001) and local recurrence (P = 0.039) in the univariate study, but not in the multivariate analysis. The ypN stage was the strongest prognostic factor in the multivariate analysis. Subgroup analysis revealed TRG to be an independent prognostic factor for the CSS of ypN0 patients (P = 0.031). TRG had a stronger impact on the CSS of ypN (-) patients (P = 0.002) than on that of ypN (+) patients (P = 0.521). In ypT2N0 and ypT3N0, CSS was better for TRG2 than for TRG3 (P = 0.041, P = 0.048), and in ypN (-) and TRG2 tumors, CSS was better for ypT1-2 than for ypT3-4 (P = 0.034). CONCLUSION TRG was found to be the strongest prognostic factor in patients without lymph node metastasis (ypN0), and different survival was observed according to TRG among patients with a specific histopathologic stage. Thus, TRG may provide an accurate prediction of prognosis and may be used for f tailoring treatment for patients without lymph node metastasis.
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Affiliation(s)
- Byung Soh Min
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Minsky BD. Chemoradiation for rectal cancer: rationale, approaches, and controversies. Surg Oncol Clin N Am 2011; 19:803-18. [PMID: 20883955 DOI: 10.1016/j.soc.2010.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The standard adjuvant treatment of cT3 and/or N+ rectal cancer is preoperative chemoradiation. However, there are many controversies regarding this approach. These controversies include the role of short course radiation, whether postoperative adjuvant chemotherapy is necessary for all patients, and if the type of surgery following chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation, as well as modify the need for pelvic radiation? These questions and others remain active areas of clinical investigation.
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Affiliation(s)
- Bruce D Minsky
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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Tan KK, Tsang CB. Staging of Rectal Cancer—Technique and Interpretation of Evaluating Rectal Adenocarcinoma, uT1-4, N Disease: 2D and 3D Evaluation. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
The standard adjuvant treatment for cT3 and/or N+ rectal cancer is preoperative chemoradiation. However, there are many controversies regarding this approach. These include the role of short course radiation, whether postoperative adjuvant chemotherapy necessary for all patients and whether the type of surgery after chemoradiation should be based on the response rate. More accurate imaging techniques and/or molecular markers may help identify patients with positive pelvic nodes to reduce the chance of overtreatment with preoperative therapy. Will more effective systemic agents both improve the results of radiation as well as modify the need for pelvic radiation? These questions and others remain active areas of clinical investigation.
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Obias VJ, Reynolds HL. Multidisciplinary teams in the management of rectal cancer. Clin Colon Rectal Surg 2010; 20:143-7. [PMID: 20011195 DOI: 10.1055/s-2007-984858] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A myriad of advances in the treatment of rectal cancer have been achieved over the last few decades. The introduction of total mesorectal excision (TME) has resulted in significant improvements in local recurrence. Surgical education on the technique has made it the standard of care. Radiation and chemotherapy combined with TME have improved results even further with stage II and III cancers. Sphincter-sparing techniques, reservoir procedures, local treatment advances, minimally invasive techniques, surgery for metastatic disease, newer chemotherapies, and extended resections for locally advanced and recurrent lesions, have all benefited the patient with rectal cancer. The goal and responsibility of colorectal surgeons treating rectal cancer patients is to understand and coordinate the wide variety of modalities available to optimize survival, minimize morbidity, and maximize quality of life for those with this difficult problem. Coordination of specialists in this time of evolution in rectal cancer treatment becomes more important than ever. Here the authors briefly review the role of the multidisciplinary team, discuss a model multidisciplinary team approach and look at evidence supporting team use as we begin this issue devoted to the multidisciplinary management of rectal cancer.
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Affiliation(s)
- Vincent J Obias
- Case Western Reserve University, University Hospitals of Cleveland Case Medical Center, Cleveland, OH 44106, USA
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