Diagnostic precision of CT in local staging of colon cancers: a meta-analysis. Clin Radiol. 2010;65:708-719. [PMID: 20696298 DOI: 10.1016/j.crad.2010.01.024]

Prognostic Implications of Node Status in Colon Adenocarcinoma With Synchronous Liver Metastasis

INTRODUCTION

In patients with metastatic colon cancer undergoing curative resection, lymph node status does not change management or staging as per current guidelines. The aim of this project is to assess the prognostic value of lymph node status and yield in clinical stage IV-A colon adenocarcinoma undergoing curative resection.

METHODS

This is a retrospective cohort study from the National Cancer Database from 2010 to 2018 that examines adults with colon adenocarcinoma with synchronous liver metastasis who underwent primary colectomy, hepatic metastasectomy, and systemic therapy. Survival analysis of subgroups with node-positive and node-negative was performed by Kaplan-Meier analysis and the Cox proportional hazards model.

RESULTS

Of 2071 patients with clinical stage IV-A colon adenocarcinoma, 25.6% had negative lymph nodes (N-LNs). Patients with N-LNs had higher median survival compared to patients with positive lymph nodes (62.03 versus 48.69 mo, P < 0.001) and lower mortality risk (hazard ratio 0.75, P < 0.001). Resection of ≥12 lymph nodes was associated with longer median survival compared to patients with <12 lymph nodes in patients with positive lymph nodes (49.64 versus 28.09 mo, P < 0.001) but not in patients with N-LNs (63.01 versus 55.46 mo, P = 0.09). This relationship remained regardless of chemotherapy sequence.

CONCLUSIONS

In the setting of hepatic metastases in clinical stage IV colon adenocarcinoma, lymph node status is prognostic as N-LNs are associated with increased overall survival. Further research is necessary to delineate underlying differences in tumor biology and to help predict nodal status preoperatively.

Predicting the risk of lymph node metastasis in colon cancer: development and validation of an online dynamic nomogram based on multiple preoperative data

BACKGROUND

Predicting lymph node metastasis (LNM) in colon cancer (CC) is crucial to treatment decision-making and prognosis. This study aimed to develop and validate a nomogram that estimates the risk of LNM in patients with CC using multiple clinical data from patients before surgery.

METHODS

Clinicopathological data were collected from 412 CC patients who underwent Radical resection of CC. The training cohort consisted of 300 cases, and the external validation cohort consisted of 112 cases. The LASSO and multivariate logistic regression were used to select the predictors and construct the nomogram. The discrimination and calibration of the nomogram were evaluated by the ROC curve and calibration curve, respectively. The clinical application of the nomogram was assessed by decision curve analysis(DCA) and clinical impact curves(CIC).

RESULTS

Eight independent factors associated with LNM were identified by multivariate logistic analysis: LN status on CT, tumor diameter on CT, differentiation, ulcer, intestinal obstruction, anemia, blood type, and neutrophil percentage. The online dynamic nomogram model constructed by independent factors has good discrimination and consistency. The AUC of 0.834(95% CI: 0.755-0.855) in the training cohort, 0.872(95%CI: 0.807-0.937) in the external validation cohort, and Internal validation showed that the corrected C statistic was 0.810. The calibration curve of both the training set and the external validation set indicated that the predicted outcome of the nomogram was highly consistent with the actual outcome. The DCA and CIC indicate that the model has clinical practical value.

CONCLUSION

Based on various simple parameters collected preoperatively, the online dynamic nomogram can accurately predict LNM risk in CC patients. The high discriminative ability and significant improvement of NRI and IDI indicate that the model has potential clinical application value.

Early Rectal Cancer: Advances in Diagnosis and Management Strategies

Colorectal cancer (CRC) is the second most prevalent cause of cancer-related death and the third most common cancer globally. Early-stage rectal cancer is defined by lesions confined to the bowel wall, without extension beyond the submucosa in T1 or the muscularis propria in T2, with no indication of lymph node involvement or distant metastasis. The gold standard for managing rectal cancer is total mesorectal excision (TME); however, it is linked to considerable morbidities and impaired quality of life. There is a growing interest in local resection and non-operative treatment of early RC for organ preservation. Local resection options include three types of transanal endoscopic surgery (TES): transanal endoscopic microsurgery (TEM), transanal endoscopic operations (TEO), and transanal minimally invasive surgery (TAMIS), while endoscopic resection includes endoscopic mucosal resection (EMR), underwater endoscopic mucosal resection (UEMR), and endoscopic submucosal dissection (ESD). Although the oncological outcome of local resection of early rectal cancer is debated in the current literature, some studies have shown comparable outcomes with radical surgery in selected patients. The use of adjuvant and neoadjuvant chemoradiotherapy in early rectal cancer management is also controversial in the literature, but a number of studies have reported promising outcomes. This review focuses on the available literature regarding diagnosis, staging, and management strategies of early rectal cancer and provides possible recommendations.

DNA methylation biomarkers for predicting lymph node metastasis in colorectal cancer

Colorectal cancer is one of the most common cancers worldwide. Lymph node metastasis is an important marker of colorectal cancer progression and plays a key role in the evaluation of patient prognosis. Accurate preoperative assessment of lymph node metastasis is crucial for devising appropriate treatment plans. However, current clinical imaging methods have limitations in many aspects. Therefore, the discovery of a method for accurately predicting lymph node metastasis is crucial clinical decision-making. DNA methylation is a common epigenetic modification that can regulate gene expression, which also has an important impact on the development of colorectal cancer. It is considered to be a promising biomarker with good specificity and stability and has promising application in predicting lymph node metastasis in patients with colorectal cancer. This article reviews the characteristics and limitations of currently available methods for predicting lymph node metastasis in patients with colorectal cancer and discusses the role of DNA methylation as a biomarker.

Diagnostic accuracy and treatment benefit of PET/CT in staging of colorectal cancer compared to conventional imaging

BACKGROUND

Until recently the use of positron emission tomography (PET) CT for staging in colorectal cancer (CRC) has been limited to the detection of distant metastasis in advanced disease. But with the introduction of neoadjuvant treatments in CRC, accurate pre-treatment staging has become more relevant.

AIMS

The aim of the study was to assess the staging accuracy for nodal and distant metastasis of PET/CT compared to computed tomography (CT) alone in CRC. Secondary endpoints were overall survival (OS) and cost of CT compared to PET/CT.

METHODS

A retrospective analysis of 539 cases with CRC staged with PET/CT and or CT between 2015 and 2021 in a Swiss tertiary referral center was performed. In 471 patients for nodal staging and 479 for staging of distant metastasis the clinical stage of both modalities was compared with pathological stage.

RESULTS

The distribution of UICC stages (n = 479) was as follows: Stage I 62 cases (12.9 %), Stage II 127 cases (26.5 %), Stage III 199 cases (41.5 %), Stage IV 91 cases (19.0 %). CT alone compared to PET was able to predict nodal involvement with a sensitivity of 55.2 % (95%CI 5.7-59.7 %) and 66.7 % (95%CI 62.4-70.9 %), respectively. The specificity was 67.0 % (95%CI 62.8-71.3 %) for CT and 63.6 % (95%CI 59.3-68.0 %) for PET. The positive predictive value was 49.5 % for CT vs. 51.8 % for PET. The sensitivity of metastasis detection was 53.6 % (95%CI 49.1-58.1 %) for CT and 82.5 % (95%CI 79.1-85.9 %) for PET.

CONCLUSIONS

PET/CT showed higher sensitivity in the detection of lymph node involvement and metastases in CRC patients compared to CT alone.

SEOM-GEMCAD-TTD clinical guidelines for the adjuvant treatment of colon cancer (2023)

Colorectal cancer (CRC) has a 5-year overall survival rate of over 60%. The decrease in the rate of metastatic disease is due to screening programs and the population's awareness of healthy lifestyle. Similarly, advancements in surgical methods and the use of adjuvant chemotherapy have contributed to a decrease in the recurrence of resected disease. Before evaluating a patient's treatment, it is recommended to be discussed in a multidisciplinary tumor board. In stage II tumors, the pathologic characteristics of poor prognosis must be known (T4, number of lymph nodes analyzed less than 12, lymphovascular or perineural invasion, obstruction or perforation, poor histologic grade, presence of tumor budding) and it is mandatory to determine the MSI/MMR status for avoiding administering fluoropyridimidines in monotherapy to patients with MSI-H/dMMR tumors. In stage III tumors, the standard treatment consists of a combination of fluoropyrimidine (oral or intravenous) with oxaliplatin for 6 months although the administration of CAPOX can be considered for 3 months in low-risk tumors. Neoadjuvant treatment is not consolidated yet although immunotherapy is achieving very good preliminary results in MSI-H patients. The use of ctDNA to define the treatment and monitoring of resected tumors is only recommended within studies. These guidelines are intended to help decision-making to offer the best management of patients with non-metastatic colon cancer.

Accuracy of Clinical Staging of Localized Colon Cancer: A National Cancer Database Cohort Analysis

BACKGROUND

This study aimed to assess concordance between clinical and pathologic assessment of colon cancer.

PATIENTS AND METHODS

A retrospective cohort analysis of patients with stage I-III colon cancer in the National Cancer Database (2010-2019) was conducted. Concordance between clinical and pathologic assessment of colon cancer was calculated using Kappa coefficients and 95% confidence intervals (CIs).

RESULTS

A total of 125,473 patients (51.2% female; mean age 68.2 years) were included. There was moderate concordance between clinical and pathologic T stage (Kappa = 0.606, 95%CI: 0.602-0.609) and between clinical and pathologic N stage (Kappa = 0.506, 95%CI: 0.501-0.511). For right-sided colon cancer, there was moderate agreement between clinical and pathologic T stage (Kappa = 0.594, 95%CI: 0.589-0.599) and N stage (Kappa = 0.530, 95%CI: 0.523-0.537). For left-sided colon cancer, there was substantial agreement between clinical and pathologic T stage (Kappa = 0.624, 95%CI: 0.619-0.630) and moderate agreement between N stage (Kappa 0.472, 95%CI: 0.463-0.480). Sensitivity of clinical assessment of T and N stage ranged from 64.3% to 77.2% and 41.6% to 54.5%, respectively. Specificity ranged from 96.7% to 97.7% for T stage and 95.7% to 97.3% for N stage.

CONCLUSIONS

Clinical assessment of T and N stages of colon cancer had good diagnostic accuracy with moderate concordance with the final pathologic stage. While clinical assessment was highly specific with < 3% of patients being over-staged, it had modest sensitivity, especially for detection of nodal involvement. Diagnostic accuracy of clinical assessment of right and left colon cancers was similar, except for higher sensitivity and accuracy of assessment of nodal involvement in right than left colon cancers.

A clinical-radiomics nomogram based on spectral CT multi-parameter images for preoperative prediction of lymph node metastasis in colorectal cancer

To develop a clinical-radiomics nomogram based on spectral CT multi-parameter images for predicting lymph node metastasis in colorectal cancer. A total of 76 patients with colorectal cancer and 156 lymph nodes were included. The clinical data of the patients were collected, including gender, age, tumor location and size, preoperative tumor markers, etc. Three sets of conventional images in the arterial, venous, and delayed phases were obtained, and six sets of spectral images were reconstructed using the arterial phase spectral data, including virtual monoenergetic images (40 keV, 70 keV, 100 keV), iodine density maps, iodine no water maps, and virtual non-contrast images. Radiomics features of lymph nodes were extracted from the above images, respectively. Univariate analysis and least absolute shrinkage and selection operator (LASSO) regression were used to select features. A clinical model was constructed based on age and carcinoembryonic antigen (CEA) levels. The radiomics features selected were used to generate a composed radiomics signature (Com-RS). A nomogram was developed using age, CEA, and the Com-RS. The models' prediction efficiency, calibration, and clinical application value were evaluated by the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis, respectively. The nomogram outperforms the clinical model and the Com-RS (AUC = 0.879, 0.824). It is well calibrated and has great clinical application value. This study developed a clinical-radiomics nomogram based on spectral CT multi-parameter images, which can be used as an effective tool for preoperative personalized prediction of lymph node metastasis in colorectal cancer.

Construction of a nomogram based on clinicopathologic features to predict the likelihood of No. 253 lymph node metastasis in rectal cancer patients

PURPOSE

To explore the high-risk factors for rectal cancer No.253 lymph node metastasis (LNM) and to construct a risk nomogram for the individualized prediction of No.253 LNM.

METHODS

This was a retrospective analysis of 425 patients with rectal cancer who underwent laparoscopic-assisted radical surgery. Independent risk factors for rectal cancer No.253 LNM was identified using multivariate logistic regression analysis, and a risk prediction nomogram was constructed based on the independent risk factors. In addition, the performance of the model was evaluated by discrimination, calibration, and clinical benefit.

RESULTS

Multivariate logistic regression analysis showed that No.253 lymphadenectasis on CT (OR 10.697, P < 0.001), preoperative T4-stage (OR 4.431, P = 0.001), undifferentiation (OR 3.753, P = 0.004), and preoperative Ca199 level > 27 U/ml (OR 2.628, P = 0.037) were independent risk factors for No.253 LNM. A nomogram was constructed based on the above four factors. The calibration curve of the nomogram was closer to the ideal diagonal, indicating that the nomogram had a better fitting ability. The area under the ROC curve (AUC) was 0.865, which indicated that the nomogram had high discriminative ability. In addition, decision curve analysis (DCA) showed that the model could show better clinical benefit when the threshold probability was between 1% and 50%.

CONCLUSION

Preoperative No.253 lymphadenectasis on CT, preoperative T4-stage, undifferentiation, and elevated preoperative Ca199 level were found to be independent risk factors for the No.253 LNM. A predictive model based on these risk factors can help surgeons make rational clinical decisions.

2-[18F]FDG PET-based quantification of lymph node metabolic heterogeneity for predicting lymph node metastasis in patients with colorectal cancer

BACKGROUND AND PURPOSE

The pre-surgical estimation of lymph node (LN) metastasis in colorectal cancer (CRC) poses a significant diagnostic predicament. The associations between LN morphology, density, and metabolic heterogeneity and LN metastasis status in CRCs have been seldomly examined through the lens of radiomics. This research aimed to assess 2-[18F]FDG PET-based quantification of intratumoral metabolic heterogeneity for predicting lymph node metastasis in patients with colorectal cancer.

MATERIALS AND METHODS

The construction of the model utilized data from 264 CRC patients, all of whom underwent preoperative 2-[18F]FDG PET/CT. Radiomic features were extracted from PET and CT images of LNs. Least absolute shrinkage and selection operator (LASSO) regression was implemented for selecting pertinent imaging features with a tenfold cross-validation. The predictive accuracy for LN metastasis status was juxtaposed against traditional methodologies (comprising CT-reported LN status and PET/CT-reported LN status) by deploying the receiver operating characteristic (ROC) curve analysis. The radiomics signature was evaluated based on discrimination, calibration, and clinical utility parameters. The model was further subjected to validation using an independent cohort of 132 patients from the period of January 2012 to June 2020.

RESULTS

The radiomics model was composed of eight significant radiomic features (five from PET and three from CT), encapsulating metabolic and density heterogeneity. The radiomics signature (area under the curve (AUC), 0.908) showcased a significantly superior performance compared to CT-reported LN status (AUC, 0.563, P < 0.001) and PET/CT-reported LN status (AUC, 0.64, P < 0.001) for predicting LN-positive or LN-negative status. The radiomics signature (AUC, 0.885) also showcased a significantly superior performance compared to CT-reported LN status (AUC, 0.587, P < 0.001) and PET/CT-reported LN status (AUC, 0.621, P < 0.001) to identify N1 and N2. This signature maintained its independence from clinical risk factors and exhibited robustness in the validation test set. Decision curve analysis attested to the clinical utility of the radiomics signature.

CONCLUSIONS

The radiomics signature based on 2-[18F]FDG PET/CT, which derived image features directly from LNs irrespective of clinical risk factors, displayed enhanced diagnostic performance compared to conventional CT or PET/CT-reported LN status. This allows for the identification of pre-surgical LN metastasis status and facilitates a patient-specific prediction of LN metastasis status in CRC patients.

Value of glucose transport protein 1 expression in detecting lymph node metastasis in patients with colorectal cancer

BACKGROUND

There are limited data on the use of glucose transport protein 1 (GLUT-1) expression as a biomarker for predicting lymph node metastasis in patients with colorectal cancer. GLUT-1 and GLUT-3, hexokinase (HK)-II, and hypoxia-induced factor (HIF)-1 expressions may be useful biomarkers for detecting primary tumors and lymph node metastasis when combined with fluorodeoxyglucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT).

AIM

To evaluate GLUT-1, GLUT-3, HK-II, and HIF-1 expressions as biomarkers for detecting primary tumors and lymph node metastasis with 18F-FDG-PET/CT.

METHODS

This retrospective study included 169 patients with colorectal cancer who underwent colectomy and preoperative 18F-FDG-PET/CT at Chungbuk National University Hospital between January 2009 and May 2012. Two tissue cores from the central and peripheral areas of the tumors were obtained and were examined by a dedicated pathologist, and the expressions of GLUT-1, GLUT-3, HK-II, and HIF-1 were determined using immunohistochemical staining. We analyzed the correlations among their expressions, various clinicopathological factors, and the maximum standardized uptake value (SUVmax) of PET/CT.

RESULTS

GLUT-1 was found at the center or periphery of the tumors in 109 (64.5%) of the 169 patients. GLUT-1 positivity was significantly correlated with the SUVmax of the primary tumor and lymph nodes, regardless of the biopsy site (tumor center, P < 0.001 and P = 0.012; tumor periphery, P = 0.030 and P = 0.010, respectively). GLUT-1 positivity and negativity were associated with higher and lower sensitivities of PET/CT, respectively, for the detection of lymph node metastasis, regardless of the biopsy site. GLUT3, HK-II, and HIF-1 expressions were not significantly correlated with the SUVmax of the primary tumor and lymph nodes.

CONCLUSION

GLUT-1 expression was significantly correlated with the SUVmax of 18F-FDG-PET/CT for primary tumors and lymph nodes. Clinicians should consider GLUT-1 expression in preoperative endoscopic biopsy in interpreting PET/CT findings.

Is CT Radiomics Superior to Morphological Evaluation for pN0 Characterization? A Pilot Study in Colon Cancer

The aim of this study was to compare CT radiomics and morphological features when assessing benign lymph nodes (LNs) in colon cancer (CC). This retrospective study included 100 CC patients (test cohort) who underwent a preoperative CT examination and were diagnosed as pN0 after surgery. Regional LNs were scored with a morphological Likert scale (NODE-SCORE) and divided into two groups: low likelihood (LLM: 0-2 points) and high likelihood (HLM: 3-7 points) of malignancy. The T-test and the Mann-Whitney test were used to compare 107 radiomic features extracted from the two groups. Radiomic features were also extracted from primary lesions (PLs), and the receiver operating characteristic (ROC) was used to test a LN/PL ratio when assessing the LN's status identified with radiomics and with the NODE-SCORE. An amount of 337 LNs were divided into 167 with LLM and 170 with HLM. Radiomics showed 15/107 features, with a significant difference (p < 0.02) between the two groups. The comparison of selected features between 81 PLs and the corresponding LNs showed all significant differences (p < 0.0001). According to the LN/PL ratio, the selected features recognized a higher number of LNs than the NODE-SCORE (p < 0.001). On validation of the cohort of 20 patients (10 pN0, 10 pN2), significant ROC curves were obtained for LN/PL busyness (AUC = 0.91; 0.69-0.99; 95% C.I.; and p < 0.001) and for LN/PL dependence entropy (AUC = 0.76; 0.52-0.92; 95% C.I.; and p = 0.03). The radiomics ratio between CC and LNs is more accurate for noninvasively discriminating benign LNs compared to CT morphological features.

Association of the pathomics-collagen signature with lymph node metastasis in colorectal cancer: a retrospective multicenter study

BACKGROUND

Lymph node metastasis (LNM) is a prognostic biomarker and affects therapeutic selection in colorectal cancer (CRC). Current evaluation methods are not adequate for estimating LNM in CRC. H&E images contain much pathological information, and collagen also affects the biological behavior of tumor cells. Hence, the objective of the study is to investigate whether a fully quantitative pathomics-collagen signature (PCS) in the tumor microenvironment can be used to predict LNM.

METHODS

Patients with histologically confirmed stage I-III CRC who underwent radical surgery were included in the training cohort (n = 329), the internal validation cohort (n = 329), and the external validation cohort (n = 315). Fully quantitative pathomics features and collagen features were extracted from digital H&E images and multiphoton images of specimens, respectively. LASSO regression was utilized to develop the PCS. Then, a PCS-nomogram was constructed incorporating the PCS and clinicopathological predictors for estimating LNM in the training cohort. The performance of the PCS-nomogram was evaluated via calibration, discrimination, and clinical usefulness. Furthermore, the PCS-nomogram was tested in internal and external validation cohorts.

RESULTS

By LASSO regression, the PCS was developed based on 11 pathomics and 9 collagen features. A significant association was found between the PCS and LNM in the three cohorts (P < 0.001). Then, the PCS-nomogram based on PCS, preoperative CEA level, lymphadenectasis on CT, venous emboli and/or lymphatic invasion and/or perineural invasion (VELIPI), and pT stage achieved AUROCs of 0.939, 0.895, and 0.893 in the three cohorts. The calibration curves identified good agreement between the nomogram-predicted and actual outcomes. Decision curve analysis indicated that the PCS-nomogram was clinically useful. Moreover, the PCS was still an independent predictor of LNM at station Nos. 1, 2, and 3. The PCS nomogram displayed AUROCs of 0.849-0.939 for the training cohort, 0.837-0.902 for the internal validation cohort, and 0.851-0.895 for the external validation cohorts in the three nodal stations.

CONCLUSIONS

This study proposed that PCS integrating pathomics and collagen features was significantly associated with LNM, and the PCS-nomogram has the potential to be a useful tool for predicting individual LNM in CRC patients.

Prognostic impact of extramural venous invasion detected by contrast-enhanced CT colonography in colon cancer

BACKGROUND

The impact of computed tomography (CT)-detected extramural venous invasion on the recurrence of colon cancer is not fully understood. The aim of this study was to investigate the clinical significance of extramural venous invasion diagnosed before surgery by contrast-enhanced CT colonography using three-dimensional multiplanar reconstruction images.

METHODS

Patients with colon cancer staged greater than or equal to T2 and/or stage I-III who underwent contrast-enhanced CT colonography between 2013 and 2018 at the National Cancer Center Hospital in Japan were retrospectively investigated for CT-detected extramural venous invasion. Inter-observer agreement for the detection of CT-detected extramural venous invasion was evaluated and Kaplan-Meier survival curves were plotted for recurrence-free survival using CT-TNM staging and CT-detected extramural venous invasion. Preoperative clinical variables were analysed using Cox regression for recurrence-free survival.

RESULTS

Out of 922 eligible patients, 544 cases were analysed (50 (9.2 per cent) were diagnosed as positive for CT-detected extramural venous invasion and 494 (90.8 per cent) were diagnosed as negative for CT-detected extramural venous invasion). The inter-observer agreement for CT-detected extramural venous invasion had a κ coefficient of 0.830. The group positive for CT-detected extramural venous invasion had a median follow-up of 62.1 months, whereas the group negative for CT-detected extramural venous invasion had a median follow-up of 60.7 months. When CT-TNM stage was stratified according to CT-detected extramural venous invasion status, CT-T3 N(-)extramural venous invasion(+) had a poor prognosis compared with CT-T3 N(-)extramural venous invasion(-) and CT-stage I (5-year recurrence-free survival of 50.6 versus 89.3 and 90.1 per cent respectively; P < 0.001). In CT-stage III, the group positive for CT-detected extramural venous invasion also had a poor prognosis compared with the group negative for CT-detected extramural venous invasion (5-year recurrence-free survival of 52.0 versus 78.5 per cent respectively; P = 0.003). Multivariable analysis revealed that recurrence was associated with CT-T4 (HR 3.10, 95 per cent c.i. 1.85 to 5.20; P < 0.001) and CT-detected extramural venous invasion (HR 3.08, 95 per cent c.i. 1.90 to 5.00; P < 0.001).

CONCLUSION

CT-detected extramural venous invasion was found to be an independent predictor of recurrence and could be used in combination with preoperative TNM staging to identify patients at high risk of recurrence.

Diagnostic Performance of Rectal CT for Staging Rectal Cancer: Comparison with Rectal MRI and Histopathology

Purpose

To compare the diagnostic performance of rectal CT with that of high-resolution rectal MRI and histopathology in assessing rectal cancer.

Materials and Methods

Sixty-seven patients with rectal cancer who underwent rectal CT with rectal distension using sonographic gel and high-resolution MRI were enrolled in this study. The distance from the anal verge/anorectal junction, distance to the mesorectal fascia (MRF), extramural depth (EMD), extramesorectal lymph node (LN) involvement, extramural venous invasion (EMVI), and T/N stages in rectal CT/MRI were analyzed by two gastrointestinal radiologists. The CT findings of 20 patients who underwent radical surgery without concurrent chemoradiotherapy were compared using histopathology. Interclass correlations and kappa statistics were used.

Results

The distance from the anal verge/anorectal junction showed an excellent intraclass correlation between CT and MRI for both reviewers. For EMD, the distance to the MRF, presence of LNs, extramesorectal LN metastasis, EMVI, T stage, and intermodality kappa or weighted kappa values between CT and MRI showed excellent agreement. Among the 20 patients who underwent radical surgery, T staging, circumferential resection margin involvement, EMVI, and LN metastasis on rectal CT showed acceptable concordance rates with histopathology.

Conclusion

Dedicated rectal CT may be on par with rectal MRI in providing critical information to patients with rectal cancer.

The impact of mismatch repair status and systemic inflammatory markers on radiological staging in colon cancer

OBJECTIVE

Mismatch repair (MMR) deficient (dMMR) colon cancer (CC) is distinct from MMR proficient (pMMR) CC, yet the impact of MMR status on radiological staging is unclear. The purpose of this study was to investigate how MMR status impacts CC CT staging.

METHODS

We retrospectively compared CT staging accuracy between dMMR and pMMR CC patients undergoing curative resection. Accuracy was assessed as individual tumour (T)/nodal (N) stages and as dichotomous "statuses" (T1/2 vs T3/4; N0 vs N1/2). Patient characteristics were analysed for factors to support staging.

RESULTS

There was no significant difference in overall staging accuracy between the dMMR (44 patients) and pMMR (57 patients) groups. dMMR tumours with incorrect N stage/"status" were more likely to be overstaged than pMMR tumours (90% vs 59%; p = 0.023 for "N status"). Platelet count, CRP and neutrophil count (AUC 0.76 (p = 0.0078), 0.75 (p = 0.034) and 0.70 (p = 0.044), respectively) were associated with "N status" in dMMR tumours.

CONCLUSION

Whilst overall staging accuracy was similar between groups, incorrectly N staged dMMR tumours were more likely to be overstaged than pMMR tumours, risking inappropriate surgical or neoadjuvant treatment. We describe novel relationships between several inflammatory markers and pathological "N status" in dMMR CC, which if integrated into routine practice may improve CT staging accuracy.

ADVANCES IN KNOWLEDGE

Compared to pMMR CC, dMMR CC is at significant risk of N overstaging. Platelet count, CRP and neutrophil count are higher in dMMR CC patients with nodal metastases than those without, and their role in refining clinical staging requires further investigation.

A randomized phase II study comparing preoperative mFOLFOX6 versus FOLFOXIRI for locally advanced colon cancer: JCOG2006

The prognosis of locally advanced colon cancer (LACC) with surgical resection followed only by adjuvant chemotherapy is poor. Preoperative chemotherapy for LACC patients with risk factors such as cT4bN+ or cT3-4aN2-3 has attracted attention. Here, the authors describe the rationale and design of JCOG2006, a randomized phase II study comparing preoperative chemotherapy with mFOLFOX6 versus FOLFOXIRI for LACC. Their efficacy and safety are evaluated and a determination of which is the more promising treatment will be conducted in a subsequent phase III trial. A total of 86 patients will be accrued from 44 institutions over 2 years. The primary end point is the proportion of patients with a Tumor Regression Score of 0-2, and secondary end points include overall survival, response rate and adverse events. Clinical Trial Registration: jRCTs031210365 (https://jrct.niph.go.jp/).

Non-exposed endoscopic wall-inversion surgery with one-step nucleic acid amplification for early gastrointestinal tumors: Personal experience and literature review

BACKGROUND

Laparoscopic and endoscopic cooperative surgery is a safe, organ-sparing surgery that achieves full-thickness resection with adequate margins. Recent studies have demonstrated the safety and efficacy of these procedures. However, these techniques are limited by the exposure of the tumor and mucosa to the peritoneal cavity, which could lead to viable cancer cell seeding and the spillage of gastric juice or enteric liquids into the peritoneal cavity. Non-exposed endoscopic wall-inversion surgery (NEWS) is highly accurate in determining the resection margins to prevent intraperitoneal contamination because the tumor is inverted into the visceral lumen instead of the peritoneal cavity. Accurate intraoperative assessment of the nodal status could allow stratification of the extent of resection. One-step nucleic acid amplification (OSNA) can provide a rapid method of evaluating nodal tissue, whilst near-infrared laparoscopy together with indocyanine green can identify relevant nodal tissue intraoperatively.

AIM

To determine the safety and feasibility of NEWS in early gastric and colon cancers and of adding rapid intraoperative lymph node (LN) assessment with OSNA.

METHODS

The patient-based experiential portion of our investigations was conducted at the General and Oncological Surgery Unit of the St. Giuseppe Moscati Hospital (Avellino, Italy). Patients with early-stage gastric or colon cancer (diagnosed via endoscopy, endoscopic ultrasound, and computed tomography) were included. All lesions were treated by NEWS procedure with intraoperative OSNA assay between January 2022 and October 2022. LNs were examined intraoperatively with OSNA and postoperatively with conventional histology. We analyzed patient demographics, lesion features, histopathological diagnoses, R0 resection (negative margins) status, adverse events, and follow-up results. Data were collected prospectively and analyzed retrospectively.

RESULTS

A total of 10 patients (5 males and 5 females) with an average age of 70.4 ± 4.5 years (range: 62-78 years) were enrolled in this study. Five patients were diagnosed with gastric cancer. The remaining 5 patients were diagnosed with early-stage colon cancer. The mean tumor diameter was 23.8 ± 11.6 mm (range: 15-36 mm). The NEWS procedure was successful in all cases. The mean procedure time was 111.5 ± 10.7 min (range: 80-145 min). The OSNA assay revealed no LN metastases in any patients. Histologically complete resection (R0) was achieved in 9 patients (90.0%). There was no recurrence during the follow-up period.

CONCLUSION

NEWS combined with sentinel LN biopsy and OSNA assay is an effective and safe technique for the removal of selected early gastric and colon cancers in which it is not possible to adopt conventional endoscopic resection techniques. This procedure allows clinicians to acquire additional information on the LN status intraoperatively.

Radiomics in colorectal cancer patients

The main therapeutic options for colorectal cancer are surgical resection and adjuvant chemotherapy in non-metastatic disease. However, the evaluation of the overall adjuvant chemotherapy benefit in patients with a high risk of recurrence is challenging. Radiological images can represent a source of data that can be analyzed by using automated computer-based techniques, working on numerical information coded within Digital Imaging and Communications in Medicine files: This image numerical analysis has been named "radiomics". Radiomics allows the extraction of quantitative features from radiological images, mainly invisible to the naked eye, that can be further analyzed by artificial intelligence algorithms. Radiomics is expanding in oncology to either understand tumor biology or for the development of imaging biomarkers for diagnosis, staging, and prognosis, prediction of treatment response and diseases monitoring and surveillance. Several efforts have been made to develop radiomics signatures for colorectal cancer patient using computed tomography (CT) images with different aims: The preoperative prediction of lymph node metastasis, detecting BRAF and RAS gene mutations. Moreover, the use of delta-radiomics allows the analysis of variations of the radiomics parameters extracted from CT scans performed at different timepoints. Most published studies concerning radiomics and magnetic resonance imaging (MRI) mainly focused on the response of advanced tumors that underwent neoadjuvant therapy. Nodes status is the main determinant of adjuvant chemotherapy. Therefore, several radiomics model based on MRI, especially on T2-weighted images and ADC maps, for the preoperative prediction of nodes metastasis in rectal cancer has been developed. Current studies mostly focused on the applications of radiomics in positron emission tomography/CT for the prediction of survival after curative surgical resection and assessment of response following neoadjuvant chemoradiotherapy. Since colorectal liver metastases develop in about 25% of patients with colorectal carcinoma, the main diagnostic tasks of radiomics should be the detection of synchronous and metachronous lesions. Radiomics could be an additional tool in clinical setting, especially in identifying patients with high-risk disease. Nevertheless, radiomics has numerous shortcomings that make daily use extremely difficult. Further studies are needed to assess performance of radiomics in stratifying patients with high-risk disease.

The Accuracy of Different Modalities Used for Preoperative Primary Tumour Localisation in Operated Colorectal Cancer Patients

Aim Colonoscopy and computed tomography (CT) scans of the abdomen and pelvis are routine pre-operative assessment tools in colorectal cancer (CRC) patients. There have been some discrepancies regarding the location of cancer when seen by colonoscopy versus CT scan. The purpose of this study was to compare the accuracy of a colonoscopy with a computed tomography (CT) scan of the abdomen and pelvis with contrast, which is done routinely before surgery to localise the exact site of the tumour within the large bowel, whilst comparing both to the operative, gross and histopathology findings of the exact location. Methods A retrospective study was carried out on 165 colorectal cancer patients operated on between January 1, 2010, and December 31, 2014, using electronic hospital records that were reviewed anonymously, comparing the location of cancer within the large bowels as was found on colonoscopy and CT scan of the abdomen and pelvis with contrast, comparing both to post-operative histopathology specimen or intra-operative assessment in cases where no resection of the primary tumour was performed. Results CT and colonoscopy were both accurate in diagnosing 70.5% of cases that had done both investigations pre-operatively. The best results were obtained when the cancer was located in the caecum as confirmed post-operatively; the combined accuracy rate was 100%. CT was accurate, whilst colonoscopy was not in eight (6.2%) cases (all are rectal or sigmoid cancers), and colonoscopy was accurate and CT was not in 12 cases, 10 of them were rectal and two were ascending colonic. Colonoscopy was not performed in 36 (21%) cases for a variety of reasons, including large bowel obstruction or perforation on presentation. In 32 of these cases, CT scan managed to accurately predict the location of cancer (mostly rectal and caecal), and CT scan was inaccurate in 20.6% of cases (34 out of 165), whilst colonoscopy was inaccurate in 13.9% of cases (18 out of 129). Conclusion Colonoscopy is more accurate in localising colorectal cancers than CT scan of the abdomen and pelvis with contrast. CT scan diagnoses regional and distant spread of colorectal cancers such as nodal status, invasion of neighbouring organs and/or peritoneum and the presence of liver metastases, whilst colonoscopy is limited to intraluminal diagnosis but can be both a diagnostic and therapeutic tool, with higher accuracy, in general, in localising colorectal cancers. Both CT scan and colonoscopy were equal in appendicular, caecal, splenic flexure and descending colon cancer localisation accuracy.

CT is unreliable in locoregional staging of early colon cancer: A nationwide registry-based study

BACKGROUND AND OBJECTIVE

The option to treat early colon cancer (CC) with local resection, as well as trials investigating neoadjuvant treatment, has increased the importance of identifying early-stage disease in the workup. Most CC patients are T- and N-staged preoperatively with CT, although its reliability in staging early CC remains elusive. The aim of this study was to investigate CT-staging accuracy in early CC by evaluating pT and pN stages in patients staged as cT1-2, and cT and cN stages in patients with pT1 tumors.

METHODS

Retrospective population-based cohort study on data from the nationwide Swedish colorectal cancer registry on all CC patients staged as cT1-2 and all patients with pT1 undergoing surgical resection 2009-2018. CT-acquired T- and N-stages were compared with final histopathology. Factors potentially influencing accuracy were analyzed with uni- and multivariate logistic regression.

RESULTS

Computed tomography (CT) staged 4849 patients as cT1-2, whereas 2445 (50%) were pT3 and 453 (9%) pT4. Positive predictive value of the cT1-2 stage was 40%. Of 1401 pT1 patients, 624 (45%) were staged as cT1-2, 139 (10%) as cT3, 15 (1%) as cT4 and 623 (44%) as cTx. In all, 1474 (30%) of the cT1-2 patients were pN+, whereas CT staged 1062 (72%) as cN0. A total of 771 patients were staged as cN+, whereas 403 (52%) were pN0. Overall accuracy in determining N+ was 67%, with 26% sensitivity and 88% specificity. Positive and negative predictive values in determining N+ were 48% and 73%, respectively.

CONCLUSIONS

This nationwide population-based study shows that CT-staging carries a substantial risk of understaging locally advanced tumors as cT1-2 and pT1 tumors as cTx, in addition to poor N-staging. Thus, CT obtained T- and N-staging should not be used for deciding treatment strategies in early CC.

The usefulness of preoperative CT in colon cancer staging: impact of radiologists' experience

PURPOSE

To assess the agreement between radiologists in the detection of specific features related to T- and N-stage and evaluate accuracy in colon cancer staging.

METHODS

Patients who underwent contrast-enhanced computed tomography (CECT) before surgery were enrolled and evaluated by three radiologists with different experience. Pathological data were used as the reference standard. Tumor location, presence of tumor bulging, fat stranding, lateroconal fascia invasion, enlarged vessels, axial short diameter of the biggest node, shape, enhancement pattern, intranodal necrosis, and cluster were collected. Reliability analysis was performed with κ statistics and intraclass correlation coefficients (ICCs). Logistic regressions were used to determine independent predictors associated with staging.

RESULTS

Seventy five patients were evaluated. The reliability analysis was moderate to substantial for tumor location (κ = 0.853), T staging (κ = 0.531), tumor bulging (κ = 0.478), fat stranding (κ = 0.490), lateroconal fascia invasion (κ = 0.436), enlarged vessels (κ = 0.401), the axial short diameter of the biggest node (ICC = 0.732), shape (κ = 0.484), enhancement pattern (κ = 0.431), intranodal necrosis (κ = 0.606), and cluster (κ = 0.358). For all readers, sensitivity was higher for T3 lesions (60-69%) and specificity was higher for T2 and T4 lesions (84.5-90.0% and 82.4-85.1%). The diagnostic accuracy was acceptable for all lesions and among all readers (50.7-92.1%). The lateroconal fascia invasion and enlarged vessels resulted as independent predictor factors (OR = 3.292 and OR = 2.651) for T staging, while nodes' cluster and dimension as independent predictor factors of N staging [OR = 3.798 and OR = 1.083].

CONCLUSION

Reader's experience is one of the most important factors associated with the correct classification of colon cancer. Moreover, CECT can help depict radiological features independently associated with the T and N stages.

Systematic reviews: A glossary for public health

Literature reviews are conducted for a range of purposes, from providing an overview or primer of a novel topic, to providing a comprehensive, precise, and accurate estimate of an effect estimate. There is much confusion over nomenclature related to literature reviews, with the term 'systematic review' often used to mean any review based on some form of explicit methodology. However, guidance and minimum standards exist for these kinds of robust reviews that are intended to support evidence-informed decision-making, and reviewers must carefully ensure their syntheses are conducted and reported to a high standard if this is their objective. The diversity of names given to reviews is reflected in the diversity of methods used for these evidence syntheses: the result is a general confusion about what is important to ensure a review is fit-for-purpose, and many reviews are labelled as 'systematic reviews' when they do not follow standardised or replicable approaches. Here, we provide a glossary or typology that aims to highlight the importance of the reviewers' objectives in choosing and naming their review method. We focus on reviews in public health and provide guidance on selecting an objective, methodological guidance to follow, justifying and reporting the methods chosen, and attempting to ensure consistent and clear nomenclature. We hope this will help review authors, editors, peer-reviewers, and readers understand, interpret, and critique a review depending on its intended use.

En-bloc resection including SMV and duodenum in patient of locally advanced colon cancer

Tumor could directly invade or is adherent to other organs, but superior mesentery vein (SMV) and duodenum invasion are very rare. A 62-year-old woman was diagnosed with abdominal pain for several months. Multiple erythematous brownish skin patches and palpable mass were found at epigastric area. Computed tomography imaging showed focal wall thickening at the transverse colon that invaded to the rectus muscle and anterior abdominal wall. On exploration, we identified tumor invaded or was adherent to the duodenum and superior mesenteric vein and performed en-bloc resection. After surgery, the patient received chemotherapy and was followed up without any recurrence for 16 months. Adhesion and invasion of tumor to surrounding organs can be unexpectedly found during surgery. In our case, we found duodenum and SMV invasion and achieved R0 resection by SMV and duodenum resection, which could improve the patient's prognosis.

Efficacy and Safety of Neoadjuvant Chemotherapy Combined with Adjuvant Chemotherapy for Locally Advanced Colon Cancer: A Propensity Score-Matching Analysis

Background and Objectives: Increasing evidence supports the use of neoadjuvant chemotherapy (NAC) for locally advanced colon cancer (LACC). However, its effectiveness remains controversial. This study explored the safety and efficacy of NAC combined with laparoscopic radical colorectal cancer surgery and adjuvant chemotherapy (AC) for LACC. Materials and Methods: We retrospectively analyzed 444 patients diagnosed with LACC (cT4 or cT3, with ≥5 mm invasion beyond the muscularis propria) in our hospital between 2012 and 2015. Propensity score matching (PSM; 1:2) was performed to compare patients treated with NAC and those treated with adjuvant chemotherapy (AC). Results: Overall, 42 patients treated with NAC were compared with 402 patients who received only AC. After PSM, 42 patients in the NAC group were compared with 84 patients in the control group, with no significant differences in the baseline characteristics between groups. The pathological tumor sizes in the NAC group were significantly smaller than those in the AC group (3.1 ± 2.1 cm vs. 5.8 ± 2.5 cm). Patients in the NAC group had a significantly lower T stage than those in the AC group (p < 0.001). After neoadjuvant chemotherapy, a significant response was observed in four (9.6%) patients, with two (4.8%) showing a complete response. The 5-year overall survival rates (88.1% vs. 77.8%, p = 0.206) and 5-year disease-free survival rates (75.1% vs. 64.2%, p = 0.111) did not differ between the groups. However, the 5-year cumulative rate of distant recurrence was significantly lower in the NAC than in the AC group (9.6% vs. 29.9%, p = 0.022). Conclusions: NAC, combined with AC, could downstage primary tumors of LACC and seems safe and acceptable for patients with LACC, with a similar long-term survival between the two treatments.

COL10A1 allows stratification of invasiveness of colon cancer and associates to extracellular matrix and immune cell enrichment in the tumor parenchyma

BACKGROUND

Treatment options for metastatic colorectal cancer (CRC) are mostly ineffective. We present new evidence that tumor tissue collagen type X alpha 1 (COL10A1) is a relevant candidate biomarker to improve this dilemma.

METHODS

Several public databases had been screened to observe COL10A1 expression in transcriptome levels with cell lines and tissues. Protein interactions and alignment to changes in clinical parameters and immune cell invasion were performed, too. We also used algorithms to build a novel COL10A1-related immunomodulator signature. Various wet-lab experiments were conducted to quantify COL10A1 protein and transcript expression levels in disease and control cell models.

RESULTS

COL10A1 mRNA levels in tumor material is clinical and molecular prognostic, featuring upregulation compared to non-cancer tissue, increase with histomorphological malignancy grading of the tumor, elevation in tumors that invade perineural areas, or lymph node invasion. Transcriptomic alignment noted a strong positive correlation of COL10A1 with transcriptomic signature of cancer-associated fibroblasts (CAFs) and populations of the immune compartment, namely, B cells and macrophages. We verified those findings in functional assays showing that COL10A1 are decreased in CRC cells compared to fibroblasts, with strongest signal in the cell supernatant of the cells.

CONCLUSION

COL10A1 abundance in CRC tissue predicts metastatic and immunogenic properties of the disease. COL10A1 transcription may mediate tumor cell interaction with its stromal microenvironment.

Role of one-step nucleic acid amplification in colorectal cancer lymph node metastases detection

Current histopathological staging procedures in colorectal cancer (CRC) depend on midline division of the lymph nodes (LNs) with one section of hematoxylin and eosin staining. Cancer cells outside this transection line may be missed, which could lead to understaging of Union for International Cancer Control Stage II high-risk patients. The one-step nucleic acid amplification (OSNA) assay has emerged as a rapid molecular diagnostic tool for LN metastases detection. It is a molecular technique that can analyze the entire LN tissue using a reverse-transcriptase loop-mediated isothermal amplification reaction to detect tumor-specific cytokeratin 19 mRNA. Our findings suggest that the OSNA assay has a high diagnostic accuracy in detecting metastatic LNs in CRC and a high negative predictive value. OSNA is a standardized, observer-independent technique, which may lead to more accurate staging. It has been suggested that in stage II CRC, the upstaging can reach 25% and these patients can access postoperative adjuvant chemotherapy. Moreover, intraoperative OSNA sentinel node evaluation may allow early CRC to be treated with organ-preserving surgery, while in more advanced-stage disease, a tailored lymphadenectomy can be performed considering the presence of aberrant lymphatic drainage and skip metastases.

Dual energy CT applications in oncological imaging

Cancer is the second leading cause of death in the United States, killing more than 600.000 people each year.¹ Despite several screening programs available, cancer diagnosis is often made incidentally during imaging studies performed for other reasons. Once the diagnosis is made, treatment assessment and surveillance of these patients heavily rely on radiological tools. Computed tomography (CT) in particular is one of the most commonly ordered modalities due to wide availability even in the most remote locations, and fast results. However, conventional CT often cannot definitively characterize a neoplastic lesion unless it was tailored toward answering a specific question. Furthermore, characterizing small lesions can be difficult with CT. An innovative technique called dual-energy CT (DECT) offers solutions to some of the challenges of conventional CT in oncological imaging.

Efficacy of PET/CT in diagnosis of regional lymph node metastases in patients with colorectal cancer: retrospective cohort study

Background

Endoscopic and transanal local resection without lymph node dissection are treatment options for patients with a low risk of lymph node metastasis; however, some patients might have undiagnosed lymph node metastases before surgery. This retrospective study aimed to evaluate the efficacy of preoperative PET/CT for diagnosing regional lymph node metastasis.

Methods

Patients who underwent curative resection with lymph node dissection for colorectal cancer at Osaka University between January 2012 and December 2015 were included. The cut-off values appropriate for diagnosing lymph node metastasis were calculated by way of a receiver operating characteristic (ROC) curves from maximum standard unit value (SUVmax) of main tumour, and lymph node short axis, and SUVmax of lymph node. The cut-off values of primary tumour SUVmax: 7, short-axis diameter of the lymph node at 7 mm, and lymph node SUVmax at 1.5 were set.

Result

A total of 541 patients were included. Regional lymph node metastases were confirmed in resected specimens from 187 patients (35 per cent). With a primary tumour SUVmax of 7 used as a cut-off value, the sensitivity and specificity of regional lymph node metastasis were 70.1 per cent and 45.5 per cent respectively. With a cut-off short-axis diameter of the regional lymph node of 7 mm, the sensitivity and specificity of regional lymph node metastasis were 75.2 per cent and 82.6 per cent respectively, and with a cut-off regional lymph node SUVmax of 1.5, the sensitivity and specificity of regional lymph node metastasis were 78.6 per cent and 96.8 per cent respectively. When the diagnostic criteria were defined by a lymph node short-axis diameter of 7 mm or SUVmax of 1.5, the sensitivity and specificity were 87.4 per cent and 81.8 per cent respectively.

Conclusion

Preoperative PET/CT is a useful modality for evaluating regional lymph node metastasis in patients with colorectal cancer.

Radiology of the Mesentery

The recent description and re-classification of the mesentery as an organ prompted renewed interest in its role in physiological and pathological processes. With an improved understanding of its anatomy, accurately and reliably assessing the mesentery with non-invasive radiological investigation becomes more feasible. Multi-detector computed tomography is the main radiological modality employed to assess the mesentery due to its speed, widespread availability, and diagnostic accuracy. Pathologies affecting the mesentery can be classified as primary or secondary mesenteropathies. Primary mesenteropathies originate in the mesentery and subsequently progress to involve other organ systems (e.g., mesenteric ischemia or mesenteric volvulus). Secondary mesenteropathies describe disease processes that originate elsewhere and progress to involve the mesentery with varying degrees of severity (e.g., lymphoma). The implementation of standardized radiological imaging protocols, nomenclature, and reporting format with regard to the mesentery will be essential in improving the assessment of mesenteric anatomy and various mesenteropathies. In this article, we describe and illustrate the current state of art in respect of the radiological assessment of the mesentery.

Characteristics of tumour stroma in regional lymph node metastases in colorectal cancer patients: a theoretical framework for future diagnostic imaging with FAPI PET/CT

Purpose

The recently developed fibroblast activation protein inhibitor (FAPI) tracer for PET/CT, binding tumour-stromal cancer-associated fibroblasts, is a promising tool for detection of positive lymph nodes. This study provides an overview of features, including sizes and tumour-stromal content, of lymph nodes and their respective lymph node metastases (LNM) in colorectal cancer (CRC), since literature lacks on whether LNMs contain sufficient stroma to potentially allow FAPI-based tumour detection.

Methods

Haematoxylin and eosin-stained tissue slides from 73 stage III colon cancer patients were included. Diameters and areas of all lymph nodes and their LNMs were assessed, the amount of stroma by measuring the stromal compartment area, the conventional and total tumour-stroma ratios (TSR-c and TSR-t, respectively), as well as correlations between these parameters. Also, subgroup analysis using a minimal diameter cut off of 5.0 mm was performed.

Results

In total, 126 lymph nodes were analysed. Although positive correlations were observed between node and LNM for diameter and area (r = 0.852, p < 0.001 and r = 0.960, p < 0.001, respectively), and also between the LNM stromal compartment area and nodal diameter (r = 0.612, p < 0.001), nodal area (r = 0.747, p < 0.001) and LNM area (r = 0.746, p < 0.001), novel insight was that nearly all (98%) LNMs contained stroma, with median TSR-c scores of 35% (IQR 20–60%) and TSR-t of 20% (IQR 10–30%). Moreover, a total of 32 (25%) positive lymph nodes had a diameter of < 5.0 mm.

Conclusion

In LNMs, stroma is abundantly present, independent of size, suggesting a role for FAPI PET/CT in improved lymph node detection in CRC.

Transabdominal Ultrasonography for Preoperative Diagnosis of Lymph Node Metastasis in Colon Cancer: A Retrospective Cohort Study

Background/Aim

Although computed tomography (CT) is the standard modality for diagnosing lymph node metastasis (LNM), transabdominal ultrasonography (US) can be useful due to its high spatial resolution and use of Doppler signals to precisely analyse lymph nodes. This study aimed to evaluate the accuracy of US for lymph node assessment, establish US-based diagnostic criteria for LNM, and compare the capability of US with that of CT for the diagnosis of LNM.

Patients and Methods

This retrospective, single-institution, cohort study included patients who underwent radical surgery for clinical stage 0-III colon cancer, between March 2012 and February 2019.

Results

Overall, 34.9% (66/189) of patients had pathological LNM. The optimal US diagnostic criteria were 1) short axis ≥7 mm and short/long ratio ≥0.75 and 2) at least two of the following: the absence of hilar echoes, expansive appearance, or peripheral/mixed vascularity by the colour Doppler and/or contrast-enhanced method. Compared to CT, US showed a higher diagnostic sensitivity (54.5% vs. 43.9%; p=0.296), higher concordance with the number of pathological LNM (correlation coefficient: US, 0.42; CT, 0.27) and pathological N diagnosis (weighted ĸ: US, 0.35; CT, 0.18), and higher sensitivity for advanced LNM, including multiple LNMs (47.4% vs. 18.4%; p=0.014) and N2 stage (27.8% vs. 5.6%; p=0.177).

Conclusion

US has higher sensitivity than CT for diagnosing LNM in colon cancer, along with a more accurate preoperative diagnosis of the N stage. Additionally, US may be more helpful than CT alone for preoperatively deciding the appropriateness of neoadjuvant treatment in colon cancer with advanced LNM.

Deep learning radiomics model related with genomics phenotypes for lymph node metastasis prediction in colorectal cancer

BACKGROUND AND PURPOSE

The preoperative lymph node (LN) status is important for the treatment of colorectal cancer (CRC). Here, we established and validated a deep learning (DPL) model for predicting lymph node metastasis (LNM) in CRC.

MATERIALS AND METHODS

A total of 423 CRC patients were divided into cohort 1 (training set, n = 238, testing set, n = 101) and cohort 2 (validation set, n = 84). Among them, 84 patients' tumour tissues were collected for RNA sequencing. The DPL features were extracted from enhanced venous-phase computed tomography of CRC using an autoencoder. A DPL model was constructed with the least absolute shrinkage and selection operator algorithm. Carcinoembryonic antigen and carbohydrate antigen 19-9 were incorporated into the DPL model to construct a combined model. The model performance was assessed by receiver operating characteristic curves, calibration curves and decision curves. The correlations between DPL features, which have been selected, and genes were analysed by Spearman correlation, and the genes correlated with DPL features were used to transcriptomic analysis.

RESULTS

The DPL model, integrated with 20 DPL features, showed a good discrimination performance in predicting the LNM, with areas under the curves (AUCs) of 0.79, 0.73 and 0.70 in the training set, testing set and validation set, respectively. The combined model had a better performance, with AUCs of 0.81, 0.77 and 0.73 in the three sets, respectively. Decision curve analysis confirmed the clinical application value of the DPL model and combined model. Furthermore, catabolic processes and immune-related pathways were identified and related with the selected DPL features.

CONCLUSION

This study presented a DPL model and a combined model for LNM prediction. We explored the potential genomic phenotypes related with DPL features. In addition, the model could potentially be utilized to facilitate the individualized prediction of LNM in CRC.

Survival Advantage Following TAG-72 Antigen-Directed Cancer Surgery in Patients With Colorectal Carcinoma: Proposed Mechanisms of Action

Patients with colorectal carcinoma (CRC) continue to have variable clinical outcomes despite undergoing the same surgical procedure with curative intent and having the same pathologic and clinical stage. This problem suggests the need for better techniques to assess the extent of disease during surgery. We began to address this problem 35 years ago by injecting patients with either primary or recurrent CRC with 125I-labeled murine monoclonal antibodies against the tumor-associated glycoprotein-72 (TAG-72) and using a handheld gamma-detecting probe (HGDP) for intraoperative detection and removal of radioactive, i.e., TAG-72-positive, tissue. Data from these studies demonstrated a significant difference in overall survival data (p < 0.005 or better) when no TAG-72-positive tissue remained compared to when TAG-72-positive tissue remained at the completion of surgery. Recent publications indicate that aberrant glycosylation of mucins and their critical role in suppressing tumor-associated immune response help to explain the cellular mechanisms underlying our results. We propose that monoclonal antibodies to TAG-72 recognize and bind to antigenic epitopes on mucins that suppress the tumor-associated immune response in both the tumor and tumor-draining lymph nodes. Complete surgical removal of all TAG-72-positive tissue serves to reverse the escape phase of immunoediting, allowing a resetting of this response that leads to improved overall survival of the patients with either primary or recurrent CRC. Thus, the status of TAG-72 positivity after resection has a significant impact on patient survival.

Deep learning can predict lymph node status directly from histology in colorectal cancer

BACKGROUND

Lymph node status is a prognostic marker and strongly influences therapeutic decisions in colorectal cancer (CRC).

OBJECTIVES

The objective of the study is to investigate whether image features extracted by a deep learning model from routine histological slides and/or clinical data can be used to predict CRC lymph node metastasis (LNM).

METHODS

Using histological whole slide images (WSIs) of primary tumours of 2431 patients in the DACHS cohort, we trained a convolutional neural network to predict LNM. In parallel, we used clinical data derived from the same cases in logistic regression analyses. Subsequently, the slide-based artificial intelligence predictor (SBAIP) score was included in the regression. WSIs and data from 582 patients of the TCGA cohort were used as the external test set.

RESULTS

On the internal test set, the SBAIP achieved an area under receiver operating characteristic (AUROC) of 71.0%, the clinical classifier achieved an AUROC of 67.0% and a combination of the two classifiers yielded an improvement to 74.1%. Whereas the clinical classifier's performance remained stable on the TCGA set, performance of the SBAIP dropped to an AUROC of 61.2%. Performance of the clinical classifier depended strongly on the T stage.

CONCLUSION

Deep learning-based image analysis may help predict LNM of patients with CRC using routine histological slides. Combination with clinical data such as T stage might be useful. Strategies to increase performance of the SBAIP on external images should be investigated.

Influence of incorrect staging of colorectal carcinoma on oncological outcome: are we playing safely?

Accurate preoperative staging of colorectal cancers is critical in selecting patients for neoadjuvant therapy prior to resection. Inaccurate staging, particularly understaging, may lead to involved resection margins and poor oncological outcomes. Our aim is to determine preoperative imaging accuracy of colorectal cancers compared to histopathology and define the effect of inaccurate staging on patient selection for neoadjuvant treatment(NT). Staging and treatment were determined for patients undergoing colorectal resections for adenocarcinomas in a single tertiary centre(2016-2020). Data were obtained for 948 patients. The staging was correct for both T and N stage in 19.68% of colon cancer patients. T stage was under-staged in 18.58%. At resection, 23 patients (3.36%) had involved pathological margins; only 7 of which had been predicted by pre-operative staging. However, the staging was correct for both T and N stage in 53.85% of rectal cancer patients. T stage was understaged in 26.89%. Thirteen patients had involved(R1)margins; T4 had been accurately predicted in all of these cases. There was a general trend in understaging both the tumor and lymphonodal involvement (T p < 0.00001 N p < 0.00001) causing a failure in administrating NT in 0.1% of patients with colon tumor, but not with rectal cancer. Preoperative radiological staging tended to understage both colonic and rectal cancers. In colonic tumours this may lead to a misled opportunity to treat with neoadjuvant therapy, resulting in involved margins at resection.

Advances in radiological staging of colorectal cancer

The role of imaging in clinically staging colorectal cancer has grown substantially in the 21^st century with more widespread availability of multi-row detector computed tomography (CT), high-resolution magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI), and integrated positron-emission tomography (PET)/CT. In contrast to staging many other cancers, increasing colorectal cancer stage does not highly correlate with survival. As has been the case previously, clinical practice incorporates advances in staging and it is used to guide therapy before adoption into international staging guidelines. Emerging imaging techniques show promise to become part of future staging standards.

Individualized Prediction of Colorectal Cancer Metastasis Using a Radiogenomics Approach

Objectives: To evaluate whether incorporating the radiomics, genomics, and clinical features allows prediction of metastasis in colorectal cancer (CRC) and to develop a preoperative nomogram for predicting metastasis.

Methods: We retrospectively analyzed radiomics features of computed tomography (CT) images in 134 patients (62 in the primary cohort, 28 in the validation cohort, and 44 in the independent-test cohort) clinicopathologically diagnosed with CRC at Dazhou Central Hospital from February 2018 to October 2019. Tumor tissues were collected from all patients for RNA sequencing, and clinical data were obtained from medical records. A total of 854 radiomics features were extracted from enhanced venous-phase CT of CRC. Least absolute shrinkage and selection operator regression analysis was utilized for data dimension reduction, feature screen, and radiomics signature development. Multivariable logistic regression analysis was performed to build a multiscale predicting model incorporating the radiomics, genomics, and clinical features. The receiver operating characteristic curve, calibration curve, and decision curve were conducted to evaluate the performance of the nomogram.

Results: The radiomics signature based on 16 selected radiomics features showed good performance in metastasis assessment in both primary [area under the curve (AUC) = 0.945, 95% confidence interval (CI) 0.892–0.998] and validation cohorts (AUC = 0.754, 95% CI 0.570–0.938). The multiscale nomogram model contained radiomics features signatures, four-gene expression related to cell cycle pathway, and CA 19-9 level. The multiscale model showed good discrimination performance in the primary cohort (AUC = 0.981, 95% CI 0.953–1.000), the validation cohort (AUC = 0.822, 95% CI 0.635–1.000), and the independent-test cohort (AUC = 0.752, 95% CI 0.608–0.896) and good calibration. Decision curve analysis confirmed the clinical application value of the multiscale model.

Conclusion: This study presented a multiscale model that incorporated the radiological eigenvalues, genomics features, and CA 19-9, which could be conveniently utilized to facilitate the individualized preoperatively assessing metastasis in CRC patients.

Development of a Novel Prognostic Model for Predicting Lymph Node Metastasis in Early Colorectal Cancer: Analysis Based on the Surveillance, Epidemiology, and End Results Database

Background

Identification of a simplified prediction model for lymph node metastasis (LNM) for patients with early colorectal cancer (CRC) is urgently needed to determine treatment and follow-up strategies. Therefore, in this study, we aimed to develop an accurate predictive model for LNM in early CRC.

Methods

We analyzed data from the 2004-2016 Surveillance Epidemiology and End Results database to develop and validate prediction models for LNM. Seven models, namely, logistic regression, XGBoost, k-nearest neighbors, classification and regression trees model, support vector machines, neural network, and random forest (RF) models, were used.

Results

A total of 26,733 patients with a diagnosis of early CRC (T1) were analyzed. The models included 8 independent prognostic variables; age at diagnosis, sex, race, primary site, histologic type, tumor grade, and, tumor size. LNM was significantly more frequent in patients with larger tumors, women, younger patients, and patients with more poorly differentiated tumor. The RF model showed the best predictive performance in comparison to the other method, achieving an accuracy of 96.0%, a sensitivity of 99.7%, a specificity of 92.9%, and an area under the curve of 0.991. Tumor size is the most important features in predicting LNM in early CRC.

Conclusion

We established a simplified reproducible predictive model for LNM in early CRC that could be used to guide treatment decisions. These findings warrant further confirmation in large prospective clinical trials.

Accuracy of preoperative staging with multidetector computed tomography in colon cancer

AIM

Multidetector computed tomography (MDCT) is the main preoperative decision-making tool in colon cancer treatment, thus the validation of daily clinical practice is warranted. The only published study validating the accuracy of MDCT in a national cohort was performed more than a decade ago. With neoadjuvant chemotherapy for patients with preoperatively assessed locally advanced cancer and the emergence of other personalized treatments we aimed to validate the accuracy of MDCT in a national cohort.

METHOD

The study is based on the Danish Colorectal Cancer Group (DCCG) database and included all Danish patients diagnosed with primary colon adenocarcinoma between January 2015 and December 2018. The primary study outcome was the accuracy of MDCT in identifying patients with locally advanced disease. The secondary outcomes were the accuracy of predicting UICC Stage I based on predicting the tumour category (pT3-T4 versus pT1-T2) and lymph node metastasis.

RESULTS

A total 3465 patients were included in the analyses regarding locally advanced colon cancer. The sensitivity and specificity were 0.61 (0.58-0.64) and 0.85 (0.83-0.86), respectively, for CT to predict locally advanced disease. The sensitivity and specificity were 0.63 (0.59-0.66) and 0.80 (0.78-0.81), respectively, for predicting UICC Stage I in 4496 patients. Thirty six per cent of the patients assessed as having locally advanced disease and 58% assessed as Stage I were misclassified by MDCT.

CONCLUSION

The present standard in Denmark questions whether the implementation of personalized medicine such as neoadjuvant adjuvant chemotherapy and tailor-made resections based on MDCT is justified.

Predictive value of the sentinel lymph node procedure in the staging of non-metastatic colorectal cancer

PURPOSE

Despite the recent growing interest of the scientific community, there is still no consensus on the actual applicability and effectiveness of sentinel lymph node (SL) procedure in colon cancers. This study aims to quantify feasibility, detection rate, negative predictive value, and accuracy of the SL identified with fluorescent dye in early colon cancers (ECC).

METHODS

This study conducted a consecutive sampling of 95 patients with non-metastatic colorectal cancer who have been treated with laparoscopic colon resection and complete mesocolic excision after a 25-mg indocyanine green peritumoral laparoscopic injection and SL identification with a near-infrared camera. The SL was later isolated and sent to ultra-staging.

RESULTS

Ninety-five patients with an average age of 71 (range 37-90) and a mean BMI of 25 (range 18-39) have been recruited. On the patient sample (92 Pts), an average of 1.49 SL (range 1-5) and a mean time of 4 min were identified. The detection rate was 96.8% and the negative predictive value and accuracy rates were 96.2% and 93.4%, respectively.

CONCLUSIONS

Mapping the SL with fluorescent dye can play an important role in the treatment of colon cancers, particularly those at early stages, and can lead to ultra-conservative surgery.

Neoadjuvant chemotherapy in locally advanced colon cancer: a systematic review

BACKGROUND

Preoperative or neoadjuvant chemotherapy (NAC) has emerged as a novel alternative to treat locally advanced colon cancer (LACC), as in other gastrointestinal malignancies. However, evidence of its efficacy and safety has not yet been gathered in the literature. The aim of the present study was to perform an extensive review of the scientific evidence for NAC in patients with LACC.

METHODS

PubMed, EMBASE, MEDLINE and Cochrane Library were searched for a systematic review of the literature from 2010 to 2019. Six eligible studies were included, with a total of 27,937 patients, 1232 of them (4.4%) treated with NAC. There were only one randomized controlled trial, three phase II non-randomized single arm studies and two retrospective studies.

RESULTS

The baseline computed tomography scan showed that most of patients had a T3 tumor. The completion rate of the planned neoadjuvant treatment ranged from 52.5 to 93.8%. Between 97.2 and 100% of patients had the scheduled surgery. The median tumor volume reduction after NAC ranged from 62.5 to 63.7%. The anastomotic leak rate in the NAC group ranged from 0 to 7%, with no cases of postoperative mortality. There was major pathological tumor regression in 4-34.7% of cases. Between 84 and 100% of NAC patients had R0-surgery. Survival after NAC seems to be encouraging although significant improvement has only been proven in T4b tumours.

CONCLUSIONS

According to our systematic review, the NAC may be a safe and effective emerging therapeutic alternative for treating LACC. This approach, which is still being tested, increases the reliance on accurate radiological staging.

High practice variation in risk stratification, baseline oncological staging, and follow-up strategies for T1 colorectal cancers in the Netherlands

Background and study aims  Based on pathology, locally resected T1 colorectal cancer (T1-CRC) can be classified as having low- or high-risk for irradicality and/or lymph node metastasis, the latter requiring adjuvant surgery. Reporting and application of pathological high-risk criteria is likely variable, with inherited variation regarding baseline oncological staging, treatment and surveillance. Methods  We assessed practice variation using an online survey among gastroenterologists and surgeons participating in the Dutch T1-CRC Working Group. Results  Of the 130 invited physicians, 53 % participated. Regarding high-risk T1-CRC criteria, lymphangio-invasion is used by 100 %, positive or indeterminable margins by 93 %, poor differentiation by 90 %, tumor-free margin ≤ 1 mm by 78 %, tumor budding by 57 % and submucosal invasion > 1000 µm by 47 %. Fifty-two percent of the respondents do not perform baseline staging in locally resected low-risk T1-CRC. In case of unoperated high-risk patients, we recorded 61 different surveillance strategies in 63 participants, using 19 different combinations of diagnostic tests. Endoscopy is used in all schedules. Mean follow-up time is 36 months for endoscopy, 26 months for rectal MRI and 30 months for abdominal CT (all varying 3-60 months). Conclusion  We found variable use of pathological high-risk T1-CRC criteria, creating risk for misclassification as low-risk T1-CRC. This has serious implications, as most participants will not proceed to oncological staging in low-risk patients and adjuvant surgery nor radiological surveillance is considered. On the other hand, oncological surveillance in patients with a locally resected high-risk T1-CRC who do not wish adjuvant surgery is highly variable emphasizing the need for a uniform surveillance protocol.

Laparoscopic sigmoidectomy for sigmoid colon cancer with left-sided inferior vena cava and persistent descending mesocolon

Left-sided inferior vena cava (IVC) is a rare congenital malformation, as is persistent descending mesocolon, a developmental anomaly in which the colonic mesentery does not fuse with the dorsal abdominal wall. Although these anomalies are mostly asymptomatic, they should be identified preoperatively to avoid iatrogenic injury. We report a case of sigmoid colon cancer in a patient with both anomalies. The patient was an 80-year-old man whose preoperative computed tomography (CT) scan showed that the IVC ascended vertically along the left side of the abdominal aorta, and the descending colon was at the abdominal midline. Coronal CT was particularly useful for visualizing these anomalies. With this better understanding of the malpositioned anatomy, we successfully performed laparoscopic sigmoidectomy with lymph node dissection. Careful evaluation of preoperative CT imaging based on a clear understanding of such anatomical anomalies is particularly important for performing safe laparoscopic surgery.

Management of malignant colonic polyps

With the implementation of colorectal cancer screening programs, there has been an increasing incidence of malignant colonic polyps (MP). The attending surgeon is often faced with the management dilemma of whether polypectomy can be considered adequate treatment or if formal oncological resection is required. While endoscopic therapy avoids the risks and morbidity of surgery, there is a potential trade-off of under-staging and inadequate treatment. Surgery, on the other hand confers the benefits of clear resection margins, nodal staging and the ability to prognosticate and guide the decision for adjuvant therapy. This article sets out to review the histopathologic prognostic factors of MP and the various management and surveillance strategies.

Development and validation of a novel nomogram for pretreatment prediction of liver metastasis in pancreatic cancer

PURPOSE

The diagnostic value of nomogram in pancreatic cancer (PC) with liver metastasis (PCLM) is still largely unknown. We sought to develop and validate a novel nomogram for the prediction of liver metastasis in patients with PC.

METHOD

About 604 pathologically confirmed PC patients from the Sun Yat-sen University Cancer Center (SYSUCC) between July, 2001 and December, 2013 were retrospectively studied. The SYSUCC cohort was randomly assigned to as the training set and internal validation set. Using these two sets, we derived and validated a prognostic model by using concordance index and calibration curves. Another two independent cohorts between August, 2002 and December, 2013 from the Sun Yat-sen Memorial Hospital (SYSMH, n = 335) and Guangdong General Hospital (GDGH, n = 503) was used for external validation.

RESULT

Computed tomography (CT) reported liver metastasis status, carcinoembryonic antigen (CEA) level and differentiation type were identified as risk factors for PCLM in the training set. The final diagnostic model demonstrated good calibration and discrimination with a concordance index of 0.97 and had a robust internal validation. The score ability to diagnose PCLM was further externally validated in SYSMH and GDGH with a concordance index of 0.93. The model showed better calibration and discrimination than CT, CEA and differentiation in each cohort.

CONCLUSION

Based on a large multi-institution database and on the routinely observed CT-reported status, CEA level and tumor differentiation in clinical practice, we developed and validated a novel nomogram to predict PLCM.

Contrast-enhanced CT imaging for the assessment of lymph node status in patients with colorectal cancer

The aim of the present study was to identify a novel strategy that predicts the metastatic status of lymph nodes (LNs) in patients diagnosed with colorectal cancer, using detailed characteristics of contrast-enhanced CT scan images. A total of 284 preoperative CT scans derived from patients diagnosed with colorectal cancer at Second Affiliated Hospital, Zhejiang University School of Medicine between January 2013 and July 2018 were retrospectively reviewed. A total of 794 LNs were assessed for size, margins, morphology and subtle internal enhancements in the equilibrium phase. Imaging features were analyzed by two abdominal radiologists (Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine and Departments of Radiology; Shaoxing Second Hospital Departments of Radiology, Shaoxing Second Hospital) in a blind manner. If the conclusions were not concordant, the final score was determined by a senior radiologist who specialized in abdominal radiology for ≥30 years. According to the histopathology results, 27.3% (217/794) of LNs were metastatic (LN+). In addition, LNs >10 mm in size demonstrated sensitivity, specificity, positive predictive values (PPVs) and negative predictive values (NPVs) of 47.0, 80.9, 48.1 and 80.2%, respectively [odds ratio (OR), 3.77; 95% confidence interval (CI), 2.69–5.28]. LNs in the shape of a kidney bean (middle fat depression like kidney) and/or those with an oblong shape were more likely to be metastasis negative LNs (LN-), while lobulated and irregular LNs were more likely to be LN+. In magnified images, internal enhancement characteristics of LN- were defined as homogeneous, spotted, striped and core enhancing. By contrast, rim and heterogeneity enhancement features for LN+ demonstrated sensitivity, specificity, PPVs and NPVs of 46.5, 89.9, 63.5 and 81.7%, respectively (OR, 7.79; 95% CI, 5.33–11.40). The results demonstrated that the internal enhancement features of LNs may be used as a predictor of metastasis. The detailed benign characteristics, such as homogeneity, spotted, striped and core enhancement of LNs may facilitate the identification of LN- in patients with colorectal cancer.

A study of radiomics parameters from dual-energy computed tomography images for lymph node metastasis evaluation in colorectal mucinous adenocarcinoma

Lymph nodes (LN) metastasis differentiation from computed tomography (CT) images is a challenging problem. This study aims to investigate the association between radiomics image parameters and LN metastasis in colorectal mucinous adenocarcinoma (MAC).Clinical records and CT images of 15 patients were included in this study. Among them, 1 patient was confirmed with all metastatic LNs, the other 14 were confirmed with all non-metastatic LNs. The regions of the LNs were manually labeled on each slice by experienced radiologists. A total of 1054 LN regions were obtained. Among them, 164 were from metastatic LNs. One hundred nine image parameters were computed and analyzed using 2-sample t test method and logistic regression classifier.Based on 2 sample t test, image parameters between the metastatic group and the non-metastatic group were compared. A total of 73 parameters were found to be significant (P < .01). The selected shape parameters demonstrate that non-metastatic LNs tend to have smaller sizes and more circle-like shapes than metastatic LNs, which validates the common agreement of LN diagnosis using computational method. Besides, several high order parameters were selected as well, which indicates that the textures vary between non-metastatic LNs and metastatic LNs. The selected parameters of significance were further used to train logistic regression classifier with L1 penalty. Based on receiver operating characteristic (ROC) analysis, large area under curve (AUC) values were achieved over 5-fold cross validation (0.88 ± 0.06). Moreover, high accuracy, specificity, and sensitivity values were observed as well.The results of the study demonstrate that some quantitative image parameters are of significance in differentiating LN metastasis. Logistic regression classifiers showed that the parameters are with predictive values in LN metastasis, which may be used to assist preoperative diagnosis.